AMA Scope of Practice Data Series: Nurse Practitioners

[David G. O'Dell, DNP, FNP]

Hello everyone. I received a copy of the AMA Scope of Practice Data Series: A resource compendium for state medical associations and national medical specialty societies regarding the Nurse Practitioner. This was published October 2009.

I'm very interested in seeing comments on this document. Please check it out - share with colleagues and add your thoughts to the conversation.

Thanks,
David O'Dell

[Michael Terry, DNP, APRN-PMH/FNP]

Clearly intended to sow confusion in stakeholder groups, this document has several unusual aspects. It decries the limitations of MS preparation for NPs while simultaneously branding DNP preparation as ill-conceived. It does, however, hold a mirror up to nursing's internal deliberations about the APRN. Their angle is not a particularly flattering reflection either.

The document does also appear to support the idea (unintended, of course ;-) of the NBME Certification Exam.

"...the many specialty areas available to NPs in their education programs and certifications may in fact contribute to variability in NP competence. Undeniably, were this controversy brought into the public eye, patients may well be upset to find that NP's do not share basic across-the-board competencies as determined by an examination commensurate to their NP education, as physicians do to their education. Advanced practice, with its attendant privileges in the care of patients, including examination, assessment, diagnosis and the development of appropriate treatment plans for patients, requires basic fundamental knowledge and skills, which can and should be tested in order to assure patients of the minimum competency level of their health care provider."

Strange, when just 11 months ago, the AMA News openly criticized the same thing. see: http://www.ama-assn.org/amednews/2009/06/08/prl10608.htm

Reading it for yourself, you will find several additional inconsistencies such as this. Essentially the new AMA approach appears to criticize all aspects of NP practice and preparation, make judgements and recommendations; and then attack the very same solutions they seemed to support elsewhere in this report. Surely that did not escape the notice of this well-heeled and influential professional organization; a group that is publishing nearly 150 pages for each of nine "limited license" professsions. An impressive feat to say the least, but not really intended to inform.

[Beth Phelps]

I found the whole paper disturbing. The AMA must be extremely nervous about mid-level providers moving in on "their" territory. The sad thing is most of us have great working relationships with our physician counterparts and papers like this one take everyone backwards to the stone age where nurses stood up and gave the doctor their chair.

[Elizabeth MB Visone, DNP, NP]

It looks like we have a new identity as well, "limited licensure (non-physician) health care profession." I have to agree the AMA must be really nervous to put out this type of document, convoluted and contradictory. I doubt the AMA speaks for most of the physicians that work with NPs.

The issues brough up in this document that we as a profession have not yet resolved leave me wondering when we are going to get our act together. I do have some concerns about us not even have a standard entry level to the profession and here we have a clinical doctorate program as the new entry level for advanced practice. Maybe those of about to graduate with our DNPs can help resolve these issues. Let's hope we can get the dialoge going in the right direction.

[Ella Ares, DNP, DCC]

How closely we (NPs and APNs) are being scrutinized, I am wondering if this because of the DNP degree. I don’t understand why the AMA went to the trouble of publishing a whole “module” that largely restates outdated internal communications from various nursing education credentialing boards, and why they see this as relevant.
Although there are quite a few contradictions and many misconceptions, I think the most valuable thing from this publication for our profession would be to use this as an opportunity to look at areas where we ourselves contribute to these misconceptions. I am sure I will be bringing some cries of protest to this, but the lack of uniform credentials IS a problem. The alphabet soup we put after our names is confusing to us, how much more is it confusing to professionals in other fields?
Another good point from this publication: Why do we require a national exam (with state licensing) to become an RN, but not to practice as a nurse practitioner? Some states do require one of the national certification exams for practice; some do not. From nurse practitioners I have worked with, the knowledge and skill base even in one specialty can vary (embarrassingly!) greatly, especially among those professionals who have chosen not to take one of these examinations. I think it is astounding that we find ourselves still not in agreement about this.
If we want to be taken seriously, we need to stop crying every time we are criticized and start looking for ways to validate our competencies that are verifiable and evidence based. Pointing to the studies that show similar outcomes with physicians are not enough if we cannot prove that all nurse practitioners are starting with a standardized skill base within their specialties.

[Diane McGinnis, DNP, FNP]

Thanks, for bringing this up for the DNP's to converse about.

I just jotted down some of my observations below.

For my input I do feel we need to have greater standardization in NP education. Having gone through one program, and now working on a post-masters certification program that in my opinion is far superior. However, my original program may have made changes from when I was there. My class was the first "online" class at my original program.

I feel I am getting more learning from the online format being used in the post-masters program ie. elluminate, macromedia breeze presentions, mailing cd's that were prerecorded, etc. than if I just had to have "face" time in a classroom. I know a DO program that is now using clickers however, which I am sure increases participation. They are also now video archiving each lecture as well, for students to view later (using MediaSite), and placing notes and powerpoints online. Not much different than NP programs are.

I believe AANP'S stance against the DNP exam was misquoted in the article to being against any standardized exam. AANP and AACN give a standardized NP exam...the FNP. The DNP degree includes the administrative track, which of course could not be expected to pass a clinical diagnose, prescribe, and treat exam. So AANP has a valid arguement that all DNP can't take the DNP exam

Another concern is that the article has enough "truths" in it to make it believeable to those who are not NP Trained, including other nurses. Which is very concerning to me. We need to educate our own about scopes of practice. Our (NV) board has LPN, RN, and CNA on it I think. With appointed Boards, nursing does not have control over who is on the board, which can create harm if the board does not understand this article well.

I would like to see higher CE and clinical requirements for recert, So I can not disagree with the article in that aspect. I do believe they've tilted there own "exam" though as I do not believe physicians take the full board exam to recert. I know several ER Docs who had to do some sort of supervised article review....but the answers were basically give to them in advance. I also know several cardiologists who would be hard pressed to pass a pediatric exam! Even after 12 years of "schooling".

Another issue is the physicians are paid a salary for their residency, that is funded by the government (taxpayers). Currently they forget to calculate that into their calculations of whether NP'S or physicians are "cheaper". Against my own "logic" in the preceding sentence however, I am sure many NP'S would participate in a residency if they were paid. I wonder how many physicians would still tout residency if they had to continue paying for the credits out of their own pockets? The other issue is that after about 4 years of practice the NP has done the "time" similar to a residency. Maybe a conscession to have higher CE's and practice hours the first 5 years?

The way the CE'S were described is not standard and is just for the renewal of the cert. They conveniently left out the analysis of individual States CE req's which are very different depending on the state.

I am not sure were they were going with the "compact" issue, there didn't really appear to be a point?

I could come up with more but that is all I recall without the article in front of me.

Thanks for representing NP'S!

[Dr.Timothy F. Gardner,FNP,NP-C]

How appauling to me, is there anything right about us? Such criticism! More in a bit..however isnt it ironic that according to them we are so unqualified..yet we provide the majority of care in many physician offices independently,they turn their head as long as the almighy dollar roll in and we remain invisible.

[Terry Sumpter DNP, CRNA]

This all about "CONTROL" I assure you. First at the practice level, licensure, and let's not forget about the most important and that is economic control. The CRNA's have been dealing with this all of my career which has spanned 30 years with the anesthesiologists. Now with the introduction of the DNP to the CRNA's degree all of the NP's are being assaulted. The DNP degree has encroached upon the sacred MD fraternity. We all are well educated to the point that it merits equality. If we were in a foreign country we all would have Medical Degrees already.

Terry A Sumpter, CRNA

[Dana Hannah]

Thank you for putting the AMA report out for nurse to review. I am impressed with the report. The AMA is obviously very interested in the NP/DNP profession. The author is passionate in their description of the nursing profession-saddly the negative emotion is easily revealed in the choice of words and sentiment.

Issues of concern: They are very correct in their critique of nursing. We need to get our act together. Get standardized. Too many labels/names/certifications. Basically---it is true--the public is confused---"what is a nurse practition?" I should not have to answer that question. Nurse practitioners needs to market themselves better to the general public. Notice the great report itself---Nurses needs to general these calliber reports to submitt to the profession and the legistlators.

I believe this AMA evaluation of the nursing profession is an excellent learning tool. It provides NP/DNP with the exact issues that need to be addressed. Use it as a guide to help evaluate how nursing is viewed by the medical profession. We obviously have them shaking in their boots.

[Donna Emanuele, DNP, FNP-BC]

The key word in your response is "standardization". However, for this to occur nursing will require an organizational culture change within the nursing profession. As such, many transformational processes are required to adopt changes needed to advance professional nursing practice; to increase our visibility and; to impact our roles among other health care disciplines, politicians, various stakeholders groups; and within our communities.

Without standardization, our profession will continue to experience difficulties in achieving and advancing autonomous practice; lacking the ability to enact legislation to improve regulations to scopes of practice that currently have wide variation across all states which impede our ability to practice and improve access to care.

Where are we as a profession regarding the Consensus Model for APRN Regulation (LACE report) developed in July 2008 in collaboration with the National State Councils of Boards of Registered Nursing Advisory Committee and the APRN Consensus Work Group? I have not been able to locate any updated information since the report was initially disseminated.

Even in the recent Southwest In-Flight magazine article of October 2009, the author poses an interesting question regarding the "branding" of advanced practice nursing as a marketing strategy to help clarify; make visible; and heighten the role of the APRN. Not necessarily a bad idea.

Donna

[Susan Lee Benson]

Susan L. Benson........11.12.09 Response to AMA defining nursing practice:
1. The hallmark of any profession is to define itself, respond to a societal need, evaluate and regulate itself, so why does the AMA think it can do this for the nursing profession in this day and age? Medicine has been in universities much longer than females, so they have had a longer time to forge a profession. It’s a matter of gender discrimination, but this history is overlooked and so medicine feels entitled to comment on nursing. We have so many kinds of nursing degrees and titles because we grew out of hospitals, colleges, community colleges, and major universities and some Ivy towers. And we have so many titles because we want clarity what we can do. Yet with all these challenges, we get voted by the general public as the most trusted health care professional year after year (except after 9/11 when fireman were heroic).
2.What’s under this whole smoke screen is about economics. The medical home means that physicians as team leaders will collect the incentives and be paid on their performance or the performance of patients that are doing self care. The team leader needs to be paid more. The physicians do not have skills for the medical home like case management for coordination, disease management for chronic disease, therapeutic communication skills that increase patient readiness to do health behavior change, palliatative or hospice skills. They cannot say we physicians and nurses have different skills, but equal skills in the medical home, so they say instead we nurse caregivers have less than physician skills (and should not be eligible for pay for performance even if we are the primary care giver which was needed in Massachusetts when they covered their citizens). This article is about a top down view..not a collaborative position which is espoused early on in the paper. Follow the money…
3. Look at this direct quote: “Are nursing education resources being spent wisely in light of the nursing shortage that has already affected many regions in the United States?” We don’t say in response, “Are medical education resources being spent wisely in light of the physician shortage (especially of family practice, geriatricians, and psychiatrists}that has affected many regions in the US?” NPs came to be because the medical profession kept the number of medical schools low so that supply would never equal demand and there would be high demand that drove high price. Look in the mirror physicians and look in your own house first before pointing the finger when you have contributed to scarcity…
4.Keep in mind that the AMA doesn’t represent a very high percent of physicians. It functions more as an economic and political arm, than a profession interested in care for all, social justice, managed care, and market principles that are not founded on any belief about the common good.
5.Specialists in medicine invited in the NPs so the NPs could see patients in the office and they could do surgery which paid more. Hospitals invited NPs in to become hospitalists because interns and residents were unsafe without sleep. The NPs were seen as extenders of the medical profession, instead of NPs owning their own skills. Specialists can afford to pay NPs more because they earn more and are not direct competitors.
6.Family practitioners and some internists are now outnumbered by the number of NPs and NPs who open clinics are direct competitors. Retail clinics, staffed by APNs, are competitors (serve 1=2% of patient population). Often disease management companies, hired by insurance companies to reduce costs, are seen as competitors. We nurse owned clinics are competing for patients that can pay. Medicare makes it hard to keep the doors open and no one knows what the public option or insurance companies will do to care and cost in the near future.
7.Because of the speed of change in health care today, there will always be blurred roles. APRNs are like amoeba in that we fill the voids that other health care professions don’t provide whether it’s primary care, specialty care, transitions care, hospice, midwives, mental health care, etc. The forecast is for all professions to work at the top of the profession and that top keeps changing.
8.Most nurse PhD are not clinical scholars; some are. Not all MDs are clinicians; many are. DNPs are practitioners that change practice and care and that takes research or QI skills. But there is no mass of DNPs yet that say they are primary care givers and also need the same pay for performance (P4P) incentives. If we don’t we are primary care givers and worth the P$P, then we contribute to physician perceptions that we are less than. When we do this, we need a political base and we need all our nursing colleagues to support all of nursing diversity.
9.Most physicians love “their” advanced practice nurse who is really smart, special, and so skilled. But, as a group, they don’t support APNs, because they’re busy too. They aren’t in control of what they are paid because they take the discounted price (which is the price) but they aren’t paid what that retail price is. I can wonder if this frustration takes the form of controlling nursing and some scapegoating that nurses are making it worse because they aren’t doctors. This could be a backlash. We nurses do need some direct to the consumer marketing, as well as relationships with payors (insurance companies, plan administrators) and buyers of health care plan such as employeers as well as our physician colleagues.
Keep in mind, physicians need nurses to make a medical home operational.
10.With the amount of patients and the shortages of physicians and nurses, it
is a less than perfect world. This imperfect health care world is what really needs to be addressed. It is the elephant in the room. Is the AMA in denial so the real conversation doesn’t happen? What’s not being talked about by the AMA? It’s about whose needs will be met (patient? Physician? APN?), payment (money), and power to control.

[Sara Clarkson Majors]

NAPNAP, NONPF, ACNP, AANP are asking for responses from organizations. This organization should respond to the educatioanl standards as they are now and the plans for the future. I have an email from them...........

I write on behalf the NP Roundtable regarding the recent draft NP Module prepared by the AMA as part of its "Scope of Practice Data Series". It is disappointing that we as a community must continue to expend time and energy responding to self-serving proclamations made by the AMA under the guise of patient safety. The NP Roundtable has convened several calls regarding an appropriate response to the AMA. As a result, we are sending this email to you, as leaders of organizations that might be interested in responding to the AMA, to ask you to consider joining the NP Roundtable in one collective response. The NP Roundtable believes one response by the many organizations would be a much more powerful and authoritative response than many individual letters. It also would serve as one consistent and global message for any type of media or public relations outreach the community believes is appropriate. The NP Roundtable is offering to take the laboring oar in preparing a collective response.
If your organization is willing to participate, we ask that you submit written comments to [e-mail] on or before November 18th. We will commit to circulating a draft letter by COB November 30th, which will give participating organizations time to provide corrections and to circulate the document through your requisite channels for sign off. We also would like to consider sharing the finished letter with the broader nursing community for their possible endorsement.

It would help us for our planning to know if your organization will participate in a collective response and whether or not you feel a conference call is necessary. The call also could serve as a platform for discussing thoughts on a public relations strategy. Please respond to this email to confirm your organization's participation in this effort and whether you are in favor of a call.

It was our goal to include on this email all the groups with a stake in the content of the AMA module re: NPs. If we have inadvertently left out an organization or individual, please bring this to our attention so we may correct our mistake asap.

We look forward to hearing from you.

NAPNAP, NONPF, ACNP, AANP
Allison Weber Shuren, MSN, JD

Arnold & Porter LLP
555 Twelfth Street, NW
Washington, DC 20004-1206
Telephone: [phone]
Facsimile: 202.942.5999
[e-mail]
www.arnoldporter.com

Thank you,
Sara Majors, DNP, CPNP-PC
NAPNAP Faculties member

[David G. O'Dell, DNP, FNP]

Sara - I am very interested in crafting a comprehensive response along with other organizations you listed. My colleagues and I will discuss this today and offer a thoughtful reply from our position as DNPs. Please know that the organization that runs this web site (Doctors of Nursing Practice, LLC) is not a membership driven organization. Our mission is to create a forum for the communication of information, ideas, and innovations to promote the growth and development of the practice doctorate degree. This forum is one tool to address this mission.
Thank you for your invitation and for sharing your perspectives with us all.
David O'Dell