Sick of the Certs!!!!! Just let 'em be an NP!

[bsnanat2]

Below is my response to the posts of others in another APN forum where a job was posted requiring ACNP and FNP certs. Some were quick to point out the wrongness of this job post. Is anyone else sick of this?

Threads like this are what make PA's laugh at us and makes me sad to be a APRN. No other profession would ever limit itself like NP's do and then fight one another over these small bits of turf. A primary care PA could easily move into pediatric inpatient and no other PA would make a peep, even though it is understood that the PA in question would have to gain some sort of additional training. NP's are so drunk off the kool-aid of a myriad certifications that it is simply sickening. All of these ridiculous certifications and everyone's insistence on pointing out everyone elses' "lack of qualifications" will indeed be the death of this profession. If an FNP wants to work inpatient, let them. They are surely smart enough to know whether or not their training or the training available to them will qualify them to do the job. That is what a professional is. CRNA's, PA's and PMHNP's typically don't have these issues, and they will survive. The rest of us? I don't know. All these alarms are set off by some imagined court action. Shut up and get out of one another's way. The consensus model, lace and the DNP should have taken care of this issue. Standard NP training and licensure should take into account primary and acute care across the lifespan, that way NP's, like CRNA's and PA's could choose where and with whom they want to work. Instead these idiotic online degree mills keep cropping up and the useless DNP focuses on more research. NP's need to get a grip or prepare to be the last generation of this great profession!

[MurseJJ]

All PA's, in every state, have to have their work cosigned. They are never independent of a physician.

While it is true that PAs are never fully independent of their supervising/sponsoring physician, it isn't true that in every state they have to have their work cosigned. It seems that many if not most states leave co-signature up to the supervising/sponsoring physician or the hospital. For example, in NY, "supervision" does not necessitate the physical presence of the SP, and co-signature of orders only happens if deemed appropriate and necessary by the SP or the hospital, but co-signature will never be required prior to execution of the order. An example of this is in my hospital. ER PAs have a list of diagnoses that they are able to assess, diagnose, and treat, as well as discharge the patient, without the attending physician seeing them at all. They then have another list (i.e. the more serious presentations) where they have to present to the attending upon admission order or prior to discharge, along with co-signature. So presumably, a new-grad may well have to have all orders co-signed (after they have been executed), but someone in practice for years probably wouldn't have all orders co-signed.

In North Carolina, for PAs new in practice, they must meet with their SP once a month for the first 6 months of practice, after which they must meet with their SP at least once every 6 months to discuss practice. There is also "no provision" for chart/order co-signature.

In contrast, in California, the SP must review and countersign at least 5% of charts within 30 days, selecting those that represent the most risk to the patient, based on diagnosis, treatment, procedures, etc.

So, that's my long-winded way of saying that it is not true that all PAs, in every state, have to have their work co-signed, and even in states that do have provision for co-signature, it certainly isn't co-signature for everything a PA does, and the things that are co-signed are co-signed after the fact (i.e. co-signature isn't required for the order/prescription to be valid).

While PAs certainly can have a great deal of autonomy, have their own medical licenses, DEA numbers, etc etc, it is true that they are not fully independent from a physician (though in many cases they function as independent clinicians in their decision making), as is possible for NPs, depending on the state, and yes, if a PA is found negligent, the SP could be involved as well, if there wasn't appropriate supervision or practice agreements.

[FuturePsychNP]

To address some of the misunderstanding in this discussion, I want to start with physicians.

1) physicians are not able to practice wherever and however. Most physicians, even specialists, are board certified Internal Medicine Physicians. Specialists (cardiology, gastroenterology, surgeon.....) all go on to fellowship or residency to learn skills necessary for their chosen specialty.

No "most" are not internal medicine. IM Is a primary care specialty in which one may subspecialize in cardiology, pulmonology, infectious disease, nephrology, rheumatology, etc. It's got nothing to do with surgery. A physician's license allows them to legally practice and do what it is they do. Their board certification earned after residency and certification (if available) after fellowship in a subspecialty is what makes them "specialists."

An internal medicine physician cannot do heart caths, manage ventilators, perform stress tests, read echo's, do colonoscopies or bronchosopies, or surgery. Even within the specialties, some cardiologists are diagnostic only, and some can do intervention. Some surgeons can do pulmonary wedge resection, others cannot.

If they know how to do it they may in fact do it. The fact is none will do caths, as a strict IM, because they're not trained to and even if they were reimbursement and their own malpractice policy may preclude it. We have an IM doctor that does stress tests and manages ventilators. An interventional cardiologist is a subspecialty, or training through fellowship after a residency, and that's a whole different ball of wax.

This comes down to payment and privileges. Many procedures will not be paid by medicare or private insurance unless the provider is trained in that procedure. Some procedures, skin suture, joint aspiration and injection, skin biopsy, can be done by internal medicine physicians. But then they have to pay insurance to cover those procedures. Often, the insurance cost is not worth it, so they just don't do it.

Why do we keep reflecting on IM?

Hospitals will not grant privileges to do the procedures without specific training. It is so specific, in fact, that we had to look up the privileges of a physician on the intranet before they could do a particular procedure. We knew the common physicians, and their common privileges, but sometimes, you still had to look to see if they could do what they wanted to do.

This is mostly correct.

2) PA's are board certified by the NCCPA, and sponsored by the AMA. They have to be certified, but they only have one exam, as far as I know. An example:

They are PA-C. PA-Certified.

In Florida, the largest settlement ever $216 million, was awarded to the family of a man who visited an ER with headache and visual disturbances. He had a negative CT, and symptoms resolved so he was seen and sent home by a PA. All PA's, in every state, have to have their work cosigned. They are never independent of a physician. As it turns out, the patient stroked and became comatose. The ER physicians group was found to have let this PA work for many years in this ER, despite the fact that he had failed the certification exam, and never actually passed.

3) Physicians don't really know the difference. I rarely meet a physician who knows the difference between a PA, NP, ARNP, FNP, etc. They just assume that if you are doing the job, you must have met the minimum standards for scope of practice. In my area, there is a mixed-bag of NP's and PA's, all working inpatient and outpatient settings. But remember, PA's are never allowed to operate independently, while in many states, NP's are.

This is the same assumption we make when someone with MD walks up and writes orders for a patient. We assume because they're doing it that they know what they're doing. A PA may require physician supervision, but given a specific state and/or institution the physician may be offsite and up to hundreds of miles away from the PA.

4) I, for one, chose Adult because it was the easiest, quickest, with the lowest enrollment. I have had no trouble getting privileges in hospitals with my colleague physicians, and I have never had a physician treat me as lesser. But it comes down to personality. I am a mid-level. I did not go to medical school. I do not have the education and experience they have. Never will. Even if I chose to pursue a Phd, it would be for personal reasons. I would never call myself "doctor" to a patient. They are already confused enough. I am a nurse.

5) I think PA's and NP's would be best-served to band together as a unified mid-level profession. It would decrease confusion and only further our cause. Band together or not the NP course of study could certainly do well to mirror the PA course of study.

To address some misunderstanding....

[bsnanat2]

My original frustration stems from the ridiculous maze we must all navigate to get our piece of cheese. This is difficult enough without all the other mice crying "foul." We must revise our education model to cover the lifespan for all and then to provide a recognized way to expand skills without returning to school for an additional expensive academic cert. The smaller the location we practice in, the more important this becomes. In small & not so small towns the local family practice MD's do still practice hospital medicine. Why would they hire a NP who was restricted from doing so, even with adequate time and training willingly provided to them? Just hire a PA who can do what I say he can and also won't be seeking plenary practice right. We must get out of own way.

[casias12]

FUTUREPSYCHNP. I am not going to cut and paste your comments, but you are not correct on a few things.

1) ALL physicians start out as "generalists" after their first year of residency. Once they have completed residency, they might move on to chief resident, specialty residency or fellowship. MANY (MOST) become board certified in internal medicine at this point. It is not a requirement, and some choose not to. Some let the certification lapse after they have moved on to a specialty. Becoming board certified while they wait bumps up their value for specialty residency and fellowship. Older physicians tend to drop the certification after they have established practice.

2) Every procedure in a facility requires privileges. Those are granted by the board of the hospital for each and every privilege. You may know IM physicians who perform stress tests and manage ventilators. It was more common many years ago, and in smaller hospitals. Some were able to retain the privileges. Larger hospitals tend to be more strict with privileges. This is where politics and need come into play. I actually worked with a gynecologist who did heart caths (many years ago). Interventional cath fellowships didn't really exist until the late 90's, and he was grandfathered in from experience. His training was provided by an older cardiologist, and the board granted him privileges. No other hospital would grant him privileges, though, so he only did caths at ours. He was actually a pretty good cardiologist. And....no. Just because they know how, does not mean they can. The last cath lab I worked in as a nurse required 75 cardiac interventions per year to maintain privileges. Some of our better, older cardiologists weren't allowed to have privileges. Funny thing.

3) Why do I keep referring to IM physicians? You don't follow a conversation well do you. You kind of seem like a troll to me. Keep up.

4) I don't just assume a physician has the ability to order anything. In the ventilator example: I have seen physicians over the years argue this one repeatedly. They can't make vent adjustments unless they have privileges. In many hospitals now, they can't transfer a patient to the ICU without obtaining intensivist coverage.

In an ICU I am affiliated with, a couple of surgeons want to wean and extubate their own surgical patients. When they have to wait for the intensivist, it really ****** them off.

5) How far are you from being done FUTUREPSYCHNP?

[casias12]

My original frustration stems from the ridiculous maze we must all navigate to get our piece of cheese. This is difficult enough without all the other mice crying "foul." We must revise our education model to cover the lifespan for all and then to provide a recognized way to expand skills without returning to school for an additional expensive academic cert. The smaller the location we practice in, the more important this becomes. In small & not so small towns the local family practice MD's do still practice hospital medicine. Why would they hire a NP who was restricted from doing so, even with adequate time and training willingly provided to them? Just hire a PA who can do what I say he can and also won't be seeking plenary practice right. We must get out of own way.

I've never actually seen this issue. In everyday practice, FNP, ANP, and ACNP can all have privileges within the hospitals, guided by the scope of their physician group. It is common practice in most states I have worked for the physician to round after the NP and cosign the orders anyway. It is usually requested by the hospital board. It is the relationship between the physician and the practitioner that makes this model work, not a stupid 150 question credentialing exam, or letters behind the name.

Why is this? Because physicians, hospitals and practitioners are in a business arrangement. If a practitioner can round early and facilitate diagnosis, treatment and ultimate discharge, hospital is happy, physicians are happy.

[core0]

FUTUREPSYCHNP. I am not going to cut and paste your comments, but you are not correct on a few things.

1) ALL physicians start out as "generalists" after their first year of residency. Once they have completed residency, they might move on to chief resident, specialty residency or fellowship. MANY (MOST) become board certified in internal medicine at this point. It is not a requirement, and some choose not to. Some let the certification lapse after they have moved on to a specialty. Becoming board certified while they wait bumps up their value for specialty residency and fellowship. Older physicians tend to drop the certification after they have established practice.

Actually this is quite incorrect. Every physician matches into a residency. Broadly there is medicine, surgery and other. Last year there were 24,000 PGY-1 (intern) slots. Of those around 5000 were internal medicine. Some specialties such as EM and neurology integrate their internship year into the residency. So you go straight into EM and never do medicine per se. Others start during the PGY-2 (second) year and require an internship year. Anesthesia for example is one year of internship followed by three years of anesthesia residency. The internship can be in surgery, medicine or it can be a transitional internship. To make things more confusing there are categorical and preliminary residency. The categorical resident is guaranteed a slot in the program to finish residency (unless something catastrophic happens). The preliminary resident is only guaranteed one or two years of residency then must find another position. If the resident already has a PGY-2 position then its fine. If they don't then they have to find one. Generally to get a state license you have to complete between one and three years of residency. Generally to get on an insurance panel you have to complete a residency.

Chief resident depends on the specialty. In surgery all PGY-5 residents are called chiefs. In Medicine its usually an extra year after the three years of medicine to buff the applicant for a fellowship. In other residencies its usually an administrative position (which can carry some honors or just be painful). The EM chief in our program is responsible for the schedule and taking complaints to the residency director.

After residency you can either go practice or do a fellowship. A fellowship requires extra years. On of our physicians has four fellowships after medicine meaning he has to keep up with five boards.

As for certifications most of them are moving to Maintenance of Certification (MOC) which requires CME every three years and a test every 10 years. Older physicians don't have to do MOC to maintain their certification. It would be unusual for a physician to drop certification. Most hospitals will require it for credentialing. Our hospital requires certification within three years of graduation or you lose privileges. Most insurance companies are unlikely to contract with specialists unless they are board certified.

2) Every procedure in a facility requires privileges. Those are granted by the board of the hospital for each and every privilege. You may know IM physicians who perform stress tests and manage ventilators. It was more common many years ago, and in smaller hospitals. Some were able to retain the privileges. Larger hospitals tend to be more strict with privileges. This is where politics and need come into play. I actually worked with a gynecologist who did heart caths (many years ago). Interventional cath fellowships didn't really exist until the late 90's, and he was grandfathered in from experience. His training was provided by an older cardiologist, and the board granted him privileges. No other hospital would grant him privileges, though, so he only did caths at ours. He was actually a pretty good cardiologist. And....no. Just because they know how, does not mean they can. The last cath lab I worked in as a nurse required 75 cardiac interventions per year to maintain privileges. Some of our better, older cardiologists weren't allowed to have privileges. Funny thing.

3) Why do I keep referring to IM physicians? You don't follow a conversation well do you. You kind of seem like a troll to me. Keep up.

There are a number of processes that control what a physician can do. They usually revolve around credentialing and reimbursement. Most physicians have an unlimited license for medicine and surgery. In theory they can do whatever they want. In reality credentialing in a hospital will limit them to what they are trained to do. Reimbursement will only pay them if they have the proper training, and common sense/their malpractice carrier will generally keep them from doing things they shouldn't do in the outpatient setting.

4) I don't just assume a physician has the ability to order anything. In the ventilator example: I have seen physicians over the years argue this one repeatedly. They can't make vent adjustments unless they have privileges. In many hospitals now, they can't transfer a patient to the ICU without obtaining intensivist coverage.

In an ICU I am affiliated with, a couple of surgeons want to wean and extubate their own surgical patients. When they have to wait for the intensivist, it really ****** them off.

5) How far are you from being done FUTUREPSYCHNP?

In the inpatient realm once again credentialing deals with what a physician can and cannot do. Its far from universal and in the ICU less than 25% of hospitals have dedicated intensivists. Many surgeons routinely manage vents and extubate patients. Many hospitalists manage ICU patients (with or without pulmonology to manage vents).

Its a big world and there are a lot of variations.

[core0]

I've never actually seen this issue. In everyday practice, FNP, ANP, and ACNP can all have privileges within the hospitals, guided by the scope of their physician group. It is common practice in most states I have worked for the physician to round after the NP and cosign the orders anyway. It is usually requested by the hospital board. It is the relationship between the physician and the practitioner that makes this model work, not a stupid 150 question credentialing exam, or letters behind the name.

Why is this? Because physicians, hospitals and practitioners are in a business arrangement. If a practitioner can round early and facilitate diagnosis, treatment and ultimate discharge, hospital is happy, physicians are happy.

It all depends on where you practice. I'm aware of at least three states that mandate (in different ways) ACNP for inpatient practice through the board of nursing. It can also be mandated by the hospital credentialing. Our hospital has given FNPs working in the ICU one year to get their ACNP. I would anticipate this will spread to other units. Also in a state requiring collaborating agreements we are seeing intermittent refusal of the medical board to grant collaborating agreements when the NP and physician specialties don't match. Finally in the Southeast the malpractice lawyers are looking at NP scope to try to get around medmal limits which has the malpractice carriers nervous.

To the OP, fundamentally this comes from two areas. One is independence. If NPs had a dependent license then this would not be as much of an issue since the scope comes from the supervising physician training. If you claim independent practice rights the scope rises and falls on the training as an NP. While this has been ignored in the past its becoming more of an issue.

The other area is intercine conflict between certification boards. Both the ANCC and the AANP certify FNPs and are interested in keeping the certification as broadly useful as possible. The AACN on the other hand only certifies ACNP and is happy to tell BONs that this is the only certification that should be working with inpatients. Throw in the certifying agencies and it becomes more confusing.

[casias12]

It all depends on where you practice. I'm aware of at least three states that mandate (in different ways) ACNP for inpatient practice through the board of nursing. It can also be mandated by the hospital credentialing. Our hospital has given FNPs working in the ICU one year to get their ACNP. I would anticipate this will spread to other units. Also in a state requiring collaborating agreements we are seeing intermittent refusal of the medical board to grant collaborating agreements when the NP and physician specialties don't match. Finally in the Southeast the malpractice lawyers are looking at NP scope to try to get around medmal limits which has the malpractice carriers nervous.

To the OP, fundamentally this comes from two areas. One is independence. If NPs had a dependent license then this would not be as much of an issue since the scope comes from the supervising physician training. If you claim independent practice rights the scope rises and falls on the training as an NP. While this has been ignored in the past its becoming more of an issue.

The other area is intercine conflict between certification boards. Both the ANCC and the AANP certify FNPs and are interested in keeping the certification as broadly useful as possible. The AACN on the other hand only certifies ACNP and is happy to tell BONs that this is the only certification that should be working with inpatients. Throw in the certifying agencies and it becomes more confusing.

And this brings up the OP's original complaint. The AANP is trying to move in and, I think, clean up the process a little bit with more common sense. The ANA/AACN on the other hand, continues to make it more confusing and more difficult. They do have the universities in their pocket, and students, at least in my experience, are dissuaded from sitting for AANP boards.

BON's of each state are just as confused, it seems. My direct experience is in Missouri and Florida. Missouri is, unless it has changed, a collaborative state and Florida is a supervisory state. Both have "paper" restrictions, and both allow any ANP, FNP or ACNP to work in both office and hospital settings. And I work daily in both hospital and office settings with all three, and many PA's as well. In real world practice, ANP, FNP, ACNP and PA are interchangeable, at least in Florida. And the irony is, even we don't understand the requirements.

But I had initially made the comment that I believe all NP's should start with a common general medicine certification, with specialty certification following experience. I am not intending to delve into the world of physicians, as their credentialing and privileges system can be complex as well. But I am not sure I have ever met a specialist who doesn't also have board certification in internal medicine. Everyone in my group has board certification in internal Medicine, plus cardiology, and nuclear. I'll ask around.

The difficulty in credentialing nurse practitioners reliably is the lack of residency availability. So post-graduate hours with attestation would have to be the substitute. But this can lead to variability, and fraud.

Unfortuanately, however, the governing bodies of the adult nurse practioner world only make it more confusing, and more difficult.

[casias12]

@ core0 : I appreciate the information on physician residency and whatnot. That was very informative. What states restrict inpatient care based on acute care certification?

Are you a PA?

[Chris Caulfield RN NP-C]

I would not go to a FNP or a ANP for any psych issues. And I would not go to a Psych NP for medical issues. Then of course there are Midwives, Acute Care NP. Some overlap... but in PA school they actually rotate through these areas. FNP is primary care rotations (adult, Pedi, women's), not pysch, acute, surgical. Of course there is on the job training and certifications to prove yourself as being a competent provider in that field. I just hope they don't get rid of Post MSN certifications before I finish.

[Corey Narry, MSN, RN, NP]

And this brings up the OP's original complaint. The AANP is trying to move in and, I think, clean up the process a little bit with more common sense. The ANA/AACN on the other hand, continues to make it more confusing and more difficult. They do have the universities in their pocket, and students, at least in my experience, are dissuaded from sitting for AANP boards.

The other area is intercine conflict between certification boards. Both the ANCC and the AANP certify FNPs and are interested in keeping the certification as broadly useful as possible. The AACN on the other hand only certifies ACNP and is happy to tell BONs that this is the only certification that should be working with inpatients. Throw in the certifying agencies and it becomes more confusing.

I think the real limitation with AANP is that they only represent a small fraction of available certification exams for NP's: FNP and ANP. Whether this is an intentional plan to simplify NP competencies to produce an all around NP who can function in all settings and acuities is not clear. I question why even have ANP in the first place.

The acute care arena is more complex than just a "battle" between AANP, ANCC, and AACN. For one AACN certification (ACNPC) is not widely accepted in all the 50 states so I think they don't exert that much influence in how things run on the in-patient side but they do have clout in critical care.

One must remember that there is a pediatric acute care certification that is available to further add complexity to the mix. Pediatric NP programs have also been dichotomized to primary care vs acute care. PNCB offers both certifications and ANCC only offers primary care pediatric certification.

It is what it is. This is a mess that nursing allowed to happen and the Consensus Model does not offer much guidance other than saying that the certifications do not limit the NP's to a specific setting. I agree with coreo that with the push for NP independence will only make it more important that the NP's training reflects the kind of practice setting they involve themselves in. Any claim of "apprenticeship" under a physician is not going to matter much unless we formalize some sort of NP residency or fellowship.

[core0]

@ core0 : I appreciate the information on physician residency and whatnot. That was very informative. What states restrict inpatient care based on acute care certification?

Are you a PA?

I am a PA that is involved in workforce research. The states if I remember correctly are Texas, Maryland and Pennsylvania. Texas does this by fiat. Maryland prohibits non ACNPs from treating patients in a monitored bed. Pennsylvania does this by certifying CRNPs in a specific specialty. There are several others that are in various stages of differentiation from what I've heard.