Should DNP's be able to practice on their own? How do you feel about midlevel encroachment

FranFNP13 · Jan 24, 2017

jaycam, ASN, RN, please consider that this is not a comparison of apples to apples. Nursing and medicine are two separate houses on the same block. Working as a CNA, practicing as an LPN/RN are vastly different from having the responsibility and practicing as a NP. RN's who go on for advanced practice have at least a BSN-bachelors in nursing which involves taking chemistry, anatomy/physiology, biology in addition to core nursing courses. Would-be physicians can enter medical school provided they meet the criteria, with any bachelor degree. So in truth the student nurse begins working with patients in school from the first semester, and the medical student begins clerkships in year three I believe which involve hundreds of hours per semester. Upon graduation and completion of boards, the RN will work with patients in that role. Some choose to return back to complete graduate level course work in advanced pathyphysiology, pharmacology, physical examination, etc. After approximately 500 clinical hours, coursework completion and a graduate degree, the NP will be certified to work with the population in which they specialized. The physician becomes an intern after graduating from medical school, and must complete additional training, thousands of hours, before they can work independently. Now the practice of the NP and MD/DO share some similarities, they cannot be compared equally. Just because a physician can take a BP and talk to a patient, they are not a nurse and just because I can diagnose and treat infectious mononucleosis as a NP, I am not a physician. Each specialty-each house-brings their own set of knowledge and skills to the party in the service to the patient. They can't take our board exams, and we can't take theirs unless we complete the specialty training involved with each distinct profession.

And BTW-the DNP is a degree, not a role. A nurse who holds a DNP, but is not a nurse practitioner, cannot do what nurse practitioners do. As nurses we need to be more proactive about what we call ourselves and clear about what that means. But that is another thread...

Please forgive any unintentional inaccuracies in my depiction of medical students/physician education.

JellyDonut · Jan 24, 2017

i sort of lean towards the supervision of PA/NPs and that is for two reasons.

1. The flood of NPs being mass produced my online programs where anyone who can figure out how to click a mouse will receive a degree in the mail. Do not get me wrong I am sue the online programs are full of RNs with years of experience who have even read most of their power point slides required by their online program, but is this who we want released to "practice" without supervision on the public?

2. I have seen too many "experienced" NP/PA start to believe they are equal to MDs. I mean these individuals become over confident in what they can or should be doing. Prescribing outside the guidelines or performing procedures that should be done by someone with more skill. I see this often in family practice where guidelines are ignored and the NP prescribes medications that can actually cause harm instead of referring the patient. In the ED I have seen PAs who think they know more than their physicians - scary! and that is why my kids will never ever ever be seen by a midlevel.

I can even see a model where new NPs are supervised for a period of time and then allowed independent practice, but peer review would need to be in place for all of us. Bottom line is it is not about us but the overall safety and best practice for our patients.

Aromatic · Jan 24, 2017

the lack of standards will soon catch up to us nurse practitioners. We all know the lawsuits will start pouring in the next few years when some of the major no nos are bipassed due to lack of training. It is just a ticking time bomb and I am sure the law offices have recognized this for their own monetary gain. More than likely we will start seeing commercials comparing physician and NP education on law commercials touting on potential malpractice claims.

If I was a lawyer and knew what I currently know I would have a whole business model in place for it, and waiting for the dollars to roll in.

Jules A, MSN · Jan 24, 2017

the lack of standards will soon catch up to us nurse practitioners. We all know the lawsuits will start pouring in the next few years when some of the major no nos are bipassed due to lack of training. It is just a ticking time bomb and I am sure the law offices have recognized this for their own monetary gain. More than likely we will start seeing commercials comparing physician and NP education on law commercials touting on potential malpractice claims.
If I was a lawyer and knew what I currently know I would have a whole business model in place for it, and waiting for the dollars to roll in.

Makes me shudder but I think the saving grace is that the physician's organizations who watch us like a hawk aren't even aware of the shoddy standards that are common now, the public adores NPs because we hold their hands and make them feel special even if we suck and I'm sure the lawyers are oblivious to all of the above. Would be a cluster if it did break loose though.

Aromatic · Jan 25, 2017

ah man we shoulda went to law school. maybe we can start a nurse witness business and contract out with lawyers ha

Darth Practicus · May 8, 2017

I live/work in a state where NPs are supervised, but I do not feel like I am supervised. They see their own patients and I see mine. They will tell me if they see something particularly interesting just to share, but never get involved with any decisions or care provided. They are available for questions and generally tell me what they may do, but always express that it is my decision how I treat. I enjoy being part of a group and learn so much from them but never feel restricted by my states approach.

Ollie, I work in a collaborative practice state as well and I share in the experience you describe. I am certainly not made to feel inferior. If anything, my MD is a great resource to have because he may provide some perspective I did not get and vice versa. An example that comes to mind is a patient I saw in the office a couple weeks ago as a new patient. The patient reported that he was experiencing rectal spasms that seemed to only occur when he was not focused on a specific task or concentrating on something. When his mind went idle, he felt some feelings of anxiety and the rectal spasms. In the interview, he denied any back problems, injury, etc. I did learn that he was a victim of sexual abuse as an adolescent. My experience led me to think outside of the box to include both a medical disorder AND a psychological disorder of PTSD. My collaborator had only thought of the medical issue and thought I should refer to GI. So, it goes both ways in my collaboration. And honestly, I'm blessed and thankful.

I know that my personal experience does not constitute the entirety of what my colleagues may experience in their own practices. I have heard of some pretty terrible stories out there of some vicious collaborative agreements and relationships.

I will say that a doctoral degree for nurses does not improve clinical proficiency at all. The Core Essentials of the DNP is well off the reservation when it comes to that.

Darth Practicus, NP

Riburn3, BSN, MSN, APRN, NP · May 8, 2017

I think it's important to point out to the OP that a "DNP" is a doctorate of nursing practice and many DNP's are just hospital administrators with no education in advanced practice. It is a terminal academic degree that many nurse practitioners do get, but it in no way changes scope of practice or clinical role.

What you're likely referring to when you say "DNP" is Nurse Practitioners, most of whom are not DNP's, and really most advanced practice nurses like CRNA's and CNS's fall under the question of autonomy as well.

All you need to know is that there is some research indicating that APRN's in independent practice, specifically in primary care, do just as good a job as physician's, but it isn't definitive in most regards. You will also find that physician lobbies hate the idea of us gaining independence because it threatens their bottom line even. They too can't cite smoking gun evidence to say that we shouldn't be independent, and their argument just boils down to "we go to school longer so we are clearly better", without the proof that the longer education means a whole lot.

Specific to this cite, independent practice threads are always very touchy where you will find trolls jump out with freshly minted accounts to bash the profession and you will find NP's and other RN's bashing themselves. If you came on here looking for general nursing advice, you would think nursing is the most self loathing career in the world, when I'm sure the reality for most of us is that it's a very supportive profession (APRN's included) where we have made incredible bonds with some wonderful people.

WKShadowNP, DNP, APRN · May 8, 2017

I think it's important to point out to the OP that a "DNP" is a doctorate of nursing practice and many DNP's are just hospital administrators with no education in advanced practice. It is a terminal academic degree that many nurse practitioners do get, but it in no way changes scope of practice or clinical role.
What you're likely referring to when you say "DNP" is Nurse Practitioners, most of whom are not DNP's, and really most advanced practice nurses like CRNA's and CNS's fall under the question of autonomy as well.
All you need to know is that there is some research indicating that APRN's in independent practice, specifically in primary care, do just as good a job as physician's, but it isn't definitive in most regards. You will also find that physician lobbies hate the idea of us gaining independence because it threatens their bottom line even. They too can't cite smoking gun evidence to say that we shouldn't be independent, and their argument just boils down to "we go to school longer so we are clearly better", without the proof that the longer education means a whole lot.
Specific to this cite, independent practice threads are always very touchy where you will find trolls jump out with freshly minted accounts to bash the profession and you will find NP's and other RN's bashing themselves. If you came on here looking for general nursing advice, you would think nursing is the most self loathing career in the world, when I'm sure the reality for most of us is that it's a very supportive profession (APRN's included) where we have made incredible bonds with some wonderful people.

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prelift · May 16, 2017

It isnt trolling just because it does not agree with you. The average NP functions at the level of a third year med student at best. A few are good but most are not. Biased nursing studies do not prove equality, but with hand picked research publishing, loose variable control, and the right wording you can make a turd sound like it treats Alzheimer's dementia. Sometimes you just need to use common sense and realize that maybe a real medical education is just a bit better than students attending a lackluster program part time while working and taking online quizzes with their friends during lunch breaks to pass classes. Dunning Kruger- read up on it. I honestly do not understand how some nurses think they have discovered pandora's box and are able to shorten a medical education to like 17 months and some how be able to "out perform a physician." Not quite sure what pandora's box looks like but I can assume it doesn't appear as a bunch of online discussion board posts, quizzes, forced nursing research, and one 4 hour board exam over a large part of nursing ethics with a few clinically oriented questions tossed in there.

Riburn3, BSN, MSN, APRN, NP · May 16, 2017

It isnt trolling just because it does not agree with you. The average NP functions at the level of a third year med student at best. A few are good but most are not. Biased nursing studies do not prove equality, but with hand picked research publishing, loose variable control, and the right wording you can make a turd sound like it treats Alzheimer's dementia. Sometimes you just need to use common sense and realize that maybe a real medical education is just a bit better than students attending a lackluster program part time while working and taking online quizzes with their friends during lunch breaks to pass classes. Dunning Kruger- read up on it. I honestly do not understand how some nurses think they have discovered pandora's box and are able to shorten a medical education to like 17 months and some how be able to "out perform a physician." Not quite sure what pandora's box looks like but I can assume it doesn't appear as a bunch of online discussion board posts, quizzes, forced nursing research, and one 4 hour board exam over a large part of nursing ethics with a few clinically oriented questions tossed in there.

And yet here you are spouting off your own opinion because of something you don't agree with. You don't provide a shred of proof in arguably one of the most incoherent posts I've read on this forum.

prelift · May 16, 2017

You sit there and ask for proof in all your posts and point towards studies that prove nothing but the fact NPs can manage HTN, cholesterol, and some Diabetes.

You know it is true that NP education is lackluster, the AMA has bigger fish to fry such as dealing with insurance companies which is the reason they do not perform studies of their own on NP performance. Some have proposed these studies yet NP groups deny to do them when sponsored by anybody but a nursing organization.

One only has to be in the same clinic/hospital with nurse practitioners to understand their lack of knowledge. The only half way decent ones are ones that were extensively trained by physicians in orientation. If it wasnt for physicians giving in and training NPs they would be completely lost. Most of them cant even read a basic chest X ray, differentiate gram positive vs gram negative bacteria, map out a simple pathway of a nerve, or even understand what receptor autonomic drugs work on. It is pathetic!

Sorry bro, you might think you know it all as an NP but if you ever went head to head with anything past a 2nd year med student you would be toast in most cases and you know it. its ok though,, the NP market will soon be saturated and once I am done in 5 years with residency I can hire a bunch of you to do all my dirty work and pay you 25 bucks an hour. Good thing NP education is so easy to obtain anybody can do it, thus shifting the market in our favor. And since I wont be doing primary care you can never branch off and do your own thing after being trained by a physician.

Lol at these NPs that get trained by physicians then come out and say they are equal and bash them with silly "how i saved the residents butt back in my nursing day" ego stories. Keep posting on your discussion boards, taking open book quizzes, and reading your nursing research, because once all of you get your little independent practice mantra going the lawyers will start raking it in with malpractice since you wont have your MD holding your hand in the clinic/hospital anymore. Cant wait to testify on the patient's behalf when simple diagnoses get missed and medication interactions get ignored. I am glad there will be independent practice though, I would never want my name cosigned to an NPs chart then get drug to court instead of the NP because of more $$$$, thus further skewing those silly malpractice surveys where they compare primary care NPs with their hand held by a FP physician has lower malpractice than a neurosurgeon using new technology lmao.

Also, hospitals have caught on to the nursing game, hence why they are denying silly online nursing program graduates from getting hired. lol! Hospitals are not dumb, hence why they pay the docs 3-4 times more. They want quality, not cannon fodder for the lawyers.

Riburn3, BSN, MSN, APRN, NP · May 16, 2017

Wow that was amazingly special. Excellent work, thanks for the "painful truths". My eyes are truly opened up now.