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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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.

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