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Prescriptive Authority for Nurse Practitioners

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lazer31285 has 10 years experience as a RN, NP .

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The physician shortage in primary care, plus the growth of nurse practitioners and increasing need for access to health care, creates a necessity for more autonomous nurse practitioners. However, current restrictions on nurse practitioners, particularly prescription regulations for controlled substances, limit what practitioners can do for patients. These restrictions also increase wait times for patients and have the potential to increase liability claims as physicians prescribe medications for patients they have not adequately evaluated. You are reading page 3 of Prescriptive Authority for Nurse Practitioners. If you want to start from the beginning Go to First Page.

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Why is it so important that the PCP (in this case NP or PA), be an independent practitioner?

As a PCP you deal with run of the mill problems that the patient comes to you with in your office. Then if their problem requires a specialist, you are going to refer them to someone else anyway. Your not running an ER with GSW coming in at 3 am. My PCP keeps regular hours.

I'm not trying to be offensive to anyone , I am actually curios about this topic.

Do you work as a PCP? If you don't, it is very difficult to truly appreciate the workflow in primary care, especially rural primary care. In rural practice (and even non-rural) there is limited (timely) access to specialists (and even diagnostics); you must be prepared to handle every situation, you are very much an independent practitioner.

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kalevra has 5 years experience as a BSN, RN and specializes in ED, Telemetry,Hospice, ICU, Supervisor.

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Do you work as a PCP? If you don't, it is very difficult to truly appreciate the workflow in primary care, especially rural primary care. In rural practice (and even non-rural) there is limited (timely) access to specialists (and even diagnostics); you must be prepared to handle every situation, you are very much an independent practitioner.

Of course I am not a PCP. If I were, I would not be asking question so that I could better understand the situation.

So what happens in rural areas when an NP decides a specialist or specific diagnostic test is required?

What do you mean by handle any situation?

What would you do in a rural setting for a patient that has had a traumatic amputation on a farm? I am assuming they would be sent to a specialist at this point. Please correct me if I am wrong.

Im just interested on how things work in real world practice.

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CountyRat specializes in Wilderness Medicine, ICU, Adult Ed..

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I actually see PAs taking the primary care provider role in the future. In the military my primary care provider was a PA as is are most other Units. We see him or her first for whatever issues we may have. Then if lets say they feel we need a specialist like Oncology then they refers us, and they take it form there. As for pain issues the usual pain meds, physical therapy consult, splints, low duty, sutures, medications etc are all handled by the PA. Regular routine hospital visit stuff anyway.

I mean the MD primary care provider is based on the medical model. The PA is also based off of the same model, except that they only take 6 years to make. Makes sense to me. Its been a proven system for years. The framework is already there.

Good morning, Kalevera. First, thank you for your service in the military. We are all in your debt. As a military person, you know that things are done very differently in the military than how they are done in the civilian world, including the way the military uses its medical personnel. I share your respect for PAs; their practice is “a proven system,” as you correctly point out. I have not had any qualms about placing myself or my children in a PA's hands. This is because years of observation have demonstrated that their education is adequate, and that they do refer to physicians when it is in the patient's best interest.

However, you may have some factual misunderstandings about NPs. NPs also have 6 years of training, including two years of graduate education with clinical training, and many have more. NPs also “issue the usual pain meds, physical therapy consult, splints, low duty, sutures, medications, etc.” I think, from your posts, that you are familiar with the education required to become a PA. You might find answers to some of your questions about NPs by sitting down with one and asking her about her education. I think that you will come away reassured.

Finally, the practice of NPs is also a proven system. It has been in place for more than 40 years, is recognized in every state, territory, and province of the U.S. and Canada, has matured significantly in terms of the rigor of candidate selection and licensure, and, in numerous outcome studies, NPs have also been shown to provide safe and effective care, just as PAs have.

Again, my thanks, and my best wishes. You raise worthwhile questions that deserve answers. I hope that I have answered some of those questions, and that others will address more of them.

Edited by CountyRat
Grammar

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CountyRat specializes in Wilderness Medicine, ICU, Adult Ed..

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OK so if you advance the prescriptive authority of an NP so that it in their scope of practice, then they will still be practicing nursing. Even though they are treating the underlying cause and not the symptom.

Yes, you are correct, Kalevra. Nursing is an autonomous, self-regulating profession. Our scope of practice is always expanding, just as it is for PAs, respiratory therapists, paramedics, and other providers. State and provincial regulatory boards (which consist of nurses, by the way) the facilities that hire us, and others also have a place in defining scope of practice. However, the job of expanding what a profession may provide is the responsibility of the members of that profession.

As for treating underlying cause, of course that is within the scope of professional nursing. We are not pillow fluffers. We provide professional services that facilitate the patient's recovery of the highest level of health possible, including addressing the cause of their health problem.

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kalevra has 5 years experience as a BSN, RN and specializes in ED, Telemetry,Hospice, ICU, Supervisor.

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Good morning, Kalevera. First, thank you for your service in the military. We are all in your debt. As a military person, you know that things are done very differently in the military than how they are done in the civilian world, including the way the military uses its medical personnel. I share your respect for PAs; their practice is “a proven system,” as you correctly point out. I have not had any qualms about placing myself or my children in a PA's hands. This is because years of observation have demonstrated that their education is adequate, and that they do refer to physicians when it is in the patient's best interest.

However, you may have some factual misunderstandings about NPs. NPs also have 6 years of training, including two years of graduate education with clinical training, and many have more. NPs also “issue the usual pain meds, physical therapy consult, splints, low duty, sutures, medications, etc.” I think, from your posts, that you are familiar with the education required to become a PA. You might find answers to some of your questions about NPs by sitting down with one and asking her about her education. I think that you will come away reassured.

Finally, the practice of NPs is also a proven system. It has been in place for more than 40 years, is recognized in every state, territory, and province of the U.S. and Canada, has matured significantly in terms of the rigor of candidate selection and licensure, and, in numerous outcome studies, NPs have also been shown to provide safe and effective care, just as PAs have.

Again, my thanks, and my best wishes. You raise worthwhile questions that deserve answers. I hope that I have answered some of those questions, and that others will address more of them.

I fully understand that both of them NP or PA can provide the required level of care for patients. Their levels of education are adequate to meet the needs of patients. With the passage of the affordable care act, there will be a shortage of PCPs. I just found having NPs and PAs fighting for the same job as redundant.

It just makes more sense to standardize across the board. My thinking was their would less resistance from the powers that be to make PA the PCP standard. The reason being they are built upon the medical model and so have less legal issues to deal with. As compared to an NP where they tread on a fine line between practicing nursing vs medicine. It is my understanding there were legal ramifications.

Thank your CountryRat, I hope I get some of these questions answered as well. I think I had inadvertently annoyed a few people on this thread already.

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kalevra has 5 years experience as a BSN, RN and specializes in ED, Telemetry,Hospice, ICU, Supervisor.

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Who would be the most vocal opponent regarding expanding the prescriptive authority of NPs?

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CountyRat specializes in Wilderness Medicine, ICU, Adult Ed..

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Fair enough, Kalevra. The bottom line is that we disagree, which should not cause either one of us any heartburn. There is, however, something on which we do agree; the development of two separate disciplines for the meeting of similar needs is, I think, very unfortunate. I think that it has added more complexity to an already poorly organized institution. I think that this was a mistake, and I think that I know why it happened, but I am not sure that I am right about that, so I will keep my speculations about cause and effect to myself.

I do not think that NP and PAs will be fighting for the same jobs; I think it more likely that there will not be enough of either to fill all needed positions, but that is mere speculation on my part. We are all waiting to see how things shake out. As for PAs getting more acceptance, I am not sure what you mean. You acknowledge that the education and capabilities within these professions are both adequate for the job, so how do we decide which one to keep and which one to replace? What, specifically, makes the PA the better choice?

Edited by CountyRat
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kalevra has 5 years experience as a BSN, RN and specializes in ED, Telemetry,Hospice, ICU, Supervisor.

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What, specifically, makes the PA the better choice?

The reason why I see the PA as having a slight edge between the two is versatility.

It is my understanding that adding on to the skills an NP is allowed to perform in a setting requires legislation to pass in their scope of practice. I understand that upon entering NP school the student must choose a specialty. Therefore they are locked into that specific role and scope. I found this out while reading through some of the old posts on the site. "NP's are restricted by their specialty, so a pediatric NP couldn't prescribe for adults, etc" https://allnurses.com/general-nursing-discussion/nurse-practitioner-physicians-406029-page6.html

The PA on the other hand requires the supervising Physician to train and give them the go ahead. No change from the state or BON. The idea of a jack at all trades and master at none. You can easily fit them in any area that has a shortage of PCP.

For example, in rural areas I expect many children to to go through the usual cuts, scrapes and bruises. Scrapes and bruises are easily remedied by either the PA or NP and there is no need to send them to an MD. Now if the child suffered a laceration that needed stitches, nothing fatal mind you just superficial. It is my understanding that the NP would not be able to place the sutures and would have to send them to a higher level of care. The PA on the other hand would be within their scope to apply sutures. As long as they have been trained and given the ego ahead by the supervising physician.

Please correct me if I am wrong

P.S I would be very much interested on your theory as to why both NP and PA were developed simultaneously to meet the PCP shortage.

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PatMac10,RN has 7 years experience as a ADN, BSN, RN and specializes in Nursing Education, CVICU, Float Pool.

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The reason why I see the PA as having a slight edge between the two is versatility.

It is my understanding that adding on to the skills an NP is allowed to perform in a setting requires legislation to pass in their scope of practice. I understand that upon entering NP school the student must choose a specialty. Therefore they are locked into that specific role and scope. I found this out while reading through some of the old posts on the site. "NP's are restricted by their specialty, so a pediatric NP couldn't prescribe for adults, etc" https://allnurses.com/general-nursing-discussion/nurse-practitioner-physicians-406029-page6.html

The PA on the other hand requires the supervising Physician to train and give them the go ahead. No change from the state or BON. The idea of a jack at all trades and master at none. You can easily fit them in any area that has a shortage of PCP.

For example, in rural areas I expect many children to to go through the usual cuts, scrapes and bruises. Scrapes and bruises are easily remedied by either the PA or NP and there is no need to send them to an MD. Now if the child suffered a laceration that needed stitches, nothing fatal mind you just superficial. It is my understanding that the NP would not be able to place the sutures and would have to send them to a higher level of care. The PA on the other hand would be within their scope to apply sutures. As long as they have been trained and given the ego ahead by the supervising physician.

Please correct me if I am wrong

P.S I would be very much interested on your theory as to why both NP and PA were developed simultaneously to meet the PCP shortage.

Idk how it may work in your area, but all of the NPs (FNP: Family Nurse Practitioners) here on my part of NC do their own suturing, I&D, Pap smear, insert IUDs etc... Idk why an NP would have to send a pt to an MD or PA simply to have a "routine" suturing. I am aware that some NP programs might not focus as much on suturing as others, but most, if not all, of the FNPs that are employed at my hospital had suture training in their NP education; and they can do the aforementioned procedures in individuals if all ages, most of the work in the ED. A few of the NPs and PAs have also told me that they got extra training once finishing their programs in order to feel more confident, by taking CEUs in suturing.

Again maybe it's different where you are. I'm in a rural area so maybe that's just the way schools here prepare their NP students.

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1 Follower; 3 Articles; 5,185 Posts; 181 Profile Views

I was trained in suturing, paps, etc. I can practice with any age group. I would never place an IUD unless I did them routinely in a GYN office as the complication rate is high for those that don't do them on a regular basis.

I think there is a fundamental misconception about NPs and their scope of practice. In many (16) states NPs already practice independently, unlike PAs that do not practice independently in any states (as far as I know).

Edited by Hyperflycemia

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Psychcns has 30 years experience and specializes in Psychiatric Nursing.

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Mandatory collaboration makes it a little harder to practice. It can be difficult finding a collaborator or something can happen to the collaborator and APRN or PA is legally unable to practice. Primary care NP's PA's and MD's do similar jobs. MD's have had a lot more education and training. As a patient I have had satisfactory treatment with all three groups of providers.

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kalevra has 5 years experience as a BSN, RN and specializes in ED, Telemetry,Hospice, ICU, Supervisor.

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These last few posts have been very informative and I think I have a few more questions now than I did when I first started. Im gonna try to get a first hand view of the situation regarding NP and PA practice, autonomy, economics etc. I have a sit down with a PA in the next few days and see if he can answers some of these questions and shed some light on how the ACA is going to impact their practice. After that Im gonna look for an NP to answer the same set of questions as well.

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