How can a DNP program be online?

[AONLINE]

An acquaintance of mine has a BSN and will be starting her online DNP program very soon. I’m very surprised and honestly can’t wrap my mind around the fact that the DNP degree can be completed online. This is a doctorate degree we are talking about, and the degree holders will become primary care providers. Comparing to other doctorate-level providers such as MD or DDS, you can never become a physician or a dentist by doing an online program. So why can a nurse do that?

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[deleted480308]

An acquaintance of mine has a BSN and will be starting her online DNP program very soon. I’m very surprised and honestly can’t wrap my mind around the fact that the DNP degree can be completed online. This is a doctorate degree we are talking about, and the degree holders will become primary care providers. Comparing to other doctorate-level providers such as MD or DDS, you can never become a physician or a dentist by doing an online program. So why can a nurse do that?

Because laws have nothing to do with competence

 

[AONLINE]

Because laws have nothing to do with competence

So you mean that graduates of these online DNP programs will not be competent providers?

 

[deleted480308]

So you mean that graduates of these online DNP programs will not be competent providers?

are you proposing they will?

 

[AONLINE]

are you proposing they will?

I actually know nothing about NP/DNP, but I am seriously concerned about the safety and well-being of our patients if their providers get their degree from online programs and thus being incompetent. Who pass their licenses for practice?

 

[andalusite_angles]

In the real world, I have come across zero doctorally prepared nurses who espouse their degree to be equal to the rigor of an MD or DO. They’re clearly out there AEB the BS I see on this site, allnurses, and KevinMD, but in my experience APPs trying to masquerade as physicians are not nearly as prevalent as made out to be online.

Keep in mind when it comes to nursing, we start seeing patients in clinicals in undergrad and most graduate nurses have years of experience with patient interaction and assessment. I don’t really see how wasting time to drive to campus on a regular basis for a practicing NP would be beneficial. Lectures teaching concepts for disease management and case studies can just as easily be done online. Any other time needs to be in the hospital seeing patients. Even if on the job, topics learned from class or clinicals are still being reenforced.

As far as online DNP programs go, the student finds their own physician and NP preceptors at facilities in their region to fulfill their clinical requirements. That’s common with brick and mortar programs, too.

Lectures are online. Papers are turned in online. There are programs like lock down browser that require students to take tests with a web cam and mic to prevent cheating while others may require them to go to a testing center or come to campus for the midterm and final. Some have required group video chats. Most (if not all) programs require on campus intensives. So, if you live in Michigan and your program is in Tennessee, you know in August 2021 and January 2022 you’re going to be getting a hotel room/AirBnB for a week.

DNP typically requires a special project with an advisor, such as developing guidelines to avoid volume overload in sepsis or improving vaccination rates in undocumented immigrants. Nurses wanting research careers pursue a PhD in nursing and have a more rigorous research component to their program. DNP is doctorate of nursing practice - it’s geared towards already practicing clinicians and nurse educators. The DNP program at my university has courses for evidence based practice, etc, in addition to the clinical courses and project.

Graduate NP programs don’t require cadaver labs like medical school - certainly a weakness. General chemistry and A&P I&II with labs are prerequisite to baccalaureate nursing programs with pathophysiology, pharmacology, and health assessment taught in the upper division of undergraduate nursing studies. Advanced patho and pharm taught in grad school don’t have lab components and are often taught in online lecture format even at brick and mortar schools, including my program. There are quite a number of medical schools that don’t require class lecture attendance and the students can watch the recordings online, so not really any different in that regard.

Advanced health assessment is required for the BSN to MSN and BSN to DNP, but not typically a part of MSN to DNP programs (the most common online DNP). My advanced health assessment course used the same book as many medical schools (Bates) and the class and lab were on campus - I’m not sure how online graduate nursing programs get around the in person lab component, though. Maybe that’s part of the campus intensive? A lot of schools require a video recording of a full head to toe assessment, so maybe that’s how? There are some painful ones on YouTube if you get bored. Since health assessment was also an undergraduate nursing course and part of the daily grind as an RN, it’s not like wheezes and heart murmurs are new concepts to the vast majority of graduate nurses, anyway. I will say, I have never percussed liverspan or the diaphragm in clinical practice, nor have I witnessed a physician do so ...but I’m checked off on it and have the souvenir on my bookshelf.

The DNP requires more clinical hours and scholarly work than an MSN provides; so yes, I would say the DNP increases competency over that of an MSN for that particular nurse, not necessarily in comparison to another nurse, as we all have varying expertise. One of the major problems comes with programs that allow direct entry. A BS in biology is not a substitute for years at the bedside with sick patients while practicing as a registered nurse. In my opinion there should be mandates for RN experience required prior to obtaining NP licensure: ICU and ED for acute care, ED and pediatrics for family, ED and psych for psych NP, etc. Not sure how many years makes a difference with competency, perhaps that could be my DNP project if I ever go down that road... I’ve worked with a few direct entry NPs and they were totally clueless. I’ve also worked with many NPs who are very talented clinicians within their niche.

I currently have over 20,000 hours as an RN but will have roughly 700 hours of clinical training in the provider role when I finish my MSN. I realize my experience and training do not make me competent to be an independent provider, but will I be able to safely practice in an acute care setting with direct physician supervision? Guess I’ll find out this time next year. If I decide to forgo medical school, then I may end up pursuing the DNP...online.

 

[MedicineZ0Z]

In the real world, I have come across zero doctorally prepared nurses who espouse their degree to be equal to the rigor of an MD or DO. They’re clearly out there AEB the BS I see on this site, allnurses, and KevinMD, but in my experience APPs trying to masquerade as physicians are not nearly as prevalent as made out to be online.

Keep in mind when it comes to nursing, we start seeing patients in clinicals in undergrad and most graduate nurses have years of experience with patient interaction and assessment. I don’t really see how wasting time to drive to campus on a regular basis for a practicing NP would be beneficial. Lectures teaching concepts for disease management and case studies can just as easily be done online. Any other time needs to be in the hospital seeing patients. Even if on the job, topics learned from class or clinicals are still being reenforced.

As far as online DNP programs go, the student finds their own physician and NP preceptors at facilities in their region to fulfill their clinical requirements. That’s common with brick and mortar programs, too.

Lectures are online. Papers are turned in online. There are programs like lock down browser that require students to take tests with a web cam and mic to prevent cheating while others may require them to go to a testing center or come to campus for the midterm and final. Some have required group video chats. Most (if not all) programs require on campus intensives. So, if you live in Michigan and your program is in Tennessee, you know in August 2021 and January 2022 you’re going to be getting a hotel room/AirBnB for a week.

DNP typically requires a special project with an advisor, such as developing guidelines to avoid volume overload in sepsis or improving vaccination rates in undocumented immigrants. Nurses wanting research careers pursue a PhD in nursing and have a more rigorous research component to their program. DNP is doctorate of nursing practice - it’s geared towards already practicing clinicians and nurse educators. The DNP program at my university has courses for evidence based practice, etc, in addition to the clinical courses and project.

Graduate NP programs don’t require cadaver labs like medical school - certainly a weakness. General chemistry and A&P I&II with labs are prerequisite to baccalaureate nursing programs with pathophysiology, pharmacology, and health assessment taught in the upper division of undergraduate nursing studies. Advanced patho and pharm taught in grad school don’t have lab components and are often taught in online lecture format even at brick and mortar schools, including my program. There are quite a number of medical schools that don’t require class lecture attendance and the students can watch the recordings online, so not really any different in that regard.

Advanced health assessment is required for the BSN to MSN and BSN to DNP, but not typically a part of MSN to DNP programs (the most common online DNP). My advanced health assessment course used the same book as many medical schools (Bates) and the class and lab were on campus - I’m not sure how online graduate nursing programs get around the in person lab component, though. Maybe that’s part of the campus intensive? A lot of schools require a video recording of a full head to toe assessment, so maybe that’s how? There are some painful ones on YouTube if you get bored. Since health assessment was also an undergraduate nursing course and part of the daily grind as an RN, it’s not like wheezes and heart murmurs are new concepts to the vast majority of graduate nurses, anyway. I will say, I have never percussed liverspan or the diaphragm in clinical practice, nor have I witnessed a physician do so ...but I’m checked off on it and have the souvenir on my bookshelf.

The DNP requires more clinical hours and scholarly work than an MSN provides; so yes, I would say the DNP increases competency over that of an MSN for that particular nurse, not necessarily in comparison to another nurse, as we all have varying expertise. One of the major problems comes with programs that allow direct entry. A BS in biology is not a substitute for years at the bedside with sick patients while practicing as a registered nurse. In my opinion there should be mandates for RN experience required prior to obtaining NP licensure: ICU and ED for acute care, ED and pediatrics for family, ED and psych for psych NP, etc. Not sure how many years makes a difference with competency, perhaps that could be my DNP project if I ever go down that road... I’ve worked with a few direct entry NPs and they were totally clueless. I’ve also worked with many NPs who are very talented clinicians within their niche.

I currently have over 20,000 hours as an RN but will have roughly 700 hours of clinical training in the provider role when I finish my MSN. I realize my experience and training do not make me competent to be an independent provider, but will I be able to safely practice in an acute care setting with direct physician supervision? Guess I’ll find out this time next year. If I decide to forgo medical school, then I may end up pursuing the DNP...online.

Don't disagree with the post but the issue is that the NP practices for 5 years then wants to practice unsupervised and thereby displace the physician. We see it in so many specialties.

 

[andalusite_angles]

Who pass their licenses for practice?

Licensure is through the state board of nursing and board certification is required. You have to meet specific clinical requirements to sit for board exams.

Part of the variance of alphabet soup is due to the numerous agencies that issue certifications. For example, AGACNP-BC is adult and gerontological acute care nurse practitioner board certified through the ANCC (American Nurses Credentialing Center). ACNPC-AG is the same certification but through the AACN (American Association of Critical Care Nurses).

Scope of practice is dictated by each state’s board of nursing and can vary widely between states from independent practice rights to permitted procedures to prescriptive authority (such as controlled substances or Botox). Scope is further limited by the type of board certification. If an FNP wants to go play in the ICU, in most places they are going to be extremely limited as to what they can do. My hospital has additional limits on NP scope of practice, otherwise as an acute care NP I could intubate, insert central lines, etc. I can’t see pediatrics, whereas I could if I were an FNP.

 

[pamac]

Don't disagree with the post but the issue is that the NP practices for 5 years then wants to practice unsupervised and thereby displace the physician. We see it in so many specialties.

Sounds like the prevailing concern there is over turf above all else.

Let’s look at the big picture. Physicians hold their ground because of the prestige in their title that they’ve earned. What do I, as an NP, get from opening up shop across the street from a practice full of MDs? I lose the marketing battle the moment they put out an ad promoting patients being seen by a doctor rather than a nurse. You see that all the time too. It’s not like I can significantly undercut them on cost like we are businesses in a price war. So where is my edge as a mom and pop provider?

Specialists losing work to independent NPs? Nah. If specialists are losing anything to NPs, it’s due to months long waiting lists. But specialists aren’t losing anything. They are top of the food chain amongst their physician peers. Specialists are so incredibly safe it’s not even worth our time arguing it.

Where physicians in general may be losing ground is in the retail clinical realm where administration is opting for NPs to significantly pad the bottom line. And I’ve seen many more doctors hiring a gaggle of NPs instead of fellow doctors vs seeing NPs going rogue and making a bundle as an independent. I’ve also seen more NPs go bust as independent providers than make it big.

Docs aren’t going into primary care.... it’s not profitable enough to pay off their loans unless they hit the FQHC circuit and work out some repayment deal. Docs aren’t going into psyche.... reimbursement is low because it lacks lucrative procedures. Hospitalist services have been using NPs to cut some costs, but I can’t help but think physicians should be able to point to their training as leading to more efficiency and overall production of revenue. That’s how it works in my workplace. I’m jealous that most of my physician colleagues can crank out cases quicker than me, at least at this point (I’m much newer than them). I’m cheaper, but they are bringing in more revenue.

I know it’s a nickel and dime industry at this point, but the docs know how to bring in lots of nickels and dimes. I just think the blame is misplaced. The fact that more docs are becoming employees (or being pushed into becoming employees) probably has more to do with lowering the bottom line than the pervasiveness of NPs. Even then, the shift to being an employee is often more of a lifestyle issue for docs. When you own a lucrative private practice, you have private practice headaches that come with essentially working two difficult jobs (physician and practice owner). Then your own partners drive you crazy as well. Going to work for the man means lower payoff, but it also means better schedule, standardized retirement plans and benefits, etc. Millennials are loving the switch.

If you don’t like the way things are going, buckle down and hire some NPs to make you a bunch of money while your name and title serves as the main event On the marquis outside. Or if you want to be an employee, show your potential bosses how your expertise brings in money and improves efficiency and production. I think a lot of docs just aren’t used to the pushback from admins, and it frustrates them to have to justify their presence. But these days, everyone gets a boss.

 

[deleted480308]

Sounds like the prevailing concern there is over turf above all else.

Let’s look at the big picture. Physicians hold their ground because of the prestige in their title that they’ve earned. What do I, as an NP, get from opening up shop across the street from a practice full of MDs? I lose the marketing battle the moment they put out an ad promoting patients being seen by a doctor rather than a nurse. You see that all the time too. It’s not like I can significantly undercut them on cost like we are businesses in a price war. So where is my edge as a mom and pop provider?

Specialists losing work to independent NPs? Nah. If specialists are losing anything to NPs, it’s due to months long waiting lists. But specialists aren’t losing anything. They are top of the food chain amongst their physician peers. Specialists are so incredibly safe it’s not even worth our time arguing it.

Where physicians in general may be losing ground is in the retail clinical realm where administration is opting for NPs to significantly pad the bottom line. And I’ve seen many more doctors hiring a gaggle of NPs instead of fellow doctors vs seeing NPs going rogue and making a bundle as an independent. I’ve also seen more NPs go bust as independent providers than make it big.

Docs aren’t going into primary care.... it’s not profitable enough to pay off their loans unless they hit the FQHC circuit and work out some repayment deal. Docs aren’t going into psyche.... reimbursement is low because it lacks lucrative procedures. Hospitalist services have been using NPs to cut some costs, but I can’t help but think physicians should be able to point to their training as leading to more efficiency and overall production of revenue. That’s how it works in my workplace. I’m jealous that most of my physician colleagues can crank out cases quicker than me, at least at this point (I’m much newer than them). I’m cheaper, but they are bringing in more revenue.

I know it’s a nickel and dime industry at this point, but the docs know how to bring in lots of nickels and dimes. I just think the blame is misplaced. The fact that more docs are becoming employees (or being pushed into becoming employees) probably has more to do with lowering the bottom line than the pervasiveness of NPs. Even then, the shift to being an employee is often more of a lifestyle issue for docs. When you own a lucrative private practice, you have private practice headaches that come with essentially working two difficult jobs (physician and practice owner). Then your own partners drive you crazy as well. Going to work for the man means lower payoff, but it also means better schedule, standardized retirement plans and benefits, etc. Millennials are loving the switch.

If you don’t like the way things are going, buckle down and hire some NPs to make you a bunch of money while your name and title serves as the main event On the marquis outside. Or if you want to be an employee, show your potential bosses how your expertise brings in money and improves efficiency and production. I think a lot of docs just aren’t used to the pushback from admins, and it frustrates them to have to justify their presence. But these days, everyone gets a boss.

Some are interested in turf, more are interested in ensuring that everyone claiming independence is adequately trained and a lot of professions are pushing independence that aren’t

 

[MedicineZ0Z]

Sounds like the prevailing concern there is over turf above all else.

Let’s look at the big picture. Physicians hold their ground because of the prestige in their title that they’ve earned. What do I, as an NP, get from opening up shop across the street from a practice full of MDs? I lose the marketing battle the moment they put out an ad promoting patients being seen by a doctor rather than a nurse. You see that all the time too. It’s not like I can significantly undercut them on cost like we are businesses in a price war. So where is my edge as a mom and pop provider?

Specialists losing work to independent NPs? Nah. If specialists are losing anything to NPs, it’s due to months long waiting lists. But specialists aren’t losing anything. They are top of the food chain amongst their physician peers. Specialists are so incredibly safe it’s not even worth our time arguing it.

Where physicians in general may be losing ground is in the retail clinical realm where administration is opting for NPs to significantly pad the bottom line. And I’ve seen many more doctors hiring a gaggle of NPs instead of fellow doctors vs seeing NPs going rogue and making a bundle as an independent. I’ve also seen more NPs go bust as independent providers than make it big.

Docs aren’t going into primary care.... it’s not profitable enough to pay off their loans unless they hit the FQHC circuit and work out some repayment deal. Docs aren’t going into psyche.... reimbursement is low because it lacks lucrative procedures. Hospitalist services have been using NPs to cut some costs, but I can’t help but think physicians should be able to point to their training as leading to more efficiency and overall production of revenue. That’s how it works in my workplace. I’m jealous that most of my physician colleagues can crank out cases quicker than me, at least at this point (I’m much newer than them). I’m cheaper, but they are bringing in more revenue.

I know it’s a nickel and dime industry at this point, but the docs know how to bring in lots of nickels and dimes. I just think the blame is misplaced. The fact that more docs are becoming employees (or being pushed into becoming employees) probably has more to do with lowering the bottom line than the pervasiveness of NPs. Even then, the shift to being an employee is often more of a lifestyle issue for docs. When you own a lucrative private practice, you have private practice headaches that come with essentially working two difficult jobs (physician and practice owner). Then your own partners drive you crazy as well. Going to work for the man means lower payoff, but it also means better schedule, standardized retirement plans and benefits, etc. Millennials are loving the switch.

If you don’t like the way things are going, buckle down and hire some NPs to make you a bunch of money while your name and title serves as the main event On the marquis outside. Or if you want to be an employee, show your potential bosses how your expertise brings in money and improves efficiency and production. I think a lot of docs just aren’t used to the pushback from admins, and it frustrates them to have to justify their presence. But these days, everyone gets a boss.

What do you mean docs are doing primary care? Residency spots fill up every year, what else is there to do?

And yes they hire NPs to be "hospitalists" who then consult every service to manage every little thing --> more total expenses .

 

[pamac]

Some are interested in turf, more are interested in ensuring that everyone claiming independence is adequately trained and a lot of professions are pushing independence that aren’t

That one always comes out. Concern trolling. Problem is that the first concern out of the posters mouth that I quoted was turf centered.

Relax. The sky isn’t falling. You guys are working. NPs are being held to account, or else you’d see lawsuits and sky high insurance rates, as well as a mass movement away from them. SB is notorious for hating on NPs as a hobby. If you are all that concerned, go get some NPs fired for negligence and show them to be the danger you say they are. This argument comes up continually and doesn’t move the needle.

 

[deleted480308]

That one always comes out. Concern trolling. Problem is that the first concern out of the posters mouth that I quoted was turf centered.

Relax. The sky isn’t falling. You guys are working. NPs are being held to account, or else you’d see lawsuits and sky high insurance rates, as well as a mass movement away from them. SB is notorious for hating on NPs as a hobby. If you are all that concerned, go get some NPs fired for negligence and show them to be the danger you say they are. This argument comes up continually and doesn’t move the needle.

I hate inadequately trained Independance. I love a properly supervised professional

 

[pamac]

I hate inadequately trained Independance. I love a properly supervised professional

And you’d suggest keeping these properly supervised professionals on the hook well after they are capable of functioning with quite a bit of daylight between them? A fish permanently on the hook to maintain the antiquated hierarchy? Gotta make sure you guys get some money for supervision too, right? Keep that good thing going for ya?

You are caught up on the notion that NPs are changing the landscape by operating independent out in the market, but very few actually do that. They are accountable to their boards, who investigate every single complaint filed. So go file some complaints against the legions of improperly trained independent NPs that you insist are putting the public in danger.

Independence is more of an issue of job site hierarchy. It makes NPs free agents like physicians. There’s no reason an employer can’t put a supervising doctor in the mix for oversight. You just don’t want to give up any control you think you have left.

If NPs were operating in an unsafe manner, you can bet the insurance industry would smell blood in the water and hike our rates up to correspond. I bet my yearly malpractice premium is less than you chip in for your employee’s Christmas party every year.

Another thing.... it’s not bad for NPs to add to the mix to be able to take home a little more of what they bring in. You act like it’s upsetting the apple cart to have a provider that brings in many hundreds of thousands of dollars per year to be able to have an easier time negotiating with admin. Having that independence allows for that. PAs should have it too, and they want it. They will probably get it someday. Most of the push for independence comes down to having a decent employment relationship rather than practicing solo for dollars you feel entitled to. It just doesn’t make sense anymore to be the squire to the physician knight when APPs can be their own kept workers in their own right.

 

[deleted480308]

And you’d suggest keeping these properly supervised professionals on the hook well after they are capable of functioning with quite a bit of daylight between them? A fish permanently on the hook to maintain the antiquated hierarchy? Gotta make sure you guys get some money for supervision too, right? Keep that good thing going for ya?

You are caught up on the notion that NPs are changing the landscape by operating independent out in the market, but very few actually do that. They are accountable to their boards, who investigate every single complaint filed. So go file some complaints against the legions of improperly trained independent NPs that you insist are putting the public in danger.

Independence is more of an issue of job site hierarchy. It makes NPs free agents like physicians. There’s no reason an employer can’t put a supervising doctor in the mix for oversight. You just don’t want to give up any control you think you have left.

If NPs were operating in an unsafe manner, you can bet the insurance industry would smell blood in the water and hike our rates up to correspond. I bet my yearly malpractice premium is less than you chip in for your employee’s Christmas party every year.

Another thing.... it’s not bad for NPs to add to the mix to be able to take home a little more of what they bring in. You act like it’s upsetting the apple cart to have a provider that brings in many hundreds of thousands of dollars per year to be able to have an easier time negotiating with admin. Having that independence allows for that. PAs should have it too, and they want it. They will probably get it someday. Most of the push for independence comes down to having a decent employment relationship rather than practicing solo for dollars you feel entitled to. It just doesn’t make sense anymore to be the squire to the physician knight when APPs can be their own kept workers in their own right.

That sure sounds like a financial argument and not a training one. We aren’t going to agree on this issue.

 

[pamac]

That sure sounds like a financial argument and not a training one. We aren’t going to agree on this issue.

This has always been a turf issue with financial underpinnings where you use training as both a sword to attack, and a shield to hide behind. If you had any purpose here other than to perennially complain about this under the holy and unimpeachable guise of “concern for patients”, you’d go ahead and do as I suggest and start reporting poor NP performers to their boards. Fact is that I’d have a hard time approaching the level of malpractice of some of the physicians I’ve come across. If terrible practice were an exclusive domain of NPs, it would get shut down and restricted in short order. NPs results aren’t poor, and they are helping to expand access to healthcare. I made the case that if an entity wants to place supervision over NPs in their workplace, they can. You can trust that a facility would do so if they found that to be a critical factor in easing liability.

 

[deleted480308]

This has always been a turf issue with financial underpinnings where you use training as both a sword to attack, and a shield to hide behind. If you had any purpose here other than to perennially complain about this under the holy and unimpeachable guise of “concern for patients”, you’d go ahead and do as I suggest and start reporting poor NP performers to their boards. Fact is that I’d have a hard time approaching the level of malpractice of some of the physicians I’ve come across. If terrible practice were an exclusive domain of NPs, it would get shut down and restricted in short order. NPs results aren’t poor, and they are helping to expand access to healthcare. I made the case that if an entity wants to place supervision over NPs in their workplace, they can. You can trust that a facility would do so if they found that to be a critical factor in easing liability.

As I said, we disagree on this issue

 

[pamac]

As I said, we disagree on this issue

Repeating that doesn't make it any more obvious, but it does highlight how you don't want to address any of the issues I've mentioned. I realize you are trying to feed a narrative where you are a plain speaker, hence your choice of avatar. Gotta keep up the image and hit it from a few different angles, right "doer of things"?

If you see such poor performing NPs that you feel compelled to take the time to regularly denigrate on this forum, then use that energy to report them to the boards of nursing. Every complaint is investigated. If NP training is poor, and causing adverse patient care, report it. Be a force for change instead of a keyboard warrior. Be a doer of things, not a troller of posts, a faker of tough, or a passer of hot air and N=1 anecdote.

 

[pamac]

Here's some wicked stats... I've been on here about 9 years, and made around 1300 comments. You've been on here 7, and made close to 21,000 (!). Do you seriously practice medicine, or is posting on SDN actually your full time job? Maybe the argument here is that you've spent more time commenting than I spent in my NP clinical training, but I think that to do that would make a good case for you needing to get out more and use your time productively. You have one life to live, and seem determined to spend it on here. I wouldn't mind if you cut at least one forum feature topic out of your daily stroll through the nearly 200 threads you seem to have the time to peruse....

 

[deleted480308]

Repeating that doesn't make it any more obvious, but it does highlight how you don't want to address any of the issues I've mentioned. I realize you are trying to feed a narrative where you are a plain speaker, hence your choice of avatar. Gotta keep up the image and hit it from a few different angles, right "doer of things"?

If you see such poor performing NPs that you feel compelled to take the time to regularly denigrate on this forum, then use that energy to report them to the boards of nursing. Every complaint is investigated. If NP training is poor, and causing adverse patient care, report it. Be a force for change instead of a keyboard warrior. Be a doer of things, not a troller of posts, a faker of tough, or a passer of hot air and N=1 anecdote.

I've been clear about my opinion. The board of nursing, who incorrectly pushes independent practice is not who I would go to in order to reign that in. Again, we're going to disagree here

 

[pamac]

I've been clear about my opinion. The board of nursing, who incorrectly pushes independent practice is not who I would go to in order to reign that in. Again, we're going to disagree here

So we whine, moan, complain, and troll. Then, when a solution comes into the picture that calls our bluff, we blow it off and use that blow off as a way to resign ourselves to continue to whine, moan, complain, and troll.... as if the whining, moaning, complaining, and trolling are tangible efforts for our holy cause (yes the holiest cause to drive our efforts).... that cause being the sacred sacrament of patient care, which we hold most dear, and is all that we are looking out for as physicians. Not money. Not authority. Not patriarchy. Not political control. Not leverage. Only proper patient care.

Earlier in this conversation, you couldn’t come to any kind of agreement because your cause was so high and noble that you wouldn't... nay, you couldn’t....deign to argue on any other grounds because dangerous NPs were at high risk to harm patients.

And yet, the person with 21,000 (holy crap that’s a lot!) comments can’t muster the kind of concern for patient care to take any of his/her time to lodge a complaint through the established regimen for addressing complaints against wayward NPs? It almost seems like you are not really in any kind of position to lodge a legitimate complaint against any NPs. Maybe you are making things up, and aren’t seeing much to complain about. Maybe your angst is primarily based in the hypothetical, or even in the philosophical realm regarding NP independence, and you lack real world experience of NP

In short, you don’t seem as sincere as you say you are about patient care being your foremost concern because all you want to do is troll about it. Seems rather shallow that you haven’t sought official redress for these supposed aggrieved patients, an you cite a conspiracy theory as your reason for not acting on their behalf.

 

[deleted480308]

So we whine, moan, complain, and troll. Then, when a solution comes into the picture that calls our bluff, we blow it off and use that blow off as a way to resign ourselves to continue to whine, moan, complain, and troll.... as if the whining, moaning, complaining, and trolling are tangible efforts for our holy cause (yes the holiest cause to drive our efforts).... that cause being the sacred sacrament of patient care, which we hold most dear, and is all that we are looking out for as physicians. Not money. Not authority. Not patriarchy. Not political control. Not leverage. Only proper patient care.

Earlier in this conversation, you couldn’t come to any kind of agreement because your cause was so high and noble that you wouldn't... nay, you couldn’t....deign to argue on any other grounds because dangerous NPs were at high risk to harm patients.

And yet, the person with 21,000 (holy crap that’s a lot!) comments can’t muster the kind of concern for patient care to take any of his/her time to lodge a complaint through the established regimen for addressing complaints against wayward NPs? It almost seems like you are not really in any kind of position to lodge a legitimate complaint against any NPs. Maybe you are making things up, and aren’t seeing much to complain about. Maybe your angst is primarily based in the hypothetical, or even in the philosophical realm regarding NP independence, and you lack real world experience of NP

In short, you don’t seem as sincere as you say you are about patient care being your foremost concern because all you want to do is troll about it. Seems rather shallow that you haven’t sought official redress for these supposed aggrieved patients, an you cite a conspiracy theory as your reason for not acting on their behalf.

I deal with legislators, not nursing boards. I’m trying to not derail this thread too hard, we can disagree. It’s ok

 

[pamac]

I deal with legislators, not nursing boards. I’m trying to not derail this thread too hard, we can disagree. It’s ok

Good for you. I guess your state might end up as one of the slower states to jump onboard with independence due to your efforts. Meanwhile, all the other states around you will have made the transition.

Derail the thread? All you ever do is drive by dis on NPs and keep moving. You might as well just have your approach to the subject as a permanent signature line. It’s not that you run the risk of derailing any threads, it’s that you don’t even contribute anything.

 

[pamac]

The best argument that NPs pull out of their hat when they go state to state to lobby for increased independence:

It’s been done in almost half of other states with no adverse effect.

Most of the holdouts are southern states... places where the protectionism of physicians keeps hold on your piece of the pie. And there you have it. It’s not that Florida is particularly more worried about NPs being independent and leading to more adverse patient outcomes than a place like Washington state. It’s that Florida physicians are more concerned about NPs being independent and leading to adverse physician financial outcomes. Go ahead and keep company with Alabama, Tennessee, Oklahoma, Arkansas....

 

[MedicineZ0Z]

The best argument that NPs pull out of their hat when they go state to state to lobby for increased independence:

It’s been done in almost half of other states with no adverse effect.

Most of the holdouts are southern states... places where the protectionism of physicians keeps hold on your piece of the pie. And there you have it. It’s not that Florida is particularly more worried about NPs being independent and leading to more adverse patient outcomes than a place like Washington state. It’s that Florida physicians are more concerned about NPs being independent and leading to adverse physician financial outcomes. Go ahead and keep company with Alabama, Tennessee, Oklahoma, Arkansas....

lol what? Oklahoma lets NPs run free. There's a big lawsuit in some town 30 mins from Oklahoma city where an NP was solo staffing an ER, missed a dead obvious PE in a younger girl that a 1st year med student would have caught, and the patient died. The "supervising" doc was at home. And places like this exist all over the country and advertise "ABEM" docs only but then have a midlevel only in-house. God knows what they do when a crashing patient comes in.
More commonly though, these places will hire a family doc at least. Rather than scam patients by advertising "board certified ED doc" then have a midlevel who's utterly clueless about EM 101 staffing the place just to save a buck.

The reason you don't see patients dying left and right is because suboptimal care and bad care do not usually lead to an absolute bad outcome. Throw any antibiotics at any infection and *usually* they'll get better at some point. Your borderline dka diabetic probably won't drop dead if you don't know how to treat dka. That lady you're going to intubate, *probably* has an easy airway.
Essentially, probability is always on your side and algorithms can get you by; especially with a less complex patient population. That's why midlevels can continue to practice. But suboptimal care down the road catches up to patients and how do you prove it was the midlevel's poor care?

 

[deleted480308]

The best argument that NPs pull out of their hat when they go state to state to lobby for increased independence:

It’s been done in almost half of other states with no adverse effect.

Most of the holdouts are southern states... places where the protectionism of physicians keeps hold on your piece of the pie. And there you have it. It’s not that Florida is particularly more worried about NPs being independent and leading to more adverse patient outcomes than a place like Washington state. It’s that Florida physicians are more concerned about NPs being independent and leading to adverse physician financial outcomes. Go ahead and keep company with Alabama, Tennessee, Oklahoma, Arkansas....

None of the state physicians want independent midlevel practice. The reason some states have it and some don’t is because of who the legislators listened to...

 

[pamac]

lol what? Oklahoma lets NPs run free. There's a big lawsuit in some town 30 mins from Oklahoma city where an NP was solo staffing an ER, missed a dead obvious PE in a younger girl that a 1st year med student would have caught, and the patient died. The "supervising" doc was at home. And places like this exist all over the country and advertise "ABEM" docs only but then have a midlevel only in-house. God knows what they do when a crashing patient comes in.
More commonly though, these places will hire a family doc at least. Rather than scam patients by advertising "board certified ED doc" then have a midlevel who's utterly clueless about EM 101 staffing the place just to save a buck.

The reason you don't see patients dying left and right is because suboptimal care and bad care do not usually lead to an absolute bad outcome. Throw any antibiotics at any infection and *usually* they'll get better at some point. Your borderline dka diabetic probably won't drop dead if you don't know how to treat dka. That lady you're going to intubate, *probably* has an easy airway.
Essentially, probability is always on your side and algorithms can get you by; especially with a less complex patient population. That's why midlevels can continue to practice. But suboptimal care down the road catches up to patients and how do you prove it was the midlevel's poor care?

I’ve watched physicians do the exact same things you just cited.... literally.

Oklahoma isn’t an NP independent state..... (crickets chirping).....

So I guess having onerous laws on the books didn’t do any good there, right? There’s how well your close supervision worked. Thanks for making a good point about the pitfalls of non independent state practice laws all by yourself!

None of the state physicians want independent midlevel practice. The reason some states have it and some don’t is because of who the legislators listened to...

Yep... nobody wants to lose their turf.

In all reality, I know quite a few physicians who don’t care about NPs practicing independently.

 

[scoopdaboop]

Gotta make sure you guys get some money for supervision too, right? Keep that good thing going for ya?

this is ridiculous. Most family docs get what? 3-4 k a month if that for supervising? And with it comes a lot more responsibility. It’s not a “good thing to keep going on” it’s a necessity and one that is not paid well as it should

 

[pamac]

this is ridiculous. Most family docs get what? 3-4 k a month if that for supervising? And with it comes a lot more responsibility. It’s not a “good thing to keep going on” it’s a necessity and one that is not paid well as it should

I’ll bite.... let’s use your numbers. Almost $50,000 per year extra to fulfill supervision. That’s pretty good scratch considering it’s a job that isn’t done at all in my neck of the woods. So since it’s not even done at all in independent NP states, it stands to reason that in dependent states, there’s not that much more to it because NPs are NPs whether they live under one state’s regulations or another. So they roll through the motions, review some charts, and get a couple years of their house payment covered for every year they perform that onerous task. Or..... like in my state, none of that goes on, and somehow our outcomes are just as good as the states that do that.....

You just aren’t convincing me one this one. Maybe we need to include a lot more anecdote like usually happens in these conversations.

But lets go back to the Oklahoma story that was brought up. Oklahoma is in the category of high NP supervision states. The poster didn’t know this, and somehow that story was supposed to show us the damage that can be unleashed by independent NPs. Meanwhile, in states with less regulation surrounding the subject, NPs are doing just fine.

The independence issue for me has more to do with cutting out red tape than flying solo and taking your money. It means I don’t need to have a formal arrangement in place where a physician is chained to me as much as I’d be chained to them. I can pick up work other places without it being anyone’s business. If an employer feels like they want me to run something’s by a doc, they can make it a requirement. The docs don’t get sued if I screw up. They don’t have to perform those terrible $50,000 per year chart reviews you whined about....

Incidentally, I don’t even know if many docs even make $3k for their supervision, so I won’t harp too much on that, but get real. If you have an NP under your purview that is taxing your patience, you might have the wrong NP. But with as much as some family docs get paid, if they were able to score $50,000 extra per year, they’d jump at the chance.

 

[scoopdaboop]

I’ll bite.... let’s use your numbers. Almost $50,000 per year extra to fulfill supervision. That’s pretty good scratch considering it’s a job that isn’t done at all in my neck of the woods. So since it’s not even done at all in independent NP states, it stands to reason that in dependent states, there’s not that much more to it because NPs are NPs whether they live under one state’s regulations or another. So they roll through the motions, review some charts, and get a couple years of their house payment covered for every year they perform that onerous task. Or..... like in my state, none of that goes on, and somehow our outcomes are just as good as the states that do that.....

You just aren’t convincing me one this one. Maybe we need to include a lot more anecdote like usually happens in these conversations.

But lets go back to the Oklahoma story that was brought up. Oklahoma is in the category of high NP supervision states. The poster didn’t know this, and somehow that story was supposed to show us the damage that can be unleashed by independent NPs. Meanwhile, in states with less regulation surrounding the subject, NPs are doing just fine.

The independence issue for me has more to do with cutting out red tape than flying solo and taking your money. It means I don’t need to have a formal arrangement in place where a physician is chained to me as much as I’d be chained to them. I can pick up work other places without it being anyone’s business. If an employer feels like they want me to run something’s by a doc, they can make it a requirement. The docs don’t get sued if I screw up. They don’t have to perform those terrible $50,000 per year chart reviews you whined about....

Incidentally, I don’t even know if many docs even make $3k for their supervision, so I won’t harp too much on that, but get real. If you have an NP under your purview that is taxing your patience, you might have the wrong NP. But with as much as some family docs get paid, if they were able to score $50,000 extra per year, they’d jump at the chance.

Here's the thing, though. Those independent NP's that somehow have "just as good outcomes" are misleading. An RN can probably have just as good an outcome for a kid with a strep throat compared to a doc and a NP. No NP in their right mind will tackle a case they don't feel comfortable in and just refer those out, and if all they do is simple stuff, then yeah the outcomes will be good. It's pretty easy to have "just as good outcomes" when you don't compare the complexity of the patient. Even if a NP is independent, he/she probably makes tons of calls to specialists in order to make sure her plan is correct. Not to say the doctor doesn't do this either, but to just look at "outcome" without all the variables; such as increased cost and speed of care, is misleading.

But that is precisely why there needs to be oversight. So they don't refer out stuff the doc can manage, so there's no more increased cost for the patient, and there are undoubtedly some NP's that are so arrogant that they think they can do everything- although most NP's I saw in the ER, knew the limits and weren't scared to say "I want you, doc, to see the patient".

Lastly, clearly there's a monetary benefit to overseeing NP's and docs want that to stay, but for good reason. If there's physician oversight, then the physician will be the one that will be sought after in any sort of malpractice claim, the NP will be fodder. That is why oversight of NP's pays like it does. Also, to pretend like 50k a year is a lot, when the risk exists that they ruin your career is silly.

Also you mentioned "concern trolling". It's pretty safe to say most docs care about their patients, and do right by them. As do most people in healthcare. But it seems so evident to me that the ones that concern troll are NP's. They market "heart of a nurse". They want the public to believe so much that docs are evil, out to get money, and the NP's are not.

If you want to say, "well if the NP did something wrong, you can tell on them to the board!!". I have 2 issues with this. If there's physician oversight, then the physician has to be worried about how he will be looked at, because he as the overseer "shouldn't have allowed it to happen", secondly, there's no doubt that the nursing board will try tooth and nail to protect their NP because they do not want any sort of bad press/light to befall the NP and hurt their "we're just as good as doctors" rhetoric and propaganda.

 

[scoopdaboop]

The independence issue for me has more to do with cutting out red tape than flying solo and taking your money. It means I don’t need to have a formal arrangement in place where a physician is chained to me as much as I’d be chained to them. I can pick up work other places without it being anyone’s business. If an employer feels like they want me to run something’s by a doc, they can make it a requirement. The docs don’t get sued if I screw up. They don’t have to perform those terrible $50,000 per year chart reviews you whined about....

I don't understand how you are "chained" to something. You can apply to work wherever you want. Yeah, some places might require you to run something by a physician and not others. Or, not even that, you just have physician oversight that can come in and say "oop, you shouldn't do that, do this instead" But, how does that chain you- it's there to make sure you are doing the right thing.

 

[pamac]

Ask a PA how he or she feels when their SP dies and they can’t do a single thing from that point on until they find another SP get back approval paperwork from the board of medicine. Similar thing if an SP gets fired.its just a relationship that has huge potential for conflict of interest. As an RN, my supervisor that I answered to was never a doctor. There’s really no need for a direct hierarchy.

The clinic doesn’t operate in a way where an SP would be waltzing through to catch anything that I messed up. If one of the docs I work with was my SP, they would be in seeing their patients all day just like I see mine. We barely talk. If I need some help, I collaborate. If I can’t handle something, I refer, just like I kick something on the medical side to the primary care folks or a specialist. You say “why not have an SP?” while I say “why have one when I can operate in pretty much the exact same manner Without one?”.

Case in point... I pick up some work at another clinic. What if my SP didn’t want me to do that because he/she didn’t want any liability from that work. It’s not even anything that should concern the SP, but as an SP, they are on the hook, and may not want that work interfering with their life in any way.

You have to understand that an SP has in his or her hands your ability to work or do just about anything else. If you disagree on just about anything, even something where there isn’t a right or wrong answer, it’s their call. Literally, if I don’t feel comfortable with a patient and want to fire them, an SP could tell me “nope”. With independence, I’m just another employee, and I don’t have a built in boss. If I suck, I get canned. The same amount of oversight can be established if a clinic or facility wants me to run something’s by a physician.

 

[PikminOC]

None of the state physicians want independent midlevel practice. The reason some states have it and some don’t is because of who the legislators listened to...

And the nursing lobby has alot of money and members.
Many times np are dropped from suits for deeper attending pockets

 

[PikminOC]

Here's the thing, though. Those independent NP's that somehow have "just as good outcomes" are misleading. An RN can probably have just as good an outcome for a kid with a strep throat compared to a doc and a NP. No NP in their right mind will tackle a case they don't feel comfortable in and just refer those out, and if all they do is simple stuff, then yeah the outcomes will be good. It's pretty easy to have "just as good outcomes" when you don't compare the complexity of the patient. Even if a NP is independent, he/she probably makes tons of calls to specialists in order to make sure her plan is correct. Not to say the doctor doesn't do this either, but to just look at "outcome" without all the variables; such as increased cost and speed of care, is misleading.

But that is precisely why there needs to be oversight. So they don't refer out stuff the doc can manage, so there's no more increased cost for the patient, and there are undoubtedly some NP's that are so arrogant that they think they can do everything- although most NP's I saw in the ER, knew the limits and weren't scared to say "I want you, doc, to see the patient".

Lastly, clearly there's a monetary benefit to overseeing NP's and docs want that to stay, but for good reason. If there's physician oversight, then the physician will be the one that will be sought after in any sort of malpractice claim, the NP will be fodder. That is why oversight of NP's pays like it does. Also, to pretend like 50k a year is a lot, when the risk exists that they ruin your career is silly.

Also you mentioned "concern trolling". It's pretty safe to say most docs care about their patients, and do right by them. As do most people in healthcare. But it seems so evident to me that the ones that concern troll are NP's. They market "heart of a nurse". They want the public to believe so much that docs are evil, out to get money, and the NP's are not.

If you want to say, "well if the NP did something wrong, you can tell on them to the board!!". I have 2 issues with this. If there's physician oversight, then the physician has to be worried about how he will be looked at, because he as the overseer "shouldn't have allowed it to happen", secondly, there's no doubt that the nursing board will try tooth and nail to protect their NP because they do not want any sort of bad press/light to befall the NP and hurt their "we're just as good as doctors" rhetoric and propaganda.

I like to sleep at night so I don't supervise or collaborate with mid-levels. My specialist friend in hospital gets 2500 per YEAR for the pleasure of supervisor/ collaborator.
She just found out one of the NP was committing billing fraud under her name and license and now has to deal with that.
Also, mid-levels are growing at a very fast clip and may oversaturate themselves.

 

[Splenda88]

An acquaintance of mine has a BSN and will be starting her online DNP program very soon. I’m very surprised and honestly can’t wrap my mind around the fact that the DNP degree can be completed online. This is a doctorate degree we are talking about, and the degree holders will become primary care providers. Comparing to other doctorate-level providers such as MD or DDS, you can never become a physician or a dentist by doing an online program. So why can a nurse do that?

Nurses are smarter than physicians... They have figured out ways to circumvent the system.

 

[Splenda88]

I currently have over 20,000 hours as an RN but will have roughly 700 hours of clinical training in the provider role when I finish my MSN. I realize my experience and training do not make me competent to be an independent provider, but will I be able to safely practice in an acute care setting with direct physician supervision? Guess I’ll find out this time next year. If I decide to forgo medical school, then I may end up pursuing the DNP...online.

Lol... That is less than 3 months of IM/FM residency.


Go to med school. There is NO substitute for med school.

 

[MedicineZ0Z]

Nurses are smarter than physicians... They have figured out ways to circumvent the system.

They're one unified unit. Doctors are so fragmented and 100x busier on top of that.