Sunday, November 14, 2010

Advocates of Independent Nurse Practitioner Practice Losing Focus Within Current Scope of Practice

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.

1 comment:

  1. I wanted to point out 3 things in particular in your post:

    1. Removing barriers to NP practice are generally not scope in nature. Oftentimes, these arguments get lumped together as scope. NPs are educated and trained to care for patients needs. For example, in NY where i practice, removing the statutory requirement of collaboration with a physician does not change anything that I currently do - it merely frees me from being formally linked to a physician. Which without, I could not practice at all. This is opposed to say a podiatrist, who may be pushing scope to treat conditions above the foot.

    2. There is much debate whether we are currently in a nursing shortage or one that is projected. Anecdotally, I know many nurses with varying degrees of experience who cannot find jobs.

    As the largest workforce in the health care sector (3 million plus), I agree, more efforts & resources must be dedicated to educate and train the next generation of nurses to care for sicker, more complex and older patients. However, please dont think that the projected shortage is a result for nurses going on to advanced practice which is less than 10% of the nursing workforce.

    3. The DNP was never intended to solely be an academic credential to teach. This is a practice doctorate that is meant to be clinical in nature to merge the best evidence into practice. Sadly, those in nursing faculty positions earn a disproportionally less amount than their clinical counterparts.

    I would welcome the opportunity to dialogue further on this. I invite you to read my blog to see my view as an NP. There is much misunderstanding, confusion and lies out there. Family physicians and nurse practitioners have generally enjoyed strong relationships on the front lines of family medicine. We are not the enemy nor do we look to supplant physicians. We seek the opportunity to care for patients the way we were educated, trained, licensed and board certified to do.

    Thank you,
    Stephen Ferrara, NP