Are We Approaching the Issue of Nurse Practitioner Independence All Wrong?

Last month I attended the NPACE conference in Nashville. The keynote presentation delivered by nurse practitioner Dr. Ken Miller, Nurse Practitioners: 192,000 Solutions to Healthcare Reform, didn't spark my interest when I initially registered for the conference. I figured that as one who stays pretty up to date with legislative issues affecting NPs he wouldn't have much new information to share. But, of course, I was wrong. 

Dr. Miller said something during his presentation that I really took to heart. "We are approaching questions of nurse practitioner independent practice all wrong", he asserted, "there isn't a single healthcare provider who practices independently". Dr. Miller's statement really stuck with me. 

In reality, no medical provider works on their own. No matter the size of the practice, the confidence of the provider, or the level of prestige, we all rely on each other. Emergency department NPs and MD's alike refer complex facial wounds to plastic surgeons, family practice physicians and physician assistants refer uncontrolled diabetics who they feel uncomfortable managing to endocrinology practices. The web of relationships among healthcare providers extends not only to those with the ability to diagnose, treat, and prescribe, but really to all levels of the healthcare system.

Working as a nurse practitioner in the emergency department, I would be nowhere without my RN colleagues. Their speed and skill in placing IV's, putting in foley catheters, transporting patients to the ICU, and alerting me to patient care decisions that need to be prioritized is essential to my ability to perform my job. Without a physician present, I would be lost when it comes to the most complex cases that make their way into the ER. Even now that I can deal with many of these on my own, I was taught by an MD. The phlebotomists with whom I work draw blood and deliver it to the lab with unmatched efficiency allowing me to get results and therefore make clinical decisions as quickly as possible.

Healthcare's hierarchy can be frustrating. Using language like "independence" when arguing that we should be allowed to practice to the full extent of our abilities makes it seem that we want to be removed from the system completely. But, we don't. As nurse practitioners we are arguing to practice to the full scope of our abilities. This includes the ability to determine if a physician or another healthcare provider must be involved in the care of and decision making process for our patients. We aren't arguing that we know how to do it all, that we never need to refer to another provider, will not ever involve physicians in the care of our patients, or that we are equip to go solo. No, the nurse practitioner independence movement is looking simply for the freedom to decide when this involvement is necessary and when we can handle things on our own. The word "independence" doesn't convey this sentiment accurately. 

So often, supervision and collaboration agreements required by state governments are simply pieces of paper. Their removal wouldn't affect the day to day care nurse practitioners offer to patients. We aren't involving our collaborating physicians in many cases, anyway. The removal of this requirement wouldn't affect the way medical care is provided but rather remove barriers to providing more care to a greater number of Americans and decrease the health costs caused by this bureaucracy. 

I'm not usually one to focus on the minutiae, or to focus on choosing my verbiage carefully (maybe I should start....). But, when referring to nurse practitioner scope of practice laws I'm planning to ditch the word independence. I think Dr. Miller is right- we are approaching this argument all wrong. Independence isn't actually what we want. We want to remain interdependent, just like all other healthcare providers. What we really want is the legal recognition required to practice to our full ability. This includes the ability to recognize when a medical situation's complexities are beyond our training and warrant the involvement of another provider. 

Thoughts?

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Comments

Many medical providers practice alone and do not make referrals for financial reasons.

I am a Psych NP and Board Certified Psych CNS with a sub-specialty in neurology and a PhD. I have patients that wet the bed a few times a week, have tactile and olfactory hallucinations, etc yet the PCP will not send the person to a neurologist or order an EEG or MRI for me.

I have people with HCV or HIV that have cognitive impairments, I cannot even get requested lab results or an EEG for suspected brain impairment such as static encephalopathy from the HCV (or HIV).

I have patients with obvious and witnessed sleep apnea and COPD yet cannot get a PCP to order a sleep study for me.

The bottom line is that people practice alone and do not make referrals due to capitated payments. They would lose money. This is unethical , immoral, and wrong!!!

I have to hear about bedwetting, sleep apnea symptoms, etc. and it makes me ill because I cannot do anything about it. I write letters to providers and do my best but no one listens.

If I call for test results during my 15 minute visit, I am on hold, have to leave a message, etc. and I still don't get the requested info. If I get through to someone, they want a release of info even though one was sent or we are in the same network. I just don't have the time or energy anymore to do all of this.

Sorry but people are still practicing alone to save money and to make money!!! Arrogance and Ignorance is a bad combination!!!

Kelly PhDNP

I agree and I don't agree! I believe Nurse Practitioners should be able to practice comparable to physicians in the respective specialty, i.e., Psychiatry- Psychiatrists practice independently in private practice and NP's should be able to practice comparable to a private practice psychiatrist if they so desire and/or a Family Practice Physician who has his own practice and a NP who wants her own Family Practice should be able to practice comparably. To be able to do this NP's need to have NO collaborative/collegial/supervisory agreements with physicians. We know what happens when the State requires these agreements--NP's have to pay monies to the physician and they cannot practice "independently" comparably to physicians in private practices.

I understand not every NP wants to have their own private practice and there are NP's like myself who have worked their whole life to have just that: a private practice with independence--with choices to collaborate when I choose to do so for the best care of my patient and to have the choice to practice independently without any collaboration which works for most of my patients.

I think we enter very dangerous territory when we take out the word independence for NP's like myself. We need to have the choice and no mandates by the State.
Let me know your thoughts!

Terri Squires, ...

So in CA we're changing what we want to "Full Practice Authority", also emphasizing that we all practice collaboratively with each other, as part of the health care team.

Patti Gurney

So well said and I applaud your insight. No one in the medical field should feel like an island - we are a village and it will take all of the village to provide great care. Thank you for understanding the verbiage.

Nancy

Ooh, I like the "responsibility" terminology! And yes, I agree, it is essential to have great mentors in the early years of practice!

Erin Tolbert

Agree fully. It's a word tat is misunderstood and conjures up fear among physicians and others.
what I have been saying to my PA and NP colleagues is that after 50 years we have earned "full responsibility". The responsibility to practice our craft without having someone else "oversee" it.
It's time. I do think we all need to practice "under" someone for a year or two and then it's time to spread our wings and be responsible for what we do.
Dave

Dave Mittman, P...

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