Independent practice: Nurse practitioners respond


Shortly after the publication of “Independent practice: Both nurse practitioners and physicians should be outraged,” the nurse practitioner (NP) leadership responded with a press release, denouncing the concerns that were cited, calling them “rhetoric.”

But in contrast to this criticism from the political end of the NP spectrum, I was inundated by emails from working NPs across the country in support of the article.

Since the NP leadership requested a response, I can’t think of a better one than to present them with the words of their own constituents. In fact, in reading these comments, they may find that they themselves are the ones “out of touch with the realities of health care delivery today.”

Take Ryan in Pennsylvania, for example. He felt so strongly about the article that he was compelled to write me: “I am a young NP and have long been an outspoken opponent against independent practice. There is certainly enough work for all of us, and it scares and angers me that schools and professional NP societies are tarnishing our reputations in the changes they pursue.”

Or Pam, an acute care NP, who wrote, “I read your article and so appreciated your approach to the issue and agree with many of your points. I, too, have patient safety first at the heart of my practice and do not believe independent practice is the ideal. I also agree that we are now pushing unqualified and largely clinically unsupervised nurses through cyber-programs that have no interest in failing a poorly prepared candidate.”

In their press release, the leadership argues that NPs are being held back by physicians, and are particularly critical of collaborative agreements, decrying them as “financial vehicles designed to profit physicians.” But many NPs wrote to me expressing their appreciation for such arrangements.

Newer NPs recognize that there is much still to learn — like Ryan, who wrote: “I enjoy the collaborative nature of practicing under a physician and believe the strengths of an NP or PA are best utilized in that format. The strength of an intelligent person is knowing one’s limits.”

Or Brian, a last-semester FNP/AGACNP student who has been an emergency department and intensive care nurse for a decade, who wrote: “The fact of the matter is that I don’t want to practice without a doc. This isn’t an ego game, and I feel that many NPs (along with our professional organizations) are making it into such.”

But even the most seasoned NPs value a relationship with a physician, like Sherry, who wrote, “As a veteran nurse of 34 years and an acute care NP for 11 years, I am fortunate to be in a wonderful collaborative practice at a community hospital in the suburbs of Chicago. I never take for granted the value of the physicians who dedicated their lives to medical school. I consider myself to be an old nurse with sharp physical assessment skills, a drive to always push myself to know more, but I will never believe my training is equal to a physician. Keep up your fight for the safety of all mankind, for some day we will occupy those critical care beds too.”

Mary, a self-described “old” NP with 20 years’ experience — “one of the first NPs in central Louisiana,” pointed out the value of working with physicians. “I agree and appreciate you voicing the reality of the difference in MD versus NP training. I feel that I had excellent university-based training, but it could never be equated to a residency. I feel I was trained to supplement/extend the physician care, not take its place.”

Carol, a family NP in Tennessee with “almost 30 years of nursing experience” before becoming an NP was very clear. “I do not want complete autonomy; I do want collaboration with my physician cohorts.”

The press release had little response to one of the biggest concerns listed in my article: the decreased quality of NP education. This is something that working NPs and students wrote me about.

Mary, the NP from Louisiana, wrote: “I am appalled at the NP schools requiring no RN experience for admission. I was an RN for 23 years and still found the shift to NP a total paradigm shift.”

Pam, the ACNP from Illinois has seen this with her own eyes. “When I began my program, there was a 22-year old girl who had not yet even sat for her RN licensure. I was astounded.”

Citing a colleague who recently graduated from the direct entry Vanderbilt program, Carol, the FNP from Tennessee wrote: “Every nurse and non-nurse that can fog a mirror wants to go to NP school and can just about get accepted by one if the money is right.”

Doug, a DNP student, agreed: “I refer to these online programs as ‘fly-by-night practitioner programs’ … I hate to see nurses with no experience or 1-2 years with a BSN and very little work experience allowed into NP or DNP programs. Unfortunately, this is what is happening.”

And M.R., a FNP student who is currently attending an online program writes: “I could not agree with you more. Most of the [online] colleges will never match medical school training and hours dedicated to becoming a physician. My son is attending medical school. As a mother of a med student and as an RN trying to obtain my NP certificate, I understand your views.”

The NP press release concluded with a call to work together to increase access to health care. Perhaps they should take their cue from Sherry, ACNP, who wrote: “Thank you for expressing your outrage with the state of health care with the projected shortage of physician providers. It is terribly unfortunate to watch the profession of nursing mass-produce nurses, and then allow these novice nurses to enter advanced practice programs that have limited curriculum to prepare them to care for patients without supervising physicians, much less independently.”

The NP leadership would be well-served to listen to its constituents, who are gravely suffering under their policies. As Carol lamented: “The NP status meant something at one time; no more. I sincerely wish I had remained an RN. I feel like I must struggle for my identity now.”

Your concerns are valid, and you are not alone. Physicians, nurses, and patients working together can make a difference in health care.

The author received permission to use each quote cited in the article.

Rebekah Bernard is a family physician and the author of How to Be a Rock Star Doctor:  The Complete Guide to Taking Back Control of Your Life and Your Profession.  She can be reached at her self-titled site, Rebekah Bernard, MD.

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