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Whether you're a practicing nurse seeking to advance your career or generally curious about the role of Nurse Practitioners (NPs), you've come to the right place. Discover the best NP programs in Pittsburgh, PA as we explore their nuances, costs, salary expectations, and more. -
Whether you're a practicing nurse seeking to advance your career or generally curious about the role of Nurse Practitioners (NPs), you've come to the right place. Discover the best NP Programs in Jacksonville, Florida, as we explore their nuances, costs, salary expectations, and more. -
Whether you're a practicing nurse seeking to advance your career or generally curious about the role of Nurse Practitioners (NPs), you've come to the right place. Discover the best NP Programs in San Antonio, TX, as we explore their nuances, costs, salary expectations, and more. -
Whether you're a practicing nurse seeking to advance your career or generally curious about the role of Psychiatric-Mental Health Nurse Practitioners (PMHNPs), you've come to the right place. Discover the best PMHNP programs in New Jersey as we explore their nuances, costs, salary expectations, and more. -
I interviewed today and was offered one of six resident positions. I lost it. The panel laughed and said my reaction was the best one so far. ? I was asked nine questions. They were along the lines of "Tell me about yourself; How will you contribute to VA care; Flexibility and describe a time when it was required; Career goals; Rate yourself 0 - 10 in the following aspects, etc.". I was sweating the whole time, but displayed a cool (I think) exterior. It starts towards the end of September, so plenty of time for me to go over all my material from school and beef up my knowledge so I don't look like a total dunce. I will periodically update this thread with all my trials and tribulations for those who are interested in applying for a spot in the future and want to know what the year will look like.
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Advanced Practice Registered Nursing (APRN) as we know it arose out of the trailblazing efforts of nurses from four separate nursing specialties whose individual histories were shaped by a common thread: to answer the call to deliver a high level of healthcare to individuals and groups in an area of clinical practice where a need for such level of healthcare existed. The APRN movement, a testament to American innovation, has been copied in many parts of the globe though not always in its entirety. All four Advanced Practice Registered Nursing groups evolved from separate historical timelines but now share common characteristics: they all build upon nursing as the basis of practice by requiring active licensure as a Registered Nurse (RN), require a graduate degree for entry to practice, require a form of certification in the specific specialty, and lastly, require its practitioners to acquire in-depth training in specialties using advanced concepts some of which are not traditionally held in the nursing realm. As part of professional nursing practice in the United States, all four APRN specialties are regulated under a nursing board in each of the 50 states, the District of Columbia, and a number of US territories. With the exception of Nebraska which has a separate board for advanced practice, APRN's are regulated by the same board that oversees the practice of RN's. The collective voice of the individual Boards of Nursing is the National Council of State Boards of Nursing (NCSBN). Among the achievements of the NCSBN is the development and implementation of two national board examinations in the US for entry to practice as either Registered Nurses or Licensed Practical/Vocational Nurses now known as the National Council Licensure Examination (NCLEX). It is along the same mission of promoting uniformity in nursing practice across all its member boards that a Consensus Model for APRN was born. Not surprisingly, 2015 became an arbitrary number as the target year when the provisions of this model shall take effect. As relatively newer and evolving professions that challenge the norms of traditional nursing practice, APRN regulation varies considerably in terms of requirements for entry to practice among the member Boards of Nursing that NCSBN represents. Four areas of concern were identified as sources of variability in regulatory standards across all member boards: licensure, program accreditation, national certification, and education. These were referred to as the acronym LACE. In terms of licensure, member boards of the NCSBN do not have uniform regulation regarding the need for Advanced Practice Registered Nurses to acquire additional licensure separate from a Registered Nurse license in order to practice their specialty. In many states, a certification in the APRN specialty is awarded after the candidate is deemed qualified based on state requirements one of which always include an active RN license. CRNA and CNM programs are accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA-NAEP) and Accreditation Commission for Midwifery Education (ACME) respectively. National certification for CRNA's and CNM's are carried out by each profession's single specialty certification board namely, the National Board of Certification & Recertification for Nurse Anesthetists (NBCRNA) and the American Midwifery Certification Board (AMCB) respectively. Both of these professions by virtue of their narrow specialty foci developed a highly organized, unified structure and set of standards in terms of program accreditation and national certification. Sadly, the same could not be said of the CNS and NP professions. No specialized accrediting body exists for CNS and NP programs; however, the Pediatric Nursing Certification Board (PNCB) offers recognition status to Pediatric NP programs in the Acute Care and Primary Care foci across the US. Programs in both CNS and NP specialties are accredited by either the Commission on Collegiate Nursing Education (CCNE) or the National League of Nursing Accreditation Commission (NLNAC) as part of their role in accrediting institutions offering a master's degree and/or practice doctorate in nursing. National certification programs for Clinical Nurse Specialist and Nurse Practitioner are not only divided by multiple subspecialty tracks but also by the fact that multiple national certification programs exist from different organizations offering the same type of subspecialty certification. Case in point, the American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners (AANP) both offer certification in the Family and Adult NP tracks. The ANCC has various CNS specialty examinations and so does the American Association of Critical Care Nurses (AACN). Although all educational programs for APRN's are offered at the graduate degree level, significant differences can be seen in the Clinical Nurse Specialist and Nurse Practitioner programs in terms of curricular offerings and specialty focus depending on institutional preference prior to the Consensus Model. As the final draft of the Model came to print, eight Nurse Practitioner tracks emerged as officially accepted specialty areas of practice namely: Family NP, Adult-Gerontology Primary Care NP, Adult-Gerontology Acute Care NP, Pediatric Primary Care NP, Pediatric Acute Care NP, Women's Health NP, Neonatal NP, and Psychiatric-Mental Health NP. Clinical Nurse Specialist foci appear to have been standardized along the same lines as the NP namely: Family, Adult-Gerontology, Pediatric, Neonatal, Women's Health, and Psychiatric-Mental Health CNS tracks though in reality, CNS program and certification options are not as varied. Also note that the Acute Care versus Primary Care delineation does not exist in the Clinical Nurse Specialist tracks in terms of the Adult and Pediatric foci. As a consequence of the newly-approved CNS and NP specialties, national certification boards for both professions followed suit by enforcing new changes to their certification credentials. Despite the confusing mess of CNS and NP specialty boards with roles that overlap against each other, many of the certification boards managed to scramble in order to update the titling of their respective certification examination programs to reflect the intended content of these new and improved CNS and NP specialties. Such haste appears to be motivated by the target implementation year of 2015. Adult NP and CNS certifications were modified to add Gerontology content. Gerontology NP and CNS certifications succumbed to an untimely demise and the Child/Adolescent Psychiatric Mental Health NP and CNS content was dissolved to give way to the single broad-based Family Psychiatric Mental Health track. What ensued was loud uproar of exasperation from many practicing CNS's and NP's who hold the older versions of these new and improved certification programs. Undeniably, some of the provisions of the Consensus model are much needed in the current APRN environment and should be accepted as steps toward progress in these professions. But the Consensus Model missed the mark on many respects and many APRN's agree. For one, the model failed to simplify certification titling for NP and CNS professions by eliminating the mambo-jambo of confusing letters and in fact added to the alphabet soup. Case in point: the ridiculously long title for Adult-Gerontology Primary Care Nurse Practitioner educational preparation and specialty certification has been lengthened to AGPCNP-BC from the previously used ANP-BC by ANCC. No other professions exhibit such a degree of obsession with acronyms in order to gain a sense of accomplishment. Multiple nursing organizations sat with NCSBN on the round-table discussions that gave rise to this Model in a Kumbayah fashion. Not surprisingly, no one dared to admonish the profession for allowing multiple overlapping entities that certify NP's and CNS's and perpetrating the lack of a unified accrediting body specific to CNS and NP educational programs. It is also important to point out that the extent of power NCSBN exerts will only go as far as the provisions of the Nurse Practice Act that is enforced in the state (or territory) of jurisdiction the board belongs to. Boards of Nursing do not write the law in their respective states, lawmakers do. Various Scopes of Practice for APRN are affected by forces outside of the nursing profession itself. For instance, a strong physician lobby against APRN encroachment on their turf is regarded as an obstacle to full realization of a uniform APRN practice standard. The statement is never truer than the reality of independent practice and prescriptive authority which varies among all APRN groups depending on the state the provider practices in. Lastly, while the Model should be lauded for finally recognizing the CNS as a legitimate profession under the APRN umbrella, Nurse Practice Acts in many of the NCSBN member jurisdictions will need to change if prescriptive authority is to be granted to Clinical Nurse Specialists as a whole. In the end, I ask whose consensus is it anyway? Feel free to discuss.
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To the APRN hecklers, critics and malcontents.Many of you say that your MSN nursing education has too much "fluff", referring to classes like cultural competency, and management that have no relevance to your jobs. I have read very little about how you will address this with the people that accredit NP curriculums. I am not sure of the credentialing process at all but I did find the American Association of Colleges of Nursing on the web and this seems like a place to start. In 2013 they developed NP competencies in which we are all expected to be proficient. These competencies expect cultural competency, trauma informed care, as well as all the things you complain there is not enough of such as pathophysiology, pharmacology, physical assessment. I have been in nursing since the early 80's and have been through a few transitions in health care and in my own nursing career. Now I just try to keep up. I have no venom to toss at nursing leaders. I am very grateful to the nursing profession for my livelihood. I work locum tenens as a psychiatric APRN. My advanced practice nursing skills allow me to find work in interesting settings on a limited basis. This semi nomadic lifestyle is mine by choice. Everyone wants to hire me permanently. The APRN role exists because of the dedication of nursing professionals with advanced degrees who have done the hard political work of fighting for the opportunity for all of us to practice to the full extent of our education. This means that our education prepares us to diagnose and treat illnesses in our respective specialties. We have a record of patient outcomes similar or better than MD's. We are not MD's and we are not junior MD's, we are nurses. If we were MD's we would be regulated by Boards of Medicine, physician extenders of some sort. As nurses, regulated by Boards of Nursing, we are eligible in many states for independent practice. There is an overlap between MD's and NP's and this is where a lot of NP's and MD's practice: Seeing patients one at a time in inpatient or outpatient settings. Since we are doing the same job as MD's in many cases we do need to catch up on their rich science background and the intense mentoring they get in residency. Or we can wonder how much education do we or they really need to do this job? We probably do not need nursing theory at this stage of our development as a profession though I did like my theory classes. We probably do not need healthcare management classes though I learned in those classes also. In today's day to day NP jobs we need to keep our diagnostic and prescribing skills sharp to give patients the best care that we can. We often have MD role models and some are surprised we are doing the same jobs as them and many are happy to consult on cases and make use of their intense education. To my colleagues who are angry with the nursing profession that benefits you, I would encourage you to review the history of nursing (we were housecleaners one hundred years ago), and as science developed nurses had to fight the AMA to be professionals as opposed to handmaidens or servants. At one time only an MD could take a blood pressure. Now we are fighting for the right to practice to the full extent of our education. We are nurses and we need to continue to define ourselves differently from physicians. That we are different from the medical profession has benefited us politically and gives us the responsibility to self-regulate our profession.The people with the energy and aptitude to criticize should learn to become political. Start by looking up the website I note above and figure out how to have input into curriculum development. You might have to join a committee. This is how hard work often starts. As in today's general politics it is possible the nursing leadership is losing touch with its base. Those who see what needs to be done would benefit all of us by becoming active and help to maintain and improve standards and influence the direction of the nursing profession.Best wishes.
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People are drawn to the nursing profession for many different reasons. For me, my beginnings in the healthcare field started by chance. An opportunity to work as a Hospitality Representative in the Emergency Room was offered to me as a young woman just finishing High School. Despite the fact that my mother and aunt were both nurses, I had no inkling what was in store for me, let alone the path that it would lead me down. I was captivated by the influence that the nurses working in the ER had on those that they were helping. It awakened a deep desire within me to provide help and care to those in need. That desire grew with each step I made in the healthcare system. As I gained more knowledge and advanced my career, my ability to help my patients was empowered. My first exposure to the healthcare system was working as a Hospitality Representative in the ER. I observed how scared patients and their family members were when they came into the ER. I wanted to be the person to help calm their fears and help to make them feel better. One night while working as a Hospitality Representative in the ER, a mother came in carrying her son in her arms. He was clearly having difficulty breathing and the mother looked terrified. I stood by helplessly as the triage nurse rushed towards them. The boy was quickly taken to the back for treatment. At work a few nights later, the same mother came back into the ER. This time, she was not carrying her son in her arms. Instead, she was carrying a big plate of home baked goods. She had tears in her eyes as she thanked the nursing staff for their outstanding care. Her son was at home recuperating and she could not have been more grateful to the nurses for all that they had done. It was in that moment I knew I wanted to become a nurse. I thought how wonderful it would be to have a job where you get to come home every night and know that you madea difference in someone else's life. After that, I transferred to the Unit Secretary position in the ER. I wanted to be closer to the patient care area and gain more experience. As I worked more closely with the nursing staff, I found myself craving hands on patient care. I took the necessary steps and became a Patient Care Assistant. As a PCA, I spent time caring for and helping my patients and their families. That was an extremely rewarding experience for me because it was my first involvement with hands on patient care. While working as a PCA, I attended nursing school at FAU. Coming up through the ranks has given me a strong and diverse nursing background that is grounded in caring. I would like to continue to grow my nursing knowledge base so that I can provide my patients with the highest level of care possible in the nursing profession. In all the positions that I held in the healthcare system, one thing has always been very apparent to me. Many people do not have access to affordable healthcare. It is my goal to work as a Nurse Practitioner in a clinic or setting designed to provide quality healthcare to those who could not otherwise afford it. I believe that everyone should have access to quality healthcare regardless of their economic status. There are too many people in this country who are denied access to resources vital to their health and well-being. Unfortunately, this became a personal issue for me when a very close family friend of mine discovered he was dying of colon cancer. He was laid off from his job and as a result lost his health insurance. He could not afford to visit his doctor to have regular checkups or the necessary preventive screenings for his age. As a result, his cancer was finally detected after an emergency transport to the hospital once it had already metastasized throughout his body. Through more affordable healthcare, situations like my friend Steven's could have a chance for a better outcome. I believe that Nurse Practitioners can be part of the solution because they are a valuable asset in making the healthcare system more affordable.
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Nurse practitioners have proven to be a safe, quality, and cost saving approach to primary care. To meet the growing needs for patients, nurse practitioners must have the ability to prescribe controlled substances in all 50 states. The passage of the Affordable Care Act (ACA) will provide many more Americans access to health care. The ACA will reduce the cost of receiving health care, while also enabling uninsured Americans access to insurance and more affordable healthcare. The Act will "promote prevention, wellness, and the public health" (Legislative Counsel, 2010, p. 463). Although the ACA will increase accessibility to primary care and prevention of diseases, there must be an adequate number of healthcare providers who can see these patients. The Association of American Medical Colleges estimates a shortage of 46,000 primary care physicians by the year 2025 (Rouston, 2010). Nurse Practitioners can easily step into the role of primary care. There are currently 150,000 nurse practitioners in the United States, and 5,500 practitioners graduate every year (Rouston, 2010). State legislatures, however, regulate Advance Practice Registered Nurses (APRN), and only 12 states currently have no restrictions for APRN prescriptive rights (Future of Nursing, 2011). For APRNs to fully care for patients at the primary care level, state legislatures must remove prescriptive restrictions throughout the United States. Nurse practitioners can and should help fill a void in providing primary care. As mentioned earlier, only 12 states currently allow nurse practitioners to prescribe medications without restriction; whereas the other 38 states require physician collaboration or restrictions on controlled substances (Future of Nursing, 2011). Patients routinely visit their family practice providers with concerns such as a sore throat, backache, or anxiety. The nurse practitioner is adequately trained, has completed a national certification examination, and possesses a license to care for these issues. However, only in certain states can these APRNs prescribe the necessary treatment for these patients. The practitioner may not be able to fulfill the need of the patient in states with stringent regulations limiting APRN prescription rights. In these states, the APRN must refer the patient to or consult with a physician to meet the patient's medical needs, thus delaying medical treatment. For example, a nurse practitioner in Florida caring for a patient with a persistent cough and sore throat cannot prescribe cough medicine with codeine for the patient's comfort (Nursing License Map, 2012). Therefore, the patient must see a physician to obtain a prescription for relief from a sore throat and cough, which both delays treatment and increases health care costs associated with a second visit. Patients will benefit from minimizing restrictions on prescription authority. Not only will patients have greater access to health care with less wait times; but patients will also benefit from continuity of care. This benefit is especially true in rural areas of the United States, where an even greater shortage of primary care physicians exist (Anguita, 2011). Another problem with the prescription restrictions for controlled substances is that nurse practitioners can care for patients receiving these medications but cannot adjust or prescribe the medications. For example, a patient with generalized anxiety disorder takes Xanax, a controlled substance, and visits her nurse practitioner for a physical examination. The nurse practitioner must take into account the effects Xanax has on her patient; however, she is not allowed to write for or adjust this medication. Furthermore, nurse practitioners have authority to prescribe significantly more dangerous medications. In the state of Florida, for instance, a nurse practitioner may prescribe a potassium replacement or Coreg, a cardiac medication. These medications, if taken inappropriately, can have fatal effects on the patient, such as lowering the patient's blood pressure or causing a fatal cardiac arrhythmia. To allow the ARNP the right to prescribe such dangerous medications but limit the use of controlled substances is not logical or appropriate (The Florida Senate, 2008). Nurse Managed Care Centers (NMCC) are prime examples of medical clinics that would benefit from lifting prescriptive authority constraints for APRNs. An NMCC offers primary care services, particularly in underserved and unemployed populations across the United States. These clinics promote wellness, disease prevention, and education for their patients. Three NMCCs exist in the state of Florida. Although most care centers have a collaborating physician who prescribes controlled substances, the physician's purpose at these clinics is also to collaborate with the nurse practitioners to maintain high quality care. This physician should not be hindered with his care because he prescribes medications the nurse practitioner cannot prescribe (Turkeltaub, 2004). Nurse Practitioners have consistently demonstrated they provide the same quality of care as physicians, but at a lower cost. In fact, in 2009, the average cost of a nurse practitioner visit was 20% less than a physician visit. The state of Massachusetts conducted a study to determine it could save 8.4 billion dollars over a 10-year period by increasing use of nurse practitioners. Patients who have greater primary care access to nurse practitioners will also benefit from cost savings associated with a reduced number of emergency room and hospital visits (The Cost Effectiveness, 2011). Unfortunately, this data does not account for the cost benefit of providing nurse practitioners full prescriptive authority. As it stands now, many nurse practitioners refer their patients to a physician for certain prescriptive needs. Physicians are among the majorities that disagree with releasing the restrictions for controlled substances prescribed by nurse practitioners. In fact, according to an article by the Sunshine State News, The Florida Medical Association stated that, "the ability to prescribe controlled substances is limited to medical doctors for a reason: to protect patient safety. Physicians go to medical school to learn how to prescribe controlled substances safely and without interacting with other medications. ARNPs do not" (Derby, 2010, para. 9). A Fort Worth, Texas physician, Dr. Gary Floyd states that nurse practitioners should attend medical school and receive additional training if they wish to have more responsibility and function independently (Ramshaw, 2010). A study published in the Journal of the American Medical Association; however, proves the assumption that nurse practitioners cannot provide adequate care and prescribe controlled substances false. This randomized study was conducted among medical clinics in states where nurse practitioners and physicians have the same prescriptive authority. The study determines if the outcomes of patients receiving nurse practitioner care or physician care differs. At the end of one year, the study proved that patient outcomes were comparable and no significant difference existed between the care provided by nurse practitioners and physicians (Mundinger, Kane, & Lentz, 2000). Another notable objection to granting nurse practitioners full prescriptive authority in all 50 states is the fear that doing so will increase liability claims. In a study done at the University of Central Florida, a researcher compared malpractice claims among physicians and nurse practitioners in states that allow full prescriptive authority and in those that have restrictions. The study researched malpractice claims from the National Practitioner Data Bank. In states where nurse practitioners have full prescriptive authority, including the ability to prescribe controlled substances, this study revealed that per 1000 nurse practitioners and physicians, the average rate of malpractice claims was seven claims per 1000 nurse practitioners and 234 claims per 1000 physicians (Chandler, 2010). Therefore, according to this study, the argument that increasing prescriptive rights for nurse practitioners would increase malpractice claims is not legitimate. In fact, according to an article by Kaplan and Brown (2004), liabilities may actually increase for physicians in states where the nurse practitioner does not have full prescriptive authority. Because of the restrictions, the nurse practitioner is not able to write for such medications as Ritalin for a child with Attention Deficit Disorder. Therefore, the physician may write prescriptions for patients with whom he may not be adequately familiar. (Kaplan & Brown, 2004). In conclusion, with the expectation for nurse practitioners to appease the primary care shortage, these practitioners must be able to meet the needs of patients. Regulating the APRNs ability to order such controlled substances as Xanax or Ritalin will not only inconvenience the patient, but will also diminish continuity of care. Nurse practitioners are more cost-effective than physicians, while continuing to provide the same quality of care. Time and time again, patient satisfaction and respect for nurse practitioners is extraordinary. The appropriate action for state legislatures is to remove prescriptive restrictions permitting nurse practitioners to provide the care they were trained to provide. Work-Cited / References Anguita, M. (2011, November 9). Leading the Way in Nurse Prescribing. Nurse Prescribing, 9(11), 526 529. Retrieved July 23, 2012, from CINAHL database Chandler, D. (2010). Comparison of ARNP and Physician Malpractice in States with and without Controlled Substance Prescribing Authority (Doctoral dissertation). Retrieved July 25, 2012, from http://etd.fcla.edu/CF/CFE0003212/Chandler_Deborah_C_201008_DNP.pdf Derby, K. (2010, March 24). Nurse Practitioners Rally, Hoping to Write Prescriptions. Sunshine State News. Retrieved July 23, 2012 Future of Nursing: Campaign for Action. (2011). Advanced Practice Registered Nurses. Retrieved July 23, 2012, from http://thefutureofnursing.org/resource/detail/advanced-practice-registered-nurses Kaplan, L. & Brown, M. (2004). Prescriptive Authority and Barriers to NP Practice. The Nurse Practitioner, 29(3), 28-35 Legislative Counsel. (2010, May 1). Compilation of Patient Protection and Affordable Care Act. Retrieved July 23, 2012, from http://www.healthcare.gov/law/full/ Mundinger, M., Kane, R., & Lentz, E. (2000, January 5). Primary Care Outcomes in Patients treated by Nurse Practitioners or Physicians: A Randomized Trial. The Journal of the American Medical Association, 283(1), 59-68. Retrieved July 23, 2012, from CINAHL database. Nursing License Map. (2012). Nurse Practitioner Prescriptive Authority. Rouston, J. (2010, November 2). The Future of Primary Care: Nurse-managed Health Centers. HealtheCarreers.com.
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I decided to become an ARNP because I knew it would be an empowering career. Although the work of an ARNP and Physician is similar, there are many differences. Physicians tend to use a scientific approach when addressing their patients, due to their rigorous science-based education. ARNPs approach the patient holistically. When I diagnose a patient with Diabetes Mellitus Type 2, I explain what this disorder is and the causes; I explain the treatment plan; I discuss nutrition and physical activity changes; I assess the patients comfort level with their treatment; I encourage the patient to discuss their feelings upon finding out they have this new chronic disorder; and I reassess the patient within a 2-4 week timeline. I am interested in making sure the patient understands their disorder and how they can manage it. Unfortunately, in Florida there are some limitations on the ARNP that allows physicians to have more power. For example, Physicians can order home health treatment,controlled substances, and open their own practices without having a supervisory protocol. It is frustrating that Florida is one of the few states that has such strong limitations on ARNP scope of practice. For example, ARNPs cannot order durable medical equipment for Medicare patients in Florida. This means I cannot order a low back brace for my patient with chronic low back pain; I cannot order diabetic shoes for my patient with DM Type 2; I cannot order a cane for my patient with Parkinson's. Moreover, ARNPs cannot prescribe controlled substances, including benzodiazepines that so many of my patients take for their anxiety or insomnia. Currently, I write out the prescription and my supervisory physician will sign the prescription. The only people suffering are my patients because this delays access to their medications. Recently,Tramadol was added to the controlled substance list. I had previously prescribed this medication frequently for my patients with chronic low backpain and severe osteoarthritis. I was not thrilled the day I received a phone call from the pharmacist telling me that tramadol was effectively now a controlled substance. In addition, ARNPs cannot order home health treatment. This does not make sense to me since I am the primary care provider for many patients and oversee their medical care. So if I have a patient with history of a stroke and hemiparesis, I believe I should be able to order home health physical therapy for them. If I have a patient with dementia and uncontrolled hypertension, I believe I should be able to order home health blood pressuremonitoring for them. Lastly, I do not like that ARNPs have to have a protocol with a supervising physician. It's as if the physician defines our scope of practice and not the state board of nursing. If I wanted to open up my own practice, I would need a physician to be the medical director. This means I would have to waste a few thousand dollars a month just to pay the physician for having their name on the wall of my clinic. I would be seeing the patients, overseeing the clinic, and reviewing charts, but would still have to pay my supervising physician to do nothing except 'supervise me'. I am hoping with the Affordable Care Act and the abundance of new people seeking primary health care, that Florida will increase the scope of ARNPs. Working with the ANA, FNA, and other nursing organizations, I plan to fight for these rights. I see myself having my own practice where I see a variety of illnesses and ages. I hope that the care provided will not be based as much on cost as it is today. We already know ARNPs will be a forefront to help with the primary care shortage.
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There are several additional points that I would like to make at this time. The concept of students finding and arranging their own preceptorships in advance nursing is an unsustainable and unethical one. For one thing, there is an unequal playing field in the process. Students that have greater access to medical professionals due to their previous experience or background will have a tremendous advantage in securing preceptorships. For instance, the son of an ICU physician would undoubtedly have almost no problems finding all his preceptors due to his father's connections. However, a first generation, aspiring nurse from a disadvantaged inner city that is pursuing an advanced degree will face significant difficulty securing preceptors. Furthermore, students, in general, have almost no leverage when trying to secure a preceptor. An advance practice student, being one of the lowest in the medical hierarchy, is in essence trying to get a highly paid medical professional (Physician, PA, NP) to teach him/her a skill or profession without any type of compensation whatsoever. The natural question is of course "Why would anybody want to do that?" And the answer to that question is that "hardly anybody" and understandably so. In addition, medicine is practiced in a highly regulated and litigious environment. Even if a student secures a preceptor (most likely due to personal connections), there are nowadays a myriad of institutional regulations by hospitals and clinics that provide significant hurdles. What kind of incentive does a hospital or medical clinic have to allow just anybody to walk through its door and provide that person with the opportunity of becoming a highly skilled professional? In the case of advance practice nursing, they have none. With the increased concentration and buyouts in medicine, many more practice environments are now regulated by big corporations. Mostly gone are the days, when a nurse could walk into the office of the local town doctor and ask him to train her. Now even the local office might be owned by XYZ Inc. which has regulations, and a lot of them. Certainly, the leaders of physician and PA programs understand this and that is why they arrange clinical experiences for their students. As nurses, we expect the same of our leaders. Unfortunately, our nursing leaders and schools have shortchanged us as students in the past, but this got to change. Most physicians and physician assistants express general satisfaction with their education. I haven't met many nurse practitioners yet that came to the same conclusion. As NP students we pay the university to provide a service to us - education. One of the most important parts of this education is the clinical experience. It is not sufficient for the university to charge tuition, write a plethora of rules about the clinical experience and to abandon students to find their own preceptors, knowing well that many will not succeed. Key Element III E of the CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (2013) states, "To prepare students for a practice profession, each track in each degree program and post-graduate APRN certificate program affords students the opportunity to develop professional competencies in practice settings aligned to the educational preparation. Clinical practice experiences are provided for students in all programs, including those with distance education offerings." It states, "clinical practice experiences are provided for students in all programs..." It does not say that students shall provide their own clinical practice experience. I believe that the CCNE should start enforcing this rule. Schools that are not willing or able to provide this most important aspect of NP education should not be accredited by CCNE. Obviously, this accreditation agency has lacked in enforcing its own standard in past times. However, I believe as an officially recognized national accreditation agency by the U.S. secretary of Education, it needs to step up to the plate and do its job. It is unfair towards the schools that follow the rules and provide clinical experiences when other schools skirt their responsibility, getting by with it. Our physician and PA colleagues have shown us that providing clinical experiences for their students is not that difficult and results in a superior educational experience. I thank you for your time and appreciate any constructive feedback.
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Certified nurse-midwives (CNM) are educated in the two disciplines of nursing and midwifery. They provide primary healthcare to women of childbearing age including: prenatal care, labor and delivery care, care after birth, gynecological exams, newborn care, assistance with family planning decisions, preconception care, menopausal management and counseling in health maintenance and disease prevention. CNMs attend a very small percentage of births in the United States. The CNM dates back to the early 1920's when Mary Breckinridge started a program in Kentucky using nurses from other countries. As the need for licensed professional nurses grew, programs started growing and now all CNM must be educated as RN's, complete a Nurse-Midwifery program, and become certified as nurse-midwives. Programs must adhere to the standards of midwifery practice in the United States as set forth by the American College of Nurse-Midwives (ACNM). The CNM works closely with Obstetricians and Gynecologists (OB-GYN physicians). They take on what is considered "low-risk" pregnancies. Should the midwife recognize the gravida is high-risk, he/she will consult and refer immediately to the OB-GYN. The majority of CNM work in hospitals and in poor, rural townships/cities. They also are employed in birthing centers and Health Departments. The role of the CNM has greatly enhanced the quality of healthcare for women in the past 40 years in areas where OB-GYNs are not available. Scope of Practice Physical Assessment Prescription privileges Education Referrals and consultations General health of women and the newborn General uncomplicated lady partsl birth of the gravida and immediate care of the newborn Regulation of the CNM The state Board of Nursing (BON) licenses the RN Only graduates of an accredited midwifery program are eligible to sit for certification as CNM CNM Education For the past several years, there has been much discussion about the education process for the APRN. Most APRN programs have moved to the Doctor of Nursing Practice (DNP) as the minimum entry into practice for Nurse Practitioners (NP) and the DNP or Doctor of Nurse Anesthesia Practice (DNAP) for Certified Nurse Anesthetists (CRNA). The Clinical Nurse Specialist (CNS) seems to follow along the same lines. According to the 2020 FAQ from the American College of Nurse-Midwives (ACNM): Educational Programs (not all-inclusive) Georgetown University School of Nursing and Health Studies - (MS, BSN to DNP) Texas Tech University Health Sciences Center School of Nursing - (MSN, Post Graduate Certificate) Baylor University College of Nursing - (Doctor of Nursing Practice-DNP) California State University, Fullerton School of Nursing - (MSN/Post-Master's Certificate) University of Colorado, Anschutz Medical Campus, College of Nursing - (MS, Post-Graduate Certificate, DNP ) Emory University Nell Hodgson Woodruff School of Nursing - (DNP, BSN-MSN, MSN or MSN/MPH, Post Graduate Certificate) Vanderbilt University School of Nursing - (MSN, Post Graduate Certificate) Differences between CNM and Lay Midwife The difference between the two is their training. Lay midwives are not nurses, rather, they're those who have had direct training in midwifery through self-study and the majority, apprenticeship. Some lay midwives later decide to enter into a Masters Nursing Program and combine Nurse-Midwifery with the program. A licensed midwife is sanctioned by her/his state after she/he passes a test administered by the state's medical board licensing division. Licensing requirements differ among states; some, like Oregon, do not require licensing at all. Lay midwives in eight states - Indiana, Iowa, Kentucky, Maryland, Missouri, North Carolina, Virginia, and Wyoming - and in the District of Columbia legally are not able to become licensed midwives. So while you may be able to have a legal homebirth in those states, a lay midwife could risk arrest by attending. Liability Insurance for the CNM Many Insurance companies will not cover the CNM. The following is one company that provides competitive premiums for the CNM and Midwifery Student. Contemporary Insurance Services Salary (2020) According to salary.com, the average annual salary in the U.S. is $110,963 with a range between $102,034 and $125,739. According to Glassdoor, the national average salary for a CNM in the U.S. is $106,576.
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The Certified Registered Nurse Anesthetist (CRNA) is an Advanced Practice Registered Nurse (APRN) who provides anesthesia to a wide variety of patients; from neonates to the geriatric population. Work Environment Most of the workday, CRNAs are in the operating room (OR) providing anesthesia to patients. There is a wide variety of OR settings. A CRNA can be in a level one trauma center with multiple ORs going many hours of the day. Or, a CRNA can be in a more rural environment where they might be the only anesthesia provider. Or, they could be active duty military deployed to some remote post providing emergent anesthesia in a war zone. Some other CRNAs work in research, pain management, office settings, and politics. With the advent of managed care on the horizon, opportunities are wide open for CRNAs to lobby on Capitol Hill. Other CRNAs teach and mentor. There are many opportunities for CRNAs. Some of the Steps Involved in Anesthesia Preoperative assessment which includes airway, need for consults/clearance from specialists, thoughts as to need for invasive monitoring Sedation, induction, advanced airway placement Maintenance of anesthesia to ensure patient safety Rapid Sequence Intubation (RSI) Extubation Postoperative visits to patients and families Qualifications CRNA school admission is very competitive. For most schools, a registered nurse will need at least one year (2 years preferred) of Intensive Care Unit (ICU) experience, along with solid letters of recommendation and an interview. Other qualifications might include specialty certifications such as Critical Care Registered Nurse (CCRN). Each school has its own nuances that go into the selection of CRNA candidates. Qualities All nurses need to be compassionate and caring. CRNAs need additional qualities (not all-inclusive): Affinity for "hard sciences" such as bio-Chemistry, physics, advanced pathophysiology and advanced cellular biology. (Each school has its own particular curriculum - this is just a general list). Confidence in their own ability to provide safe and cost-effective anesthesia. Ability to work with many different types of people, including attending physicians, nurses, techs and patients and families Must be able to explain complex medical concepts to patients and families in a way that they understand Professional Organizations The American Association of Nurse Anesthetists is the organization that represents CRNAs. This organization lobbies for CRNA specific legislation and develops policy, practice standards and guidelines. Education (not all-inclusive) Graduate from accredited Registered Nurse (RN) nursing program Successfully pass the NCLEX-RN Unencumbered, current RN license in U.S. state of practice Master's degree and more frequently, the Doctor of Nurse Anesthesia Practice (DNAP) or the Doctor of Nursing Practice (DNP). Certification As with other APRNs, the CRNA must successfully pass a certification test in order to use the title CRNA. The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is nationally recognized by the U.S. Department of Education (USDE) and the Council for Higher Education Accreditation (CHEA) as an accrediting agency for the "accreditation of institutions and programs of nurse anesthesia at the post-master's certificate, master's, or doctoral degree levels in the United States, and its territories, including programs offering distance education.” Graduates of a COA-accredited and approved school of anesthesia are eligible to sit for their National Certification Examination (NCE) through The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA). Here is a list (2020) of the COA-accredited/recognized Nurse Anesthesia programs. Salaries (2020) A CRNA can expect a starting salary in the 6 figures. Payscale The average salary for a CRNA is $152,222. salary.com The average CRNA salary in the U.S. is $130,527 and ranges upwards of $234,778. ZipRecruiter Average CRNA Salary by State.
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After thirty years psychiatric nursing experience in various roles, locum tenens is perfect for me. When I want to work, I sign up with a few agencies, tell them my availability and hope something will come through. This time I can only work in 2 month blocks- a normal assignment is three months so I was not sure anyone would take me for only two months. Luckily my recruiter found me a spot. "The position is in corrections." She said. My husband was immediately worried about my safety. I had my interview and I found out the facility was a forensic hospital, not a correctional setting and that I would have inpatient responsibilities. I have many years of inpatient experience working as a staff nurse and a manager. This will be my first inpatient experience as a provider. After a week of orientation mostly about HIPAA, and using the computer system, I start on the units. I have two inpatient units and one 4 hour block of outpatients. I am on transition units where patients are preparing for discharge to the community. They work at least 15 hours per week at on campus jobs, go to groups, and have privileges to go outside, some alone.. For admission to the facility patients are committed by a judge as mentally ill and dangerous. Many of these patients have caused harm to other people, usually when they were not taking medications or were abusing substances. The average length of stay is seven years and the patients home community has input into advancing privileges and determining discharge. My role is to do a psychiatric interview and review psychiatric medications at least every three months on my assigned units. On the inpatient units, this is called "rounds". Patients are invited in one at a time by appointment. Several staff are in the room to observe or participate in my interview. I have never interviewed patients like this before. One of the social workers told me she likes to come in the room to make sure the patients are giving me the correct information and this can be helpful. A pharmacist is there also, to take notes and sometimes participates. I try to talk to her before or after my time with the patient so I am not distracted by medication information during my interview. Since I am doing the assessment and making the medication decisions, I have to make sure I am comfortable. I also put in my own orders which is a change for them. Because of the cumbersome computer system, previous locums had operated using mostly verbal orders which were inputted by either the nurse or the pharmacist. There is a shortage of psychiatric providers at this facility. Systems like the pharmacist taking notes, which are minutes of the interview, and verbal orders are a way to provide some continuity and compensate for the shortage. I am the sixth psychiatric provider in two years. They are recruiting and in the meantime I learn a lot. The main things I learn about are high dose neuroleptics, polypharmacy, and clozapine. Traditional psychopharmacology tells us to streamline medications. With these patients, it is not entirely clear if patients could do as well on lower doses or if they need the high dose for stability. There also seem to be a lot of negative symptoms of schizophrenia, ie poor motivation, blunted affect, which one of the psychologist says is not treatable with medication. My research tells me medication is worth a try but I am not there long enough to introduce this. I wonder if some patients are overmedicated but I am reluctant to adjust doses very much because of being new, unless, of course it was clearly indicated. And I become proficient in laboratory guidelines for long term medication monitoring. Every patient has a primary MD who has been treating them for years and each patient gets a comprehensive physical every year. These MD's are readily available for consultation. The pharmacists are also available for consultation and also seem to like attending my rounds. There are also other professionals including psychologists, social workers, nurses, and security counselors. I found out later that there are some psychology fellowship classes I could have attended if I had known about them. I am scheduled to return to this facility in a few months. Locums gives me the opportunity to learn. When I return, I look forward to getting a better understanding of high dose neuropletics and polypharmacy and I may try to medicate negative symptoms . Or since I now know the system, I may be assigned to an acute admission unit where I will learn about rapid titrations of psychiatric medications and ordering seclusions and restraints. If I come back to this unit, I will better be able to treat the patients since I have interviewed everyone at least once and have the trust of some of the staff. Forensic psychiatry is not a popular area of psychiatry. Many of these patients are severely and persistently mentally ill and have crossed the line into criminal activity. They are well care for at this facility as the long term psychiatric patients which they are. Many of them will never be able to live in the community. In the old state hospitals and if they hadn't committed a crime, many of these patients would have stayed for years living in a community within the hospital. Some may have been discharged to group homes with case management. Some of my forensic patients may also be discharged. Evaluating stability, degree of outpatient containment and likelihood of relapse is very challenging and the focus of much of their treatment.
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Well...the title says it all: when do you know its time to move on? There are lots of reasons but here are some of the more common ones: Poor hoursLots of callLow compensationToo much work to do in the time allottedJust don't like it anymoreBurnt outSometimes the job isn't what was promised with regards to patient load, hours involved, call or something else. Other times, the practice might be poorly managed. Communication is always a two-way street - very important that administration has good skills in this department so that the APRNs can function in their role. Another issue can be collaboration with co-workers, physicians. This can happen for a number of reasons, some fixable, others not so much. If you are the first APRN the practice has hired, the physicians might not be used to working with APRNs and this can cause friction between MD-APRN. For experienced APRNs, its usually not one incident but rather a culmination of multiple incidents. The considerations for experienced APRNs wanting to change jobs can involve more thought as there usually is an increased comfort level that comes with years in the same position. Usually when you are hired into an APRN position, there is a round of interviews and sometimes a shadowing experience. Even with all of this, there can be situations that are not anticipated: Speciality turns out to not be interesting to youPatient load could increase to the point of being intolerableDisinterest in the actual day to day jobCall schedule is not as it was explained pre-employmentFor more experienced APRNs, the decision to leave a long term position is difficult. You are giving up the familiar environment, familiar co-workers, physicians, and sometimes patients. You may be at the top of the totem pole with respect to pay, PTO, and other benefits. However, even for very experienced APRNs, there can be the make or break situations. Or...it can just be the culmination of several issues that lead to global unhappiness. Is the job salvageable? Hmmm...well if a 10% raise would convince you to stay, its worth asking for it; especially if you can prove you are underpaid. Is the call schedule untenable? Maybe negotiating that aspect of employment would keep you at your current job. Co-worker strife? Again, maybe negotiation, a frank sit down talk is in order. However, maybe the job is just not salvageable....yikes...now what to do!? So...you've now made the decision to leave your position. First, find another job before quitting your current one. This can't be over-emphasized. Nothing raises red flags to HR folks more than a lapse in employment. It can appear that you are flaky, irresponsible and its just plain not smart. Don't burn bridges - it often comes back in the weirdest ways. Second, give plenty of notice - being APRN is not a two-week notice job for most of us. Its not unreasonable to give 30,60,90 days. It does take awhile to get someone new hired and oriented. Also, if you have a non-compete or some other type of contract - make sure you read it in its entirety to ensure you are in compliance. And last...leave gracefully: Make an in-person appointment with your boss and tell them face to face you are leavingFollow this up with an official letter of resignation; giving the date of your last workday.Most important of all, thank your current employer for the opportunity to work for them and learn.So...now you've done it! You've quit your current job AFTER you have obtained a new one and you are off and running and excited for the future.
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The term Advanced Practice Provider ("APP") has usually been limited to advanced practice registered nurses in a medical context. I believe recent trends and the efficacy of care is starting to really contemplate what that term can mean in surgical care. Nurses that go on to pursue advanced degrees such as an Acute Care Nurse Practitioner ("ACNP") bring years of high-stakes critical care knowledge and a level of independence that can only be accretive to the performance of a surgical team. As they progress in their abilities to manage the critically ill, why should that stop at the O.R. doors? I firmly believe that in the next 5 - 10 years we are going to see something that already has momentum start to really take effect, and that is the use of APRNs, ACNPs, and other advanced-level nurses take a larger role in the Operating Room as first assists. I think it is very exciting that UAB is offering an ACNP program with an RNFA certification. I work with some wonderful surgical PA's, but there is a gap between the model in which they've been taught and the nursing model + nursing experience. There are tremendous synergies that can be obtained by having someone like an ACNP be involved in the full lifecycle of acute care surgery - from consult to pre-op to first-assist to recovery. I think a lot of institutions are starting to see that...and patients want it. Continuity of care is often discussed as important for patients to follow. Well, I think it's equally important that healthcare professionals reciprocate that continuity. Historically, NPs haven't really pursued intraoperative roles, and I think many want to [I acknowledge some do not]. So, I think it's time that they receive the appropriate training to become valuable members of the intraoperative surgical team. I think they bring a wealth of knowledge to very complex cases and can take what they see on the table and help calibrate the recovery off of what they see...not off of an operative dictation or chart. There's an amazing article about an ACNP / RNFA named Trisha Hutton who is living this new reality as a Cardiothoracic Surgery First Assist and I think her interview provides an invaluable backdrop as to why this is not about 'personal interest', rather, 'in the best interest of the patient.' It has truly inspired me to reach further, explore more possibilities, and take pride in the experience of nursing that cannot be taught. We are the lucky few who have been in the trenches working as partners with residents, fellows and attendings before and after surgery, so why should we be left out of the middle part - "during surgery". As a teenage cardiac surgery patient, I got to know my advanced practitioner nurse very well - she was the glue of my care. When I asked if she would be able to help me in the Operating Room, she said, "no, there are plenty of amazing hands in there to heal you." And she was right, but is that right? Being a patient and now working on a cardiac surgery team, I understand the value of these amazing nurses who can do everything, but aren't often given the opportunity to prove just that. The debate between going to nursing school and eventually becoming an NP versus going to PA school is often debated. But, they shouldn't be. Nursing is a very special and unique experience, and we need to show others why that experience is valuable in ALL aspects of care...including in the Operating Room. PAs may be able to assist in surgery, but can they care for post surgery acute care patients after? Would it be beneficial if there was a practitioner that had the aperture to bridge the two? I think undoubtedly the answer is, 'yes it would be.' Advancing a profession is not about crossing lines of proficiency. Advancing a profession is educating others about the value of proficiency that inherently exists.
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Hi everyone, I am a practice manager for one doctor and 4 nurse practitioners (all NPs part time- most work 1-2 days per week for example. This is their choice because they all like the flexibility and down time. We have accommodated very unusual schedules specifically on their behalf and are happy to do so.) My question is this: what is the ethical standard for an APRN for patient commitment and shift abandonment? I am struggling with one NP who continually makes up a questionable reason to not do her 5 hour shift and sticks the doctor with a double schedule. Her view is that he can just cover for her, which is not always possible (nor is it fair). This is a physician who is extremely kind and supportive of the NPs and gets taken advantage of continually (by people who are takers of course- there are people who understand and nurture the relationship in spite of his being a big bad MD who is of course the enemy in every instance *eyeroll*). Without making this person feel that I am somehow demeaning her because she is an NP instead of a doctor (this has never come up, EVER, but NP's seem to have an obsession about this) how can I make it clear that sticking the patient schedule to the doctor is not doctor-level-pay acceptable and professional? Our NPs are all 6 figure earners. Or is this considered acceptable (I.e. shift work- oh well, not my shift, if I can't be there I will just let the management worry about it a la Wendy's or McD's)? Is this considered part of the ethical standard for the advanced nursing degree? It is absolutely not considered acceptable for any DO/MD. Thanks so much for any ideas!
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While I love the Christmas season and truly look forward to it every year, I also feel a bit of relief on those last days of December. The several weeks prior were filled with decorating, gift shopping, baking, holiday excursions, and entertaining. But now the gifts and baking supplies are put away, the parties are over, and there is a calm in the house. It is now a time for reflection, resolutions, and goal setting. I love evaluating the past year and making plans for the next. It gets me excited for the potential I have in my career as an APRN. So every late December, I sit down and think about my role. I work at one of the local universities in the student health center. A typical day is spent in the clinic seeing acute complaints, such as URIs, UTIs, and STIs. While I am happy with the previous year and have seen progression in my career, I know that there are things that I can improve upon. Below are some of my intentions for the new year. 2022 Professional Goals and Resolutions Smile The clinic can be bustling at times, and this can cause me to feel overwhelmed with trying to stay on schedule and keep up with charting. This affects my demeanor: I enter the room and get right to the point, asking questions and typing away on my laptop, appearing distant and rushed. I know this is not the best way to interact. My first goal is to slow down, provide eye contact, and smile, no matter how busy I am. Making the patient feel comfortable is the first step to a successful encounter. Address Mental Health The pandemic has brought to light the depression and anxiety that agonizes much of the population. The college student population is specifically vulnerable to mental health disorders. The transition from living at home to a college dorm can be very challenging. Being away from family and friends can make them feel alone and with a lack of support. While many students adjust well, some may need extra guidance. We know as nurses that many with depression or anxiety do not outwardly seek help and so the college health center can and should be a check-in point for emotional health. Asking each student a couple of quick questions is a way I can help to identify vulnerable students and provide them with our counseling centers information. Research When it comes to determining a treatment plan, using evidence-based medicine guidelines is the standard of care. My goal is to research anything I am uncertain about and confirm that the planned course of action is a "best practice." I will do this by collaborating with fellow practitioners and referring to reputable resources. I like to use UptoDate, Merck Manuals, Medline, and Medscape. Stay Up To Date The medical industry is constantly evolving. It takes a lot of effort to keep up with research studies and other health news. But I know that being up to date is an important aspect of caring for patients. For this goal, I will be subscribing to journals and medical news websites. I will set aside at least 15-30 minutes per day to read through the latest news and studies. To make it easier, I will subscribe to hard copies of these journals and put them on my coffee table as they come through the mail. If I see it, I will read it. Some journals that I plan on looking at are The Nurse Practitioner, The Journal for Nurse Practitioners, The New England Journal of Medicine, The Journal of the American Medical Association, and The Lancet. Be More Confident I tend to doubt myself. I guess you can say I have imposter syndrome. But I need to learn that if I use my education and experience and follow the guidelines, I am most likely providing the appropriate care to my patients. I will do my research, collaborate if needed, and make evidence-based decisions. And I will be confident with my course of action. Reflect As I sat down to reflect on the year I tried to think of a particular patient that stood out to me. I tend to see a lot of the same complaints over and over again and so I wanted to think about different scenarios - something that I learned something new from. It was hard! I just couldn't remember many of them. But I know they were there. And so that's why this year I want to write about them, of course, while protecting their private health information. I hope to take notes of those "different " patients and reflect back on them throughout the year. Hopefully, this will contribute to my learning even more. There they are - my professional goals for 2022. I am excited to see where the year takes me. Did you make any goals for 2022?
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What's the least saturated specialty in APRN?
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Hi everyone, I would love to connect with any other NPs or get any suggestions anyone may have on specializing in the field of nutrition. I worked as a primary care provider for many years until I pretty much burned out, and have realized that my interests have always been more concentrated on prevention than managing chronic diseases in 15 minute office visits (which is most of primary care in my experience). I have a strong interest in plant-based nutrition, and would love to focus my career on providing health education to clients on this topic. I have searched high and low, and have been unsuccessful in finding any programs for licensed APRNs or other medical providers to get some credentials in plant-based nutrition. There is the eCornell T. Colin Campbell program, though I believe this course is open to anyone and I'm not sure if it would allow me to create the role I am thinking of (though if someone has experience with this program I would love to hear from you!). I am the primary breadwinner in my family, so I do not have the option of going back to school full-time to become a registered dietitian given how vigorous the program requirements are. The role I am imagining for myself is one in which I obtain clients motivated to improve or reverse chronic disease through diet and lifestyle modification, but I would rather work in conjunction with their PCPs than be the PCP myself. Any ideas or recommendations would be most appreciated!
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On May 2, 2023, Georgia Governor Brian Kemp signed into law a bill part of a larger act called the Health Care Practitioners Truth and Transparency Act. This bill, SB197, though notably missing from the 5/2/2023 press release highlighting recently signed legislation designed to improve access to healthcare in Georgia, has added fuel to an ongoing debate in the healthcare community as it prohibits non-physicians from using specialty titles. The bill summary reads as follows: “…relating to general provisions relative to professions and businesses, so as to prohibit deceptive or misleading terms or false representations by health care practitioners in advertisements and representations; to prohibit the misappropriation of medical or medical specialty titles by health care practitioners in advertisements and representations; to provide for definitions; to provide for related matters; to provide for a short title; to repeal conflicting laws; and for other purposes.” The actual bill can be read here. Related: Georgia law prohibits DNPs from using the term "doctor" Effective July 1, 2023, advanced practice registered nurses (APRNs) and physician assistants (PAs) who possess doctoral degrees can no longer introduce themselves as "doctor.” During patient encounters, APRNs and PAs must also advise patients that they are not medical doctors or physicians. Violations of this law place the offending APRN or PA in jeopardy of legal action or other injunctions to be taken by their respective professional licensing boards. While transparency in healthcare should be at the forefront of patient-centered care, and patients should be educated on the differences in providers' scopes of practice, it's important to do so in a way that does not diminish the valuable contributions of other professions. Coincidentally, there are many similarities to be recognized between Nurse Practitioners (NP), Physician Assistants (PA), and Medical Doctors (MD). To name a few, all are trained to diagnose and treat illness, and all can prescribe similarly. They each bring a unique skill set to the interdisciplinary care team, however. NPs, for example, have full practice authority in some states, which means they can practice completely independently without physician oversight. PAs cannot but do have more formal medical education in their coursework than NPs. NPs can also be first assists in surgeries like PAs and tend to specialize, while PAs tend to work with a larger general population. Typically, even though their duties intersect, NPs, PAs, and MDs do distinctly identify themselves and their credentials with identifying badges. Many doctorate-prepared NPs also introduce themselves to patients as such—saying something like, "Hi, I'm Dr. X, the Nurse Practitioner.” Though healthcare providers strive to provide clear patient education, there is some degree of accountability that should be shifted onto the patient in understanding the members of their healthcare teams. In a time when there is a critical shortage of all healthcare providers and workers, unity amongst the profession is vital. This law, whilst pitched as a patient advocacy law protecting patients, has inadvertently worsened the already deep divide between healthcare providers. Other states are taking note of this new Georgia law and may be enacting their own similar legislation. Curiously enough, Georgia is one of only 11 states in the United States in which NPs have restricted practice authority. Will a law like SB197 combined with already restrictive practice authority cause APRNs to no longer pursue the DNP or stop practicing in Georgia altogether? In the United States, Doctor of Nursing Practice (DNP) program enrollment is on the rise nationwide, as it was decided by the American Association of Colleges of Nursing (AACN) back in 2004 to change the requirements of APRN practice from the master's degree to the doctorate level. And in a time where many professions, especially APRNs, are pursuing terminal degrees, should "doctor" be redefined? Only time will tell. References/Resources Gov. Kemp Signs Legislation Strengthening Healthcare Access, Supporting Healthcare Heroes, and Expanding Assistance to Expectant Mothers Georgia blocks nonphysicians from using specialty titles The linguistic controversies of clinical titles Senate Bill 197 By: Senators Hufstetler of the 52nd, Watson of the 1st, Butler of the 55th, Kirkpatrick of the 32nd, Kennedy of the 18th and others; SB 197 "Health Care Practitioners Truth and Transparency Act"; enact AACN Fact Sheet - DNP 23 SB 197/AP S. B. 197 - 1 - Senate Bill 197 By: Senators Hufstetler of the 52nd, Watson of the 1st, Butler of the 55th, Kirkpatrick of the 32nd, Kennedy of the 18th and others Use of Terms Such as Mid-level Provider and Physician Extender State Practice Environment: AANP A Public Health Crisis: Staffing Shortages in Health Care: Master of Public Health (MPH) Online: The University of Southern California
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Let's Celebrate National Nurse Practitioner Week I became a nurse practitioner (NP) in part because I received excellent care from one years ago. I imagined myself helping others in a similar way, giving back to society by providing the kind of comprehensive, individualized, health care that had been so helpful to me personally. Little did I know that my work as an NP would put me on the front lines as the healthcare industry experienced a sea change in response to an aging population and the advent of new technologies. You likely already know that NPs are registered nurses with additional education, at the masters or doctorate level, which allows them to diagnose and manage acute and chronic illnesses, prescribe medications, and order diagnostic tests and treatments. NPs also routinely integrate health promotion, disease prevention, counseling, and patient education to help patients understand the big picture of their overall health. This comprehensive approach to whole-person health is particularly useful in a population that is aging and plagued by chronic disease. Some 75 million baby boomers will become senior citizens over the next decade, and 50 million of them are expected to have multiple chronic conditions. According to a 2012 Economist article on the future of medicine, the health problems of the 21st century cannot be resolved by 20th-century approaches. The article also points out that because trends in medical education have consistently emphasized treatment of communicable diseases and acute injury, many of today's physicians are often not adequately prepared to care for patients with chronic conditions. An additional factor is that physicians graduating from medical school today do not often choose primary care or family practice as a career focus. Nurse practitioners are filling these gaps. According to the American Association of Nurse Practitioners (AANP), 234,000 NPs are currently licensed in the United States, and some 23,000 NP students graduate each year. The NP role emerged in 1965, primarily as a response to manage an existing and anticipated physician shortage. Although the role of NP has existed in the United States for more than 50 years, evolving and responding to the needs of a changing population and industry, not everyone in healthcare or the public fully understands the role of a nurse practitioner. Here are some facts about NPs that are worth knowing: The biggest difference between a medical doctor, a PA, and an NP is educational philosophy and background NPs are NOT physicians, nor are they physician assistants; NPs did not go to medical school. Nurse practitioners are nurses first, which means their academic training is based on the nursing model, a fundamentally different way of thinking, distinct from the medical model under which physicians and physician assistants are educated and trained. Accredited nurse practitioner program curricula builds medical model concepts on top of a nursing model foundation. Some NPs may be doctorally educated Nurses who have earned a doctoral academic degree may be referred to as "doctor," even though they are not educated as physicians and did not attend medical school. This is not meant to be confusing to patients or colleagues, but sometimes it can be. Licensure requirements for NPs vary from state to state Although there are national certification exams for NPs, specific licensure requirements for NPs vary widely from state to state. NPs are able to diagnose and prescribe in all 50 states, with the ability to do so independently of physician oversight or prescription sign-off in 22 states and the District of Columbia. NPs may be specialists Beyond primary care, nurse practitioners may choose to further their education in oncology, gerontology, pediatrics, psychiatry and other specialty areas. NPs represent one type of advanced practice nursing role Other advanced practice nursing roles include nurse midwives, nurse anesthetists, and clinical nurse specialists. Each advanced practice role has its own specific educational, licensure and certification requirements. The fact that the NP role is built on the nursing model is the key to the value of NPs in the changing world of healthcare. The nursing model is holistic and humanistic at its core, providing an ideal foundation on which to integrate the more reductionistic medical model approaches. An integrative approach that marries systemic thinking with mechanistic techniques will be needed to navigate the future trajectory of medicine. Recall that the nursing model is uniquely comprehensive and holistic because it addresses the patient's response(s) to health threats and treatments, both current and potential. As emerging technologies such as genome analysis, artificial intelligence, and wearable digital devices democratize individuals' access to medical data, an educational, humanistic view of how technology impacts health will be in high demand. As such, the nursing model provides an ideal foundation for graduate-level education, positioning NPs perfectly to integrate emerging technologies, such as genome analysis and digital informatics (wearables) into the next generation of healthcare delivery. Whether you are already an NP, studying to be one, working with one or receiving care from one, take a moment this week, to consider the role of the NP. Ultimately, as health care continues to change, NPs will continue to provide high quality cost-effective, personalized health care - on the front lines, as part of a collaborative team in partnership with healthcare professionals at all levels. The AANP is the largest professional organization for NPs of all specialties in the US, and promotes National Nurse Practitioners Week each November to showcase the NP role. The aim of NP Week is to acquaint local citizens with the role of NPs as providers of high-quality, cost-effective, personalized health care and to highlight the value of NPs. NP practice offers a unique combination of nursing and health care service to patients. For more information, visit AANP.org. Questions for Discussion What has been your experience with nurse practitioners-working with them, receiving care from them, or even studying to become one? Sources and Resources Expanding the Role of Advanced Practice Nurses - Risks and Rewards Historical Timeline National Nurse Practitioner Week Resource Guide (AANP) The Nursing Site Blog: The Nurse Practitioner Will See You Now What's an NP? Why NPs are Important Squeezing out the doctor | The Economist The impact of the medical model on nursing practice and assessment - ScienceDirect
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NURSE PRACTITIONER HISTORYWhen Drs. Loretta Ford, RN and Henry Silver, MD developed the first NP certificate program in 1965 it provided experienced registered nurses (RN) with the additional training to work in pediatric primary care settings collaboratively with physicians to manage acute and chronic illness (American Academy of Nurse Practitioners, n.d.). Drs. Ford and Silver believed that majority of the healthcare needs presenting in pediatric primary care settings could safety be overseen by nurses with advanced training in physical assessment, pathophysiology, pharmacology, and disease management. After creating the program at UC, Dr. Ford continued to work to develop the NP role and advocate for its implementation throughout the country. Since the NP role began, education has evolved from certificate to graduate degree programs and now includes acute and primary care specialties serving patients across the lifespan. NPs work in clinics, community settings, hospitals and private offices; some work completely independently while others work collaboratively in multidisciplinary treatment teams. Even with all of the progress achieved in advancing the NP role, debate continues regarding the necessary education and training required for NPs. Some of the biggest points of dispute include minimum number of clinical practice hours, degree for entry to practice, prerequisite RN experience, and necessity of post-graduate residency/fellowship training. In this two-part series I will discuss each of these topics and offer my take on what is broken within the current system and then suggestions on how we can improve it for future practitioners. Please keep in mind that these are my opinions and do not reflect the views of any college/university or professional organization. This is not a critique of any specific education program but rather a general commentary about NP education in the United States with the hope of starting an open and productive dialog between members of this forum. EDUCATION SYSTEM PROBLEMSThe first NP programs were designed to build upon the practice of experienced nurses but as time has marched on we have seen the emergence of new educational formats including online and accelerated programs. Students can now complete NP programs in online classrooms from anywhere in the world and non-nursing professionals from a variety of backgrounds can join our field through accelerated degree programs. Utilizing new educational tools and alternative paths to entry are important to remaining current but these methods present challenges for maintaining quality standards and the "nurse" identity of nurse practitioner. Studies have found that having previous clinical experience as an RN was not associated with improved academic success or stronger clinical skills as a new NP (El-Banna et al., 2015; Rich, 2005, Rich & Rodriguez, 2002). While I won't debate that non-nursing professionals can effectively complete accelerated programs and become successful NPs, I believe that these NPs miss out on critical socialization aspects of being an RN and are less likely to identify with the "nurse" aspect of being a nurse practitioner. Another issue that comes under frequent discussion is the variation of clinical practicum hours that NP students have to complete depending on their program. The Commission on Collegiate Nursing Education (CCNE) mandates that programs have a minimum of 500 direct patient care hours but offer few other specific guidelines (2016). A review of programs from around the country, the average number of clinical practicum hours range from 500 - 1000 hours when a masters degree or post-graduate certificate is conferred and 750 - 1250 when a doctoral degree is awarded. At first glance, one might assume that the higher clinical hours associated with completing a doctoral program would mean more direct patient care hours but in most circumstances the additional hours are for the completion of a capstone quality improvement or research project. This has come under serious discussion as it has been suggested that the entry degree to practice be changed from the Master of Science in Nursing (MSN) to the Doctor of Nursing Practice (DNP). The idea of raising education requirements and improving scholarship is good in theory but many question the "value add" of the DNP degree for NP when the additional clinical hours required for the degree are not typically related to direct patient care but are instead focused on a quality improvement or research project. The purpose of this article is not to debate the merits of a particular degree but to consider its value specifically as it relates to improving the ability of a NP to provide direct patient care as a clinician. Another major hurdle for many programs is securing appropriate clinical sites and preceptors. Many prospective NP students and healthcare professionals outside of nursing are unaware that in a number of programs it is the responsibility for students to find their own preceptors and clinical sites, which is challenging and results in unnecessary delays for program completion. For the more programs that take the responsibility of matching students with preceptors it can still be difficulty because most nursing programs do not pay experienced practitioners a stipend for having a student work with them and instead rely on volunteering and offers of continuing education credits or course credit at the affiliated college/university. In this writer's opinion, forcing students to find their own preceptors is inappropriate and contributes to a lack of standardization in quality education. Also, by not offering some form of financial compensation or stipend to preceptors it sends the message that the preceptor's time is not valuable and the education of NPs is less valuable than physicians or physician assistants (many PA and medical school programs provide financial compensation to preceptors for their time working with students). In the next segment I will discuss some problems seen with the modern graduate student and then provide a "prescription" for how fix a broken system. My question for the readers is, do you think that any major change is needed to this system at all? Do you feel that most NP programs are successfully producing graduates who are fully ready to assume the NP role in our current healthcare landscape? Or do you think that a majority of the issues are due to problems in education programs, healthcare institutions, and to a degree, the students themselves (e.g. professionalism, behavior, experience, expectations)? REFERENCES American Academy of Nurse Practitioners. (n.d.). Historical timeline. Retrieved from AANP - Historical Timeline Commission on Collegiate Nursing Education. (2016). Frequently asked questions: Clinical practice experiences. Retrieved from American Association of Colleges of Nursing (AACN) > Home El-Banna, M., Briggs, L. A., Leslie, M. S., Athey, E. K., Pericak, A., Falk, N. L., & Greene, J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5), 276-280. doi: 10.3928/01484834-20150417-05 Rich, E. (2005). Does RN experience relate to NP clinical skills?. Nurse Practitioner, 30(12), 53-56. Rich, E., & Rodriguez, L. (2002). A qualitative study of perceptions regarding the non-nurse college graduate nurse practitioner. Journal of the New York State Nurses Association, 33(2), 31-35.
