Worsen the nursing shortage with more nurse practitioners?

by mdstudent31

One of the hot topics occurring in the health care debate deals with figuring out appropriate leaders of the Patient Centered Medical Home (PCMH). With the recent report by the IOM advocating for independent practice by nurse practitioners, many physician groups, including the AAFP and AMA, have come forth with strong statements advocating against the IOM report and independent practice by CRNPs.

A recent editorial by the AAFP, titled “Nurse Practitioners Are Team Members, Not Leaders, in the PCMH” points out some very disturbing numbers and trends. It begins by pointing out that the IOM and nursing organizations are correct in their analysis that there is a primary care physician shortage and that the role of CRNPs and the medical team could be increased to help with this shortage. However, it provides numbers produced by the American Association of Colleges of Nursing (AACN) that the IOM, CRNP advocates, and the media fail to mention when talking about the expansion of the current scope of practice and independent practice:

“the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025 … U.S. nursing schools turned away 54,991 qualified applicants from baccalaureate and graduate nursing programs in 2009 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. In addition, almost two-thirds of nursing schools say faculty shortages are the reason they cannot accept more entrants into their programs.”

When thinking about faculty shortages as a medical student, we look to attending physicians as our faculty to help us along our pathway in becoming physicians. In turn, nursing students look towards nursing leaders to help in their training to ultimately become nurses at all levels of nursing education. What better nursing leaders to help in this shortage than CRNPs? Better yet, the Doctor of Nursing Practice (DNP) was originally developed for nurses to have a PhD for academic and faculty purposes to educate future nurses. Are DNPs solely practicing academic nursing as faculty to the extent at which this degree was originally developed?

Why focus so much effort on increasing scope of practice when there are such deficiencies within the current scope of practice? One of the issues that a CRNP or DNP faces by going into academic nursing is a pay decrease and that may keep potential academic nurses away from becoming faculty. I hope that is not the case, especially when encountering all of the physicians that are faculty at academic medical centers that take large decreases in salary to remain in academic medicine instead of private practice.

Let me offer a different and possibly refreshing argument against the independent practice of CRNPs which goes against the usual argument pointing out disparities in education and standardized training/certification.

Medical students, nursing students, physician assistants, physicians, nurses — the entire medical team can agree that patient care comes first. A lot of focus goes into resident working hours and sleep deprivation but what about the bedside nurses that take on extra shifts and patients all the time because there are not enough nurses for coverage?

Expanding the scope of practice for nursing without addressing the current shortage of nurses within the current scope of practice will only spread the nursing workforce even thinner – and in my opinion, will only compromise patient care further than it already does. Increasing advocacy efforts for independent practice and encouraging current nurses to pursue higher education to provide outpatient primary care in the PCMH without increasing the amount of resources and faculty to contribute to a larger nursing workforce will lead to adverse unintended consequences.

“mdstudent31″ is a medical student who blogs at Future of Family Medicine.

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  • Nancy Short

    So many inaccuaracies:
    The acronym CRNP does not exist. The correct term is APRN – Advanced Practice Registered Nurse and includes the 4 recognized advanced clinicians in nursing: nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists.
    The DNP is a terminal degree…it is an applied doctorate and is not a PhD. Nursing also has a PhD for researchers.

    The ACA and the IOM’s Future of Nursing report do not focus on EXPANDING the scope of practice for APRNs. Rather, the focus is on removing barriers that currently prohibit APRNS from practicing at the top of their current scopes of practice and education. Physicians do not need to supervise the work of APRNs. APRNs are responsible and know the limits of both their education and their personal knowledge or experience.

    • http://abnormalfacies.wordpress.com/ Jim

      I’m wondering why, if the acronym CRNP doesn’t exist, it’s used so often, and why many practitioners put the title after their names.

      They seem to me to be synonymous, and may just differ regionally.. anything to this?

    • Halothane

      You are incorrect. CRNP is the legal title of nurse practitioners in PA. It is not APN, APRN, or ARNP in PA.

      • http://abnormalfacies.wordpress.com/ Jim

        Well, that makes sense. I’m from NY, and now study in PA. Most of my interactions with the nursing profession have been in PA, and I’ve never seen the title APRN.

      • http://futureoffamilymedicine.blogspot.com mdstudent31

        Thank you for the clarification. I was confused at first at this comment because I was just working w/ a CRNP when the post went up (I am in Pennsylvania). In PA, physicians are MD and DO. Is there a reason for the variation in legal titles? Are there efforts in standardization?

        Another thing I am confused about – at this point in my training, (BS, MS, and in a few months, MD) I have accumulated, what seems to be, the number of years of training and certifications needed that independent practicing NP/DNP/CRNP/APRN/APN/ARNPs have. The studies are showing equivalence or better outcomes in certain measures (though I’m also confused if standardized for #patients seen/hour, overhead, supervised/unsupervised, #consults, # years in healthcare delivery prior to advancing degree, online degree vs on-site degree).

        Hypothetically, am I ready for independent practice? (as my attending physician screams “are you crazy?”)

  • Candi, CRNP

    Huh? The Phd of nursing is designed for the academics and future nursing educaters. The DNP was developed as basically a clinical doctorate for those who do NOT wish to pursue an academic or educator track.

    • http://futureoffamilymedicine.blogspot.com mdstudent31

      From the AACN: http://www.aacn.nche.edu/DNP/dnpfaq.htm

      …DNP graduates will likely seek practice leadership roles in a variety of settings-management of quality initiatives, executives in healthcare organizations, directors of clinical programs, and faculty positions responsible for clinical program delivery and clinical teaching would be appropriate.

      • Jman

        That seems to imply quite the opposite…

  • Valerie CRNP

    @ Nancy Short.

    CRNP most certainly does exist!

  • http://www.john-goodman-blog.com Devon M. Herrick, PhD.

    I find the nursing shortage argument a rather flimsy excuse to restrict the scope of practice for Advanced Practice Registered Nurses. The proportion of medical students pursuing primary care (rather than a higher-paying specialty) is quite low. If physicians don’t want the job; and APRNs do want the job of providing primary care, I see little reason to restrict APRNs from working independently. That said, both the nursing shortage and the shortage of primary care physicians is a serious problem that needs to be dealt with over the coming years.

    • http://futureoffamilymedicine.blogspot.com mdstudent31

      Scenario: When applying for med school, a premed advisor tells a student interested in primary care to become an APRN instead of going through med school and residency. Thoughts?

      • http://www.john-goodman-blog.com Devon M. Herrick, PhD.

        That’s not bad advice. APRN would be a quicker route to practicing primary care and provide more “bang” for your educational buck. One drawback is the uncertainty about the scope of practice regulations graduates could expect. Each state has different regulations on which services APRNs can provide and how much physician supervision is required.

        One program I find interesting is a Texas Tech project, where medical students who want to practice Family Medicine can graduate in three years rather than the traditional four. The last year of medical school is skipped (rotation to explore the various specialties). Besides getting through the program one year earlier, I believe the school provides an additional $13,000 scholarship to offset some of the first year expenses. Programs like this might encourage more people to practice primary care. It might also allow some people to pursue a career in medicine who otherwise would not have the funds or time. Of course, that still doesn’t fix the problem of a limited number of residency programs necessary to practice medicine.

        • http://futureoffamilymedicine.blogspot.com mdstudent31

          Of course it’s not bad advice, my $280k investment to go into primary care is a financial planner’s nightmare.

          Is this not taking away from the number of potential primary care physicians who could do fairly well in medical school and residency? From the NP and PA students I have worked with, many of them could have flourished in medical school, and are going into primary care.

          The Texas Tech project is very intriguing. We have a school here in Erie that has a similar primary care pathway.

          Another scenario that always fascinates me involves the RN who really wants to go to medical school to go into primary care. I have rotated with medical students and residents who were former RNs but went to medical school to become primary care physicians. Are we now losing out on these potential primary care physicians and further contributing to the shortage in this specialty?

        • primaryMD

          Re: 3 years of medical school:

          the 4th year is not a medical tour to “explore the various specialties.” It’s valuable exposure to pathophysiology, patients, and the treatment options of those patients who need specialty care. Invaluable experience, one could argue, to someone hoping to be a competent generalist physician one day.

          I would make the counterargument that those wishing to be a Family Physician or Internist should have more training than someone planning to specialize.
          But what do I know, I’m just a generalist who apparently didn’t need to go to medical school for 4 years.

          • Jman

            Nope, you could have just done four years of undergrad to get your BSN, then enroll in a direct entry NP program online and practice independently right out of school. I hear some places are even making combo programs and getting it done in 5 years (take a year off the BSN). Apparently four years of undergrad, four years of med school and at least three years of residency (11 years) is just too much school.

            It’s always refreshing to hear that someone could do your job with less training. Then again, why not have CNAs do a nurse’s job with just a little bit of training – all they are supposed to do is follow orders right ???? (from independently practicing NPs)

  • Bob

    Arguments over scope of practice do nothing to improve the current state of “delivering healthcare” or “practicing medicine” or whatever term gets people out of bed in the morning. Constant turf wars between the perceived “takeover” by ARNP (CPRN, etc, etc) in primary care is neither helpful nor productive for either side of the argument. Both PAs and NPs have a field that is roughly 45 years old. Physicians have been around much longer. Changing 100s of years of culture is a most challenging feat. Many lay people have no idea what the current scope of practice is for both PA/NP. I still get asked, “So you went to PA school because you couldn’t get into medical school?” Ignorance is bliss I guess. Collaborative relationships understanding that the Physician has significantly more extensive training is key to recognizing your own limitations as a “mid-level practitioner” or “Physician Extender”. All too often, people get there undergarments in a wad over “terminology”. Seriously, people? Assistant vs Associate, “Doctor Nurse” ad nauseum. Often I think we forget we’re here for the patients andworry too much about silly titles or letters after our last name.

  • soloFP

    As a primary care doc, I would add that the last 6 months of medical school are a waste of time. The core rotations were in the third year, and many of the students would leave 4th year rotations early. Scheduling interviews took up a lot of the first 6 months of the 4th year. Much of medical could be condensed, and there are combined six year programs for bachelors/MD degrees in the US.

  • PICUDoc

    Ahh, the NP vs. MD debate… a few points…

    Over the years I’ve worked with several NPs in the inpatient setting. Like MDs I’ve seen a wide range of skill, from those who function at the level of a good attending MD to those who were not as good as some of my strongest nurses.

    My biggest concern with NPs is the lack of standardization of training. For example, when you walk into a PICU in a children’s hospital and the attending shakes your hand you know that the person in front of you has completed 4 (med school) + 3 (peds residency) + 3 (fellowship) =10 years of training and is most likely board certified/eligible in critical care. NPs in a PICU can range from either a) having done a general NP program and never worked in an ICU before to b) having been a PICU nurse for several years and then done one of the few peds critical care NP programs. Both of these people could take a PICU NP position. Obviously we would want the latter.

    I don’t mind expanding the scope of practice for NPs. What I don’t like is that while for MDs boarding, and residency determines what I can do, while for NPs its really based on how liberal the state laws are with regard to their scope of practice.

  • Erica, APRN

    In my experience, many APRNs have enough flexibility in their advanced practice positions that they are able to take on part-time or per diem nursing shifts as well. I do, as do many of my colleagues. Many of us feel that taking MedSurg or other acute care shifts within our specialty helps us to stay current. Meanwhile, hospitals benefit from having a more highly-trained nursing staff, and actually save money by not having to award benefits as they would to a full-time nurse. Attaining a higher level of education does not necessarily preclude APRNs from still practicing basic nursing.

    I also know many APRNs who teach, especially as clinical instructors. Personally, all of my clinical rotations were instructed by APRNs who were simultaneously practicing in their given fields – some as APRNs, some as RNs depending on their circumstances. To my knowledge, many nursing schools are willing and able to generously accommodate clinical instructors – even if they are only actively teaching for one day/week.

    That being said, I’m not sure I understand the point of this post. Is the point that APRNs (or CRNPs) should not be allowed to practice independently because of the nursing shortage? Isn’t that like saying that medical schools should not allow medical students to specialize because of the primary care shortage?

    I think the reality here is that we already exist, you might as well use us.

  • imdoc

    “I think the reality here is that we already exist, you might as well use us.”… Which is what LPN’s have been telling RN’s for years.

    No wonder the patients are confuse about titles and who has what kind of training and competency. Based on the above posts, the midlevels can’t figure out their own designations and credentials.

  • Candi, CRNP

    But what some folks tend to forget is that NPs spend (on average) years working as RNs before becoming NPs. Somehow that seems to just not register. It is training and it does count towards our education. While I do not have a medical degree, I am required as an RN to know if every single thing an MD orders is safe and standard of care for my patients. It is my license if I carry out the order that was unsafe (and it usually nothing more than a slap on the wrist for the MD who writes an incorrect order but an end to the RN’s career). All of that knowledge goes into becoming an NP. I am well aware of what I know and what I do not know. I am not sure how my beoming an NP hurts nursing. I am first and foremost and RN and I always will be. I maintain my RN license, then my NP license, then my prescriptive authority license, and lastly my DEA number. Note the RN is first and none of the others can happen without it!

  • PICUDoc

    “But what some folks tend to forget is that NPs spend (on average) years working as RNs before becoming NPs. Somehow that seems to just not register. It is training and it does count towards our education.”

    This education is not required which I think is a detriment to your profession. I think it wouldn’t be a bad idea to require 5 years of nursing experience in a given area before you can be licensed to work as an NP in that area. Right now when you see an NP as a patient you don’t know what background they have and what experience they have in that area.

    • http://futureoffamilymedicine.blogspot.com mdstudent31

      And when you want to practice primary care and are faced with the choice of going to medical school/residency vs becoming an NP, what’s the better choice? What do you tell this person to do?

      My prediction is, given the current environment, that there will be a lot more younger NPs going straight through with their schooling without any non-educational clinical/professional experience within the next several years. The RN with 5+ critical care, etc years may not be the proto-typical NP student of the future.

      • PICUDoc

        It’s funny. There are nurses (not even NPs, but just regular RNs) in my PICU who make more than some of the residents doing primary care pediatrics. I think primary care medicine and pediatrics has been horribly undervalued. What bothers me though is that this is causing in fighing between the specialists and the generalists which is not a good thing for the field. We for better or worse are in a capitalist system. If people aren’t motivated to do primary care they wont do it.

        There are a lot more younger NPs these days. In fact most of the NPs I see are folks who went straight through and worked as a nurse while in NP school. I don’t think you can really fault them for doing this since the system allows them to. Like the NPs in the forum are saying many know their limitations and aren’t going to go beyond what they feel comfortable doing. The problem is that there’s no regulations that prevent them from doing this, while there are for MDs.

  • http://emergency-room-nurse.blogspot.com girlvet

    Many, many nurses I know are becoming NPs. Staff nursing is a thankless, stressful, underpaid job that will have to change drastically in order to have the number of nurses that will be needed in the years ahead. NPs are the future of primary care whether docs like it or not. Of course the AMA is against expanding the practice of NPs, they are protecting their own interests. The AMA needs to come into the 21st century

    • Jman

      The AMA doesn’t want someone who may have little to no nursing experience coming out of 5-6 years of school (total) – some or most of which can be done online – and having full independent practice rights. Contrast that with medical school during which students take three different tests and do a residency before being given the same responsibility. That is the concern. You see a physician – you know they passed their USMLE/COMLEX and completed a residency (and most are board certified – yet another exam) prior to becoming an attending physician. I call that concern for patient safety, not protecting one’s own interests.

      • Erica, APRN

        The point of our author’s blog post is not whether NP’s are qualified to practice primary care. His/her argument is that NP’s should not be allowed to practice primary care and/or open their own practice because of the nursing shortage. He/she argues that NP’s or nurses with higher degrees should seek teaching positions so that nursing schools have the means to shoot more nurses into the workforce.

        Whether or not NP’s are qualified to practice independently is a completely separate argument. It’s also one that I do see being a detriment to NP practice: NP’s, without a doubt, receive less training and have less clinical exposure (at least in an advanced position) than MD’s, and that is a very good argument against our practice.

        In terms of certification, NP’s are required to pass the NCLEX (you could think of it as being our “MCAT”) to receive their RN and later a specialized exam in their chosen specialty (PNPs must be certified by the PNCB: http://www.pncb.org/ptistore/control/index). So there is some standardization there. If your argument is that we should not be allowed to practice because we have not been tested/do not possess certifications then you are incorrect. If your concern is whether or not our standards are difficult enough then you might have an argument.

        • http://futureoffamilymedicine.blogspot.com mdstudent31

          Almost…

          Part of the idea of the post was to just spark conversation about issues within nursing that the entire medical community (physicians, nurses, everybody) should remember that need be addressed. IMO, the IOM failed to recognize these issues when they decided they could not come up with any new good ideas or dedicate more quality time and effort to fix the primary care workforce with physicians. Are they giving up?

          In terms of NPs in practice, you have heard it all before – collaboration/team-based care is optimal patient care. We already have a fragmented health care system that is specialty/procedure-driven. We need more NPs, more physicians, psych/behavioralists, pharm, social workers, therapists, etc and all working in collaboration with each other on the same team, in the same practice. It just does not seem appropriate for the patients and community to start fragmenting primary care when this is the time we need to strengthen it together.

  • jsmith

    Ok, mdstudent31, I gotta ask. Are you going into primary care?

    • http://futureoffamilymedicine.blogspot.com mdstudent31

      I will be starting my family medicine residency in July

      • jsmith

        Well done. Welcome.

  • SmartDoc

    The dirty little secret of all this is that NPs are not as pliable as some politicians believe them to be.

    Many, many NPs are heavily specialized and have suburban practices. In other words, they show exactly the same practice patterns as physicians. They will, in general, not be able to care for vast armies of new Medicaid cases.

  • imdoc

    Do the midlevels seeking independent practice support a single legal standard of care? There is currently a lot of luxury deferring liability to the supervising physician. “Team” sounds great until something adverse happens.

    • jsmith

      I supervise a NP. Here in WA state she can practice independently, although she is well-calibrated enough to know that would be a disaster, for the pts and for her. She consults with me several times during the day, as she should. The other docs in the clinic almost never have to run a case by.
      If she were crazy enough to practice along or with only other midlevels, she wouldn’t have a doc available so there would be a whole lot of consults. The specialists and well-insured pts would be ok with it. . Not sure it would have society much money.

  • KB

    Anecdotal evidence shows the argument that independent ARNP practice will adversely affect nursing education is not viable. First, there are waves of nurses trained at the masters level; some new, some heading into retirement. They can fulfill faculty positions. Secondly, every month, another school starts a nursing program; many starting advanced degree programs. As a result, there are more than enough newly graduated or newly licensed nurses for every available position (a casual review of nursing forums will show that a lot of recent grads are still without jobs). I don’t suspect it will change as long as the “nursing shortage” drum continues to be beat. I’m with Erica, APRN on this one. If the issue is independent practice, then standards and standardization should be the focal point. If the issue is limiting scope of practice to leave resources for nursing education, then it’s time to put that away.

  • Erika DeLorme

    Excellent post, MDstudent31.

    I have had two experiences with nurse practioners (one in the state’s leading private medical center, one in a public hospital)when doctors were unavailable. One NP was to give me a “well woman” gynecological exam before a mammogram. One was an initial visit as a new primary care patient. Based on those two experiences, I will never, ever allow myself to be shuttled off to an NP in lieu of a physician. I have several serious medical conditions, all noted in detail on my intake forms, and neither NP talked with me about my illnesses or performed exams with the expertise or thoroughness of a doctor, e.g., no digital rectal exam, no discussion of my estrogen use, etc. during a gynelogical exam.

    A nurse is an important member of a medical team, but is in no way qualified to act as a substitute doctor!

    • NurseKicko

      Im sorry for your experiences with NPs, but NPs arent meant to replace physicians. In fact, what NPs and nurses are asking for is simply to be allowed to practice to the full extent of their “scope of practice” (which varies state to state in all licensed positions from MDs to RNs to NPs, etc which is why you must be relicensed when you chose to practice in other or multiple states). Nurses, Advanced Practice nurses, and Nurse Practitioners are educated, licensed, and each assigned a “scope of practice” that determines their capabilities as a health care provider. The NP who did your “well woman” visit was probably assigned to you BY A PHYSICIAN because you were in fact, at a “well” visit. If you were having symptoms or required extra testing, you might have been placed with a physician instead. If the NP thought your exam was remarkable for any pressing signs and symptoms, he or she would have consulted an MD to ensure you received the type of care you needed at that time.

  • NurseKicko

    To sum up my opinion about this piece, as a nurse, I am embarrassed that our position is so poorly understood and each level so poorly recognized by society. It definitely hurts our social recognition and acceptance into higher positions of responsibility when people still think that all nurses do is clean out bedpans. We are clinical, professional, well-educated members of a team that includes our own profession, doctors, social workers, case managers, etc who simultaneously engage in the care of patients. We are team players, we CAN be great leaders, although we arent historically trained to be so, and we aren’t trying to take over the MD role. What current legislature is seeking to do is simply allow the various nursing roles to practice to the full extent of their “scope of practice” (which differs from state to state) and is usually greatly limited from practice to practice, hospital to hospital, for various reasons. With the health care reform coming into play, the face of medicine has no choice but to change. Frankly, it is cheaper to address the nursing side of patient care as a solution, and the nursing profession proves to be extremely effective at achieving high patient outcomes. There is a physician shortage as well as a nursing shortage, especially in primary care, which is going to be the answer to “universal” health care in this country. I am a newly graduated nurse, and I was trained to be a clinical expert, a leader among not only my peers, but also a leader of my patient’s care, and everything I do is done because there is clinical evidence to prove that those actions yield the best outcomes for patient care. There is a new generation of nurses being trained that will surprise the health care industry. We are politically savvy, hungry for respect for our profession, and eager to improve the nursing stratosphere into an organized, well-defined, well understood body of practitioners.

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