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!

[core0]

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.

I agree somewhat. The ANCC is trying to play both ends against the middle. If you look at the FNP blueprint from the ANCC six or seven years back it clearly stated the scope of practice for the FNP was ambulatory primary care medicine. As there were more challenges to the FNP in the inpatient setting the the wording changed to reflect lifespan regardless of the setting. On the other hand the blueprint content did not change. There was also an interesting agreement between ANCC and AACN that AACN would not develop an NP certification for 10 years after the ANCC developed their certification.

You are also correct that the AACN certification is not as common (although I believe most states now take it). You have also identified the power that AACN has through its CCRN program. Most ICU nurse managers are CCRN and they are very much toeing the party line of ACNP for the inpatient. In our institution the drive for ACNP did not come from the medical staff but the nursing school.

[nursegreen]

Juan,

Here is an article I read the other day. I think it is great that they are implementing a paid one year post grad fellowship and hope that others will follow.

Carolinas HealthCare System, based in Charlotte, N.C., launched one of the nation’s first comprehensive centers for advanced

care practitioners this spring. The Center for Advanced Practice will improve the recruitment, retention and training of advanced practitioners, including nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists nurse midwives and physician assistants, according to a news release. The center will offer services to enhance the professional development of advanced practitioners; a graduate ACNP program in partnership with the University of North Carolina Charlotte; and a paid, post-graduate fellowship program for NPs and physician assistants. The ACNP program and the fellowship program will accept 30 students and 50-60 fellows each year, respectively. The one-year fellowship includes three months of ICU rotations followed by nine months of clinical experience in a chosen field of specialty. "The Center for Advanced Practice will provide the foundation of support for all advanced practitioners in the Carolinas Healthcare System," Mary Ann Wilcox, RN, NEA-BC, senior vice president and system CNE, said in the release. "The CAP is unique in that it is proactively addressing the serious issues of access and clinical preparation in this complex healthcare environment. We believe the CAP is innovative in its scope and design."

http://news.nurse.com/article/20130506/SC02/105060051

[nomadcrna, DNP, CRNA, NP]

I want to address some the this posters misunderstanding.

Take a family practice or IM physician. They can do primary care. They can do hospitalist. They can even do intensivist work. They can work in an ER.

How about a surgeon? Can they do primary care? Yes.

I even worked with a primary care physician who had a specialty of preventive medicine.

BTW, I am saddened by one of our own, considering that their care is less than their physician counterparts. You keep providing "mid-level" care.

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.

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.

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.

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.

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:

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.

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.

[FuturePsychNP]

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.

Correct. Graduation from medical school provides the diploma, and as my understanding goes the internship and successive tests culminate in a license. At which point, anyone may claim to be a general practitioner. Lawfully, the things a physician may do is derived from this state issued license. The remainder of residency allows for specialization and fellowship for subspecialization. I guess you're saying most physicians that enter an internal medicine residency become board certified in the field. There are countless other residency programs for other specialties. Many forgo the certification later, and some remain only eligible for a period of time. I don't recall emphasizing that a board certification was a requirement as it isn't. It is, however, helpful and for a myriad of reasons.

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.

What did I say for which this is a counter argument? Privilegs must be granted by the facility, and I couldn't care less about the facility. Never did I mention what a facility will allow. In my statements I'm trying to reiterate that a license allows these providers to lawfully do whatever it is that they do. That stems from give NPs a license to provide general primary care, which would call for an evolution in training curricula, and then let them choose a specialty to board certify in such as psych.

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.

The things that come to mind to respond would get me banned from this board. PM me and I'll let you know what I was thinking.

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.

Again, privileges. I'm talking about doing what is lawfully allowed, i.e. scope of practice. Any organization can make up it wants as "privileges" (assuming the privilege is in the scope of practice of the provider) based on the whims of the board behind said actions.

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? Apparently I'm a long way from it. I suppose my method of typing directly into your quote is what angered you.

Shall we continue?

[casias12]

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.

It is too cumbersome to read the state regulations and compare them to actual practice. Does anyone from Texas, Maryland or Pennsylvania have any real-world info about this?

[casias12]

I want to address some the this posters misunderstanding.

Take a family practice or IM physician. They can do primary care. They can do hospitalist. They can even do intensivist work. They can work in an ER.

How about a surgeon? Can they do primary care? Yes.

I even worked with a primary care physician who had a specialty of preventive medicine.

BTW, I am saddened by one of our own, considering that their care is less than their physician counterparts. You keep providing "mid-level" care.

A professional should always be aware that self-assessment of skills is an important trait. Do I feel that my online degree, 2 years of clinicals, and 25 years as an ICU, critical care, and post-heart recovery nurse puts me in the same level as physicians I work with? Nah.

I didn't go to medical school. I didn't spend thousands of clinical hours in the roughest educational environments, and I absolutely respect those that did.

My opinion, of course.

[casias12]

@FUTUREPSYCHNP: No, it is that I used the example of physician training as a model for an abbreviated version for NP's. The regulating bodies of our profession have created a huge controversy that confuses even the state board of nursing. If you want to argue about the licensing and residency requirements of physicans, feel free to go to studentdoc.net. They love this topic.

As for us, the nurse practitioners. Most would agree that we have a system that leaves open a huge issue. I, for one, see patients in a hospital setting and office setting. In Florida, any ACNP, FNP, or ANP can see patients in either setting. I, for one, have no issue with the requirements of supervisory or physician-colleague status, because I like my group, trust them, and work well with them. I would like to see board certification for post-graduate experience, based on attestation, for many of the specialties similar to the physician model. Like many physicians do who hold multiple board certifications, I would do the same. I believe it is important for both clarification, and focus.

It would also help NP's achieve more of a blended office/hospital role. Speaking from the cardiology role, continuation of care is very important. I often follow my hospital patients in the office after they have been hospitalized. I know them, they know me. When patients are discharged, for some reason they don't always end up on the meds we want them on. I like to verify that what they were discharged on is correct. And nothing is harder than seeing a patient for hospital follow-up, not having known them. They will have about 47 pages of discharge summary, reports, labs, consult notes. Sometimes I am only guessing when I try to summarize their hospital stay.

Any attempts to separate the two - Hospital and office, is short-sighted. In my opinion, of course. It is not the location of the patient, but the patient's condition, that should lead any practitioner to treat or refer. Even with practitioners.

[Corey Narry, MSN, RN, NP]

You are also correct that the AACN certification is not as common (although I believe most states now take it). You have also identified the power that AACN has through its CCRN program. Most ICU nurse managers are CCRN and they are very much toeing the party line of ACNP for the inpatient. In our institution the drive for ACNP did not come from the medical staff but the nursing school.

Oh of course. I also work in critical care as a nurse practitioner and in our practice, only ACNP trained candidates are considered for an interview. It's an unspoken rule between the group and some of the NP's in our group have actually spoken in SCCM-sponsored conferences advocating for ACNP's only in critical care. The nursing school here also prides itself with one of the top rated ACNP programs so we don't have a scarcity of qualified ACNP candidates.

[Corey Narry, MSN, RN, NP]

Juan,

Here is an article I read the other day. I think it is great that they are implementing a paid one year post grad fellowship and hope that others will follow.

Carolinas HealthCare System, based in Charlotte, N.C., launched one of the nation’s first comprehensive centers for advanced

care practitioners this spring. The Center for Advanced Practice will improve the recruitment, retention and training of advanced practitioners, including nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists nurse midwives and physician assistants, according to a news release. The center will offer services to enhance the professional development of advanced practitioners; a graduate ACNP program in partnership with the University of North Carolina Charlotte; and a paid, post-graduate fellowship program for NPs and physician assistants. The ACNP program and the fellowship program will accept 30 students and 50-60 fellows each year, respectively. The one-year fellowship includes three months of ICU rotations followed by nine months of clinical experience in a chosen field of specialty. "The Center for Advanced Practice will provide the foundation of support for all advanced practitioners in the Carolinas Healthcare System," Mary Ann Wilcox, RN, NEA-BC, senior vice president and system CNE, said in the release. "The CAP is unique in that it is proactively addressing the serious issues of access and clinical preparation in this complex healthcare environment. We believe the CAP is innovative in its scope and design."

Carolinas center meets needs of advanced practice nurses | South Nursing News

I know these programs exist. They are not the standard right now because they're not consistent, not regulated, and not publicly funded like physician residencies and fellowships. There is a proposal to extend the use FQHC's as a setting for primary care NP residencies since these places get federal funding. Acute care focused residencies are still mainly hospital sponsored though I'm not familiar with how it's funded. The University of Maryland Trauma NP fellowship appears to grant privileges to NP fellows and maybe bill for the services provided by the fellows.

Edit: have to add that the U of Maryland residency is now ONLY open to ACNP's given the BON regulation in that state: http://www.umm.edu/np/residency/

[casias12]

In Tampa, USF dropped the ACNP education track, and University of Cincinnati did as well. These are each programs I am familiar with. To some degree, it is geographically dependent. The education was dropped by these colleges because of lack of interest. If you are spending $30k + and years of your time, you are probably more likely to take family or adult as your base, then add ACNP from one of the many post-graduate certificate programs. That's what I chose. So far, I have not had to add the acute component, because it hasn't been a requirement yet. Many hospitals won't allow NP's to do clinical hours unless they are with an affiliated college. So in Tampa, you probably aren't going to get clinical hours for an online program. There is not a local program. It's a bit of a pickle.

This is why I think the educational model directed by the ANA is broken. If the state change the regulation, or hospitals in this area suddenly decided to require ACNP for NP's who practice in the hospitals, it would really put a crunch on care. If they choose to require it from NP's they hire, that's their choice.

Probably the most efficient method would be for an allowed time for certification by attestation. If you are employed by a physician who oversees your hospital work, then attests to your competence, you are allowed to sit for board certification.

[nomadcrna, DNP, CRNA, NP]

Do I feel like my 12 years of advanced education after 13 years of ICU/ER experience as an RN puts me at the same level? Absolutely.

Do the courts judge me as a mid-level or on the same level as as either Family Practice Physicians or Anesthesia Physicians? Absolutely.

Do I do the exact same job when I admit and follow a patient in the hospital, treat a patient in the ER, provide care to a patient in the clinic or perform an anesthetic? Absolutely

Are there many scientific peer reviewed studies that say that my care is equal or better than my physician colleagues? Absolutely.

Do I collaborate with other physicians, NPs and Pas? Absolutely. We all have our strengths.

So I respect your "opinion" but that opinion is ONLY about yourself. Don't project your opinion about your lack of knowledge onto other NPs who may be better prepared. No offense intended, just hard to make a point via written word. I struggle, so please forgive me.

A professional should always be aware that self-assessment of skills is an important trait. Do I feel that my online degree, 2 years of clinicals, and 25 years as an ICU, critical care, and post-heart recovery nurse puts me in the same level as physicians I work with? Nah.

I didn't go to medical school. I didn't spend thousands of clinical hours in the roughest educational environments, and I absolutely respect those that did.

My opinion, of course.

[nomadcrna, DNP, CRNA, NP]

Personally, I see no reason a ACNP could not do primary care in a clinic if they choose. OJT would be very easy, same applies to the FNP that wants to do hospitalist or intensivist.

I'm adding my 3rd certification (ACNP) and find there is a huge overlap between the two.

Or even some sort of educational pathway without having to do the whole cert.

I think we (NPs) are shooting ourselves in the foot by forcing NPs into narrowly defined roles.

Oh of course. I also work in critical care as a nurse practitioner and in our practice, only ACNP trained candidates are considered for an interview. It's an unspoken rule between the group and some of the NP's in our group have actually spoken in SCCM-sponsored conferences advocating for ACNP's only in critical care. The nursing school here also prides itself with one of the top rated ACNP programs so we don't have a scarcity of qualified ACNP candidates.