CKRN

Thoughts on nursing and health care from an RN who has worked home health, oncology, emergency, orthopedics, and hospice. I'm entering my 7th year of practice and have spent the last 3 years teaching at a school of nursing in addition to maintaining a professional practice. I am enrolled in a DNP program with a focus in FNP. I passionately believe in the right of every person to quality health care. I love the profession of nursing, but also think we have a lot of growing to do. Thoughts and opinions are my own, and certainly don't constitute professional advice. - CKRN, MNSc, CHPN
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Dear Morning Edition,

I am an Assistant Professor of nursing at Colorado Mesa University in Grand Junction Colorado. I am also a second time graduate student working on my Doctor of Nursing Practice. When I finish, I will have a terminal degree in my profession and will be prepared to provide primary care to families to the fullest extent of my training.

I frequently listen to NPR, and have for years. I often listen when driving around to visit my nursing students, and appreciate the breadth of stories offered. I was listening this morning, when at the end of Morning Edition’s business news, a controversy over changing graduate education for law professionals was highlighted. One potential solution that was offered to appease both sides of the issue, was to create a limited scope certification to practice law, requiring less education. The comparison used, for illustration of the point, was “kind of like a nurse practitioner.”

Let me be clear. When I finish my DNP, I will have a terminal degree in my profession and will be practicing nursing to the highest degree possible. If you compare me to medicine, a profession of which I am not a part, then yes, my scope is limited. But I am not a doctor, and I am not becoming an NP to be one. I am a nurse. Though nursing and medicine have overlapping roles and skill sets, we are different professions, with distinct histories and cultures. When I graduate I will be a licensed professional practicing the full extent of my relevant skills, not a limited practitioner in my own profession.

Perhaps a better illustrative comparison would have been first-year resident physicians as compared with board certified physicians. These professionals have graduated medical school, but still have many years of being a learner ahead of them. They begin seeing and treating patients under supervision, but before they receive their state medical licensure.

I hope you can see how your comparison was offensive to myself and my profession, as well as how such a comparison could continue to contribute to public misinformation regarding the profession of nursing and the role of nurse practitioners.

Sincerely,

Courtney Kasun
RN, MNSc, CHPN
DNP-FNP Student

The written and audio transcripts can be found here:

http://www.npr.org/2013/09/18/223610581/should-it-take-3-years-to-earn-a-law-degree

I’m not quite sure when I first heard the term “mid-level” as a phrase used to refer to physician’s assistants and nurse practitioners. I’ll be honest that I don’t know much detail regarding the etiology of the phrase. What I do know is that it bothers me.

As a registered nurse and future NP, I find the phrase to be insulting. The term “mid-level” implies not only a hierarchy in which I am just one in the chain, but also implies I may have less value than those who aren’t “mid.”

Just yesterday, someone asked me, why, since I’m getting so much education, I wouldn’t just be a physician. This is a frustrating question for me.

I have so much respect for my physician colleagues. Many of the people I choose to spend my free time with are physicians. My medical colleagues are a profession of smart, educated, expert diagnositicians and clinicans. They teach me things every day and open my mind.

Between physicians and nurses, and especially advanced practice nurses, there is redundancy. We each have sets of skills and knowledge that overlap. However, in contrast, we also each have skills, knowledge, experiences, and outlooks that make our professions unique.

The redundancy between health professionals can be distressing; I know it is for nurses. When I taught in an interprofessional clinic, my nursing students struggled the most with finding their unique professional identity when working alongside students from medicine and pharmacy. I would imagine the expansion of scope of practice for NPs and PAs could feel similarly for physicians. Unfortunately, in my experience, this isn’t a distress that will be resolved by telling other professionals where they belong.

I want to be a nurse practitioner, not because I’m not smart enough or motivated enough to go to medical school, but because I like being a nurse. I believe THIS professional frame best suits the skills I have to offer my community in the advancement of their health.

Make no mistake, however, there will be nothing “mid” about my preparation or skills when I start providing care. I will have a terminal practice degree in my profession, and though I will be starting a new role, I will also have a decade of experience in health care, as a nurse clinician. Will I be able to do all of the same things as a physician? No. Should I? No.

But the fact that I won’t do everything a physician does, doesn’t make me lesser. We’re a team, and it’s increasingly important that we respect one another. What a physician’s role, an NP’s role, a PA’s role are may change depending on context. It’s the duty of those professionals to establish clearly who is responsible for what and to hold each other accountable.

As long as the term “mid-level” is acceptable, people will continue to ask me questions that imply I’ve wasted my time and talent in my profession. In addition, throwing Physician’s Assistants and Nurse Practitioners under one umbrella, is unfair to both professions that have different backgrounds, educations, and histories. And while PAs do fall under the regulatory scope of state boards of medicine, NPs do not. Nurse Practitioners are the highest functioning clinical practitioners in a unique profession with it’s own regulatory bodies.

I will be a doctorally prepared Nurse Practitioner, and proud of it. I will, as I do in my current practice, aim to provide the best care I can for patients, and to connect them with things they need I can’t provide. I will continue to learn and grow, to seek out new evidence, best practices, and knowledge. I will be expected to be a leader, an educator, an advocate for policy changes. I will function at the top of my profession and push myself to be the best I can.

There’s nothing mid about that.

Today, the AAFP, or American Academy of Family Physicians, released a statement on how Nurse Practitioners are ruining primary care. You can find it here

Frankly, I find this statement condescending and disheartening. First of all, the statement over simplifies a much more complicated issue. Yes, I believe in removing barriers to nurse practitioner scope of practice. One practical reason for this is that when nurse practitioners are authorized to diagnose and prescribe, they can also bill more comprehensively for services. If nurse practitioners cannot bill for services, they aren’t useful additions to the health care team, instead they become overly trained cogs with no legitimate place in the system.

Might these authorities lead some NPs to practice independently? Yes. But you know what? That’s not really medicine’s issue. Nurse Practitioners are highly trained individuals. Do they have the same training as physicians? No, and we don’t want it. We’re nurses. Our training has a different focus and intensity. There are things we learn that medicine doesn’t, and things that medicine learns that we don’t (the AAFP and I agree on this, at least).

Any nurse practitioner will have a bachelor’s of nursing science, a four year degree with a focus on pathophysiology, psychosocial development, pharmacology, the delivery of nursing care, and health care leadership. Let us not forget, a first year medical student may have a B.S. in Biochem, but they may also have a B.A. in English. Neither of these degrees include hands-on, patient focused experiences. However, nursing, as a profession, starts our practice at the undergraduate level.

After their BSN, most, but granted, not all, NP candidates will practice as an RN for 2 or more years before starting school. I, myself, will have 6 years of clinical experience before I start my DNP training. That’s two Family Medicine residencies full of seeing, assessing, and being with patients, as well as learning all I can from my physician, nursing, pharmacy, and other practice colleagues. A master’s prepared NP will have at least 2 years of graduate work, including additional clinical time, and a doctorally prepared NP will have 3-5 (depending on the pace of the program). Furthermore, most NP students CONTINUE to practice as RNs while in school, and many do so full time. This gives them even more hours that, while not in an NP role, they can be practicing and refining their new knowledge and skills. You don’t have to be the person writing the prescription to critically think about whether it makes sense and what the implications of that action may be.

Furthermore, Nurse Practitioners are independently licensed, board certified professionals regulated by state boards, just as physicians are. We should be able to see patients independently and should be trusted to know when they’re in over their heads. Those are the rights and responsibilities of professional licensure. Just as a family physician may need to refer a patient to a specialist, an NP practicing independently should know when they need to refer a complex patient to a physician or to consult with a colleague. Knowing your limits is just as important a part of professional training as all of the medical and biological knowledge. 

The implication that Nurse Practitioners are not smart enough to realize when they are not capable of providing the highest quality care is insulting. I am a nurse, I advocate for patient quality and safety EVERY, SINGLE day, and do so passionately. I don’t care who treats the patient, who solves the puzzle, or who has the right skills for the job, I care about the patient. However, the AAFP’s policy statement makes it sound as if NPs are unable to make these distinctions, and that they are unconcerned with quality care and patient safety.

Indeed, it is our professional passion for quality and safety has led the nursing profession to push for the Doctorate of Nursing Practice (DNP) to be the standard of entry to advanced practice. This degree has both more didactic and clinical hours to better prepare practitioners to provide high quality care.

I have had the privilege of being a part of a high functioning interprofessional health care delivery team. I know that the quality of my care is improved when I work collaboratively with other health professionals. Many NP candidates know this as well. However, convincing us to work in teams with physicians is not going to be achieved when physician organizations like the AAFP release statements that disparage us as professionals. As the AAFP has reminded me many times today via twitter, “NPs=MDs? Not So Much.” Very true, which is why it shouldn’t be medicine’s job to define our practice or role boundaries.

The way the AAFP has presented their argument leaves me throughly disheartened. I spent an entire year of my career teaching nursing, medicine, and pharmacy students in a family medicine clinic. I taught them about professional respect and collaboration. Through my own collaboration with my faculty colleagues in the clinic, my professional world was expanded and improved. These experiences led me to elect a Family Practice focus in my NP program, rather than Adult Acute Care. I’ve been an advocate for Family Medicine at every turn, supporting publicly the specialty and its mission.

After today, I’m not so sure. With one statement, the specialty that made me believe in the future of healthcare has made me feel like a second class citizen. It has told me that I should dream a little less big, and that my place at the table is whatever medicine decides it is - NOT as an respected equal with a different world view and training.

Believe it or not, that attitude doesn’t make me want to collaborate. I doesn’t make me want to advocate for family practice or take an active role in helping to train and support medical students and residents. In fact, it makes me want to not focus on primary care. AAFP, if you want your turf, you can have it. I’ll practice elsewhere.

Over the last three years of my teaching career at the schol of nursing, there has been an increasing focus on fostering professionalism among our students. Our school of nursing, having rewritten our curriculum, has added three classes on nursing professionalism. The most common reasons that our students need remediation or experience failure in clinical courses are all related to professionalism. If we expect our nursing students to learn about professional image and standards, we cannot just pay lip service to it, we must also role model it. 

However, recently, in both my hospital role as a staff nurse and my role as a nurse educator at the school of nursing, I’ve had two similar experiences that left a bad taste in my mouth and have left me questioning our deeper professional values.

For a brief period this spring, I was dating a friend who also happens to be a hospital co-worker. Though we were approaching the point where we would have discussed this with our bosses, we went our separate ways before we got to that point. Even if we had continued to date, I was scheduled to transfer to a new unit in the coming weeks.

We each told exactly one coworker about our personal lives, but rumor that we were dating started spread in spite of us keeping mum on the subject. To some extent, I expected this. However, when it was revealed to me that it was my Unit Educator, one of the nursing leaders on the unit, was asking around about whether my friend and I were still dating, and that she was asking colleagues who had no prior knowledge of our relationship, I became irate. Neither myself nor the other person involved in the relationship had spoken with our educator about it. We certainly didn’t want her advertising and casually discussing our dating with other unit staff, especially as we had already broken up by this point.  This situation was frustrating, but at first, I counted it a rogue occurrence.

Fast forward to 4-6 weeks later. I am now officially relocating to Colorado, for many, many reasons, both personal and professional. When I told my immediate supervisor at the school of nursing that I was leaving, I did not include the fact that I am dating someone in Colorado among the reasons for my relocation. As far as I’m concerned, it’s none of her business.

However, last week, when out to breakfast with a friend, I ran into the dean for our entire school of nursing, as well as our school of health professions. Our dean is very warm and personable, and I think she generally does a good job of representing our school and campus. However, she’s a busy person, and as such, we have encountered one another on a one on one basis only once. Furthermore, it has only been in the last few months she has come to be able to connect my name with my face as I was scheduled to become a faculty scholar, a program she oversees, this year. 

On my way out of the restaurant, I had to pass the dean’s table. She grabbed my hand and told me she wished me well. She then proceeded to introduce me to her school of medicine colleague, with whom she was dining, and tell that colleague “Courtney is leaving us and heading west for love.” She also then asked if the gentleman I was dining with was my new beau (he wasn’t). 

After this second incident, I have found myself increasingly frustrated that nursing leaders at both of my places of employment have not only inserted themselves uninvited into my personal life, but they have discussed it with professional colleagues as if this is okay. 

Sure, it is easy to role model professional values like dressing appropriately and arriving on time. However, do we as a profession fall short when we start getting into more difficult professionalism issues like boundaries? We as nurses have an unfortunate reputation amongst other health professions for gossip. That things like this occur and we continue to live up to such a stereotype makes me crazy. It is one thing to care for your co-workers, it is another to not ask them directly but proceed to speak with others about their personal lives. Sadly, this is only one of many examples I can cite from the last year of lacks of professionalism in nursing.

Or maybe I’m just being overly critical because I’m personally annoyed.