Questions about Nurses

[Merely]

Can someone either explain or link me to an explanation of the various types of nurses, their education, and what they can do in terms of scope of practice. For example, can NPs prescribe all kinds of meds? I didnt even know that non-doctors could prescribe anything so I guess I have a lot to learn. Thanks.

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[DocVapor]

Can someone either explain or link me to an explanation of the various types of nurses, their education, and what they can do in terms of scope of practice. For example, can NPs prescribe all kinds of meds? I didnt even know that non-doctors could prescribe anything so I guess I have a lot to learn. Thanks.

Clicky clicky

 

[PikminOC]

Thanks for the link. Here's one of the comments:
"The flaw in this logic is that you have to have assimilated the book learning before you can get out there on the floor."

 

[NickNaylor]

Nurses: RNs, generally execute orders written by physicians or other "providers" and are responsible for the minute-to-minute care of patients. Depending upon the setting, RNs can have a relative degree of independence and do things like order labs, dispense meds, etc..

NPs: RNs that have received a master's degree; the training program is usually 2-3 years, though there are "fellowships" that are 1-2 years long that allow the NP to "specialize" in a certain area of care (e.g., FM, EM, psych, etc.). NPs were initially meant to serve as providers under the guidance of supervising physicians, but that role has slowly grown into independent practitioners. They are allowed to practice independently and effectively do anything a physician can in just over 20 states (including prescribing) thanks to a highly successful and coordinated lobbying effort at the state level.

DNP: terminal degree for the NP. It's actually unclear to me what this is, and I haven't run into DNPs myself so I know very little about the training pathway.

CRNA: certified nurse anesthetist, essentially an NP specifically for anesthesia. Again, they were originally intended to work under the supervision of physicians, but depending upon the practice setting that may or may not be true. I believe the program is 3 years of training, but I could be wrong about that.

Expanding the role of non-physician "providers" isn't limited to the nursing area. Psychologists, for example, have been waging this battle for quite some time and have won some victories in a few states with respect to the prescription of psychotropic drugs. Pharmacists seem to be leaning towards this model as well though I haven't read too much about it.

 

[Promethean]

Nick's description above is very on point.

RNs: There are three paths to getting a license. BSN - a 4 year undergrad program. ASN - 2 year community college program. Diploma - a nondegree granting program that was the traditional education for nurses in a hospital setting. Average about 2 years.

BSNs get full college degrees, including a lot of clinically irrelevant education. I've found that their clinical exposure can be relatively weak, and many graduate without having mastered hands on skills. There is a push for all nurses to be bachelors trained, because the leaders of the profession feel that this will give them more clout and because of the perception that more education = better education. Clearly, my bias as a diploma nurse shows. When these nurses hit the floor as GNs, many of them need some extra handholding at first.

ASNs and Diploma nurses have less liberal arts and humanities, but the same amount of basic science and far more clinical. These programs focus more on hands on, and their shorter duration means that clinical experiences are more concentrated, that is, less spread out over time. These nurses roll out ready to handle full assignments much more quickly, in my experience.

Not mentioned above are LPNs. Licensed Practical Nurses. They get even less theory and science, and are very much more oriented to performing tasks as ordered. Their training doesn't focus as much on critical thinking and is much more about just implementation. The same push for all nurses to be BSN trained aims to see LPNs go extinct in favor of having all nurses be at least RNs. But there is a role for LPNs. They have a wider scope than nursing assistants, in that they are actually licensed nurses and can perform assessments, medication administration, and treatments. But they are more limited in scope than an RN. The specifics of those limitations vary based on the State and its Nursing Practice Acts, as established by the local Board of Nursing.

You mostly see LPNs working in home care and long term care settings, while hospitals tend to prefer RNs. Even nursing has its midlevel providers, you see... and there is just about as much role confusion as with midlevels in medicine. If you ask an RN the difference, they will tell you that they have a longer and better education than an LPN. If you ask an LPN, they will tell you that the difference is about $10/hr.

As for different specialties, in most cases, this is on the job training. Nursing school, like medical school, gives a broad overview of the profession and provides a minimal basis for one to be a safe practitioner of the profession. Many programs have virtually no specialty exposure. An OB rotation might involve presence at a couple of births, maybe a dozen. OR experiences are a day or two of observation. Anyone interested in specializing right out of school is advised to arrange their own shadowing experiences in order to get hired some place willing to orient them to the specialty. Becoming an OR nurse takes about a 6 month orientation period in order to learn the specifics of that field through on-the-job training. And a good OR nurse requires at least 2 years of experience before the deer-in-the-headlight look fades completely. I imagine the same is true of Labor and Delivery, ICU, and other specialties.

The need is greatest in med/surg, since that is the infantry / FM of nursing, and most people want to avoid it if at all possible because it is where the hardest, dirtiest, and most thankless labor happens. So, schools really hammer that specialty, and spread the lie that one has to spend at least a year working in med/surg before specializing or else risk "losing your skills." This is propaganda to keep the ranks filled with the credulous. You don't need to know how to pass 30 meds each to 12 inpatients per shift with no aide once you have decided on a career in the OR. Those skills are okay to lose.

There are MSN and DNP degrees that you need to get if you want to teach nursing or go into nursing administration. Consider them like nursing MBAs. They may or may not make you more qualified, actually, than any other RN, but they look great on the resume and most employers will insist on them for certain positions.

That pretty well encompasses everything that I consider nursing. Everything else:

I think that "Advanced Practice RNs" like CRNAs and NPs are not really practicing nursing anymore beyond a certain point. I think that they are basically PAs with a nursing background. They may bring some of their background with them into their practice of medicine-disguised-as-nursing, but that doesn't mean that they are still functioning as nurses.

I didn't want to do undertrained-medicine-disguised-as-nursing. I wanted to practice medicine, so I bailed on the NP pathway to doing that.

As for the DNP degree... it is becoming the standard for practice as an NP in many states. That same push, the bias that more education = better education, is moving to make NPs require a doctorate in medicine-disguised-as-nursing. This is very concerning to those of us who have noticed that many DNP programs are fully on-line and seem to provide little or no clinical education. In some, just working at your regular job and having someone there sign off on a form claiming to have precepted you counts as clinical education. This is appalling to those of us with a conscience and a wish to be actually competent in order to care for patients who come to us with the expectation that the letters after our name have some meaning.

Again, my bias is thick. Try to scrape it off and see if I said anything useful to help answer your questions.

 

[TraumaLlamaMD]

Much more succinct and clear than anything I found on the first page of Google. Thanks!

 

[Tired]

...

 

[PikminOC]

Nurses: RNs, generally execute orders written by physicians or other "providers" and are responsible for the minute-to-minute care of patients. Depending upon the setting, RNs can have a relative degree of independence and do things like order labs, dispense meds, etc..

NPs: RNs that have received a master's degree; the training program is usually 2-3 years, though there are "fellowships" that are 1-2 years long that allow the NP to "specialize" in a certain area of care (e.g., FM, EM, psych, etc.). NPs were initially meant to serve as providers under the guidance of supervising physicians, but that role has slowly grown into independent practitioners. They are allowed to practice independently and effectively do anything a physician can in just over 20 states (including prescribing) thanks to a highly successful and coordinated lobbying effort at the state level.

DNP: terminal degree for the NP. It's actually unclear to me what this is, and I haven't run into DNPs myself so I know very little about the training pathway.

CRNA: certified nurse anesthetist, essentially an NP specifically for anesthesia. Again, they were originally intended to work under the supervision of physicians, but depending upon the practice setting that may or may not be true. I believe the program is 3 years of training, but I could be wrong about that.

Expanding the role of non-physician "providers" isn't limited to the nursing area. Psychologists, for example, have been waging this battle for quite some time and have won some victories in a few states with respect to the prescription of psychotropic drugs. Pharmacists seem to be leaning towards this model as well though I haven't read too much about it.

Many NP's in most states need a "collaborative" agreement with a physician. So we know who takes the fall in case there is a bad outcome.

I'm not sure what terminal degree means. I don't think an MD is a terminal degree. I don't know why they use these terms for DNP.

The CRNA's still are under the umbrella of the physician, such as a GI physician in a case so when there is a bad outcome, the GI doc is on the hook as well.

I don't believe at all the nurses "do the same things as physicians".

 

[NickNaylor]

Many NP's in most states need a "collaborative" agreement with a physician. So we know who takes the fall in case there is a bad outcome.

I'm not sure what terminal degree means. I don't think an MD is a terminal degree. I don't know why they use these terms for DNP.

The CRNA's still are under the umbrella of the physician, such as a GI physician in a case so when there is a bad outcome, the GI doc is on the hook as well.

I don't believe at all the nurses "do the same things as physicians".

I totally agree with you - I'm hardly a proponent of independent NP practice - but from a legal perspective, the licensing bodies of many states have essentially equated NPs with physicians with respect to practicing privileges, scope of practice, etc.. I don't think it's right and I don't think it will serve patients well in the long run, but it is the situation nonetheless. In the states I mentioned above, the usual "collaboration" agreement is no longer required. NP practice in those states is completely unrestricted.

 

[PikminOC]

I totally agree with you - I'm hardly a proponent of independent NP practice - but from a legal perspective, the licensing bodies of many states have essentially equated NPs with physicians with respect to practicing privileges, scope of practice, etc.. I don't think it's right and I don't think it will serve patients well in the long run, but it is the situation nonetheless. In the states I mentioned above, the usual "collaboration" agreement is no longer required. NP practice in those states is completely unrestricted.

I can't find the source on this but there is a website that has the actual information. Other than the collaboration agreement, there may also be restrictions on controlled substances, etc. It really is not the majority of the states without limitations.

 

[NickNaylor]

I can't find the source on this but there is a website that has the actual information. Other than the collaboration agreement, there may also be restrictions on controlled substances, etc. It really is not the majority of the states without limitations.

The AANP offers a breakdown by state, but the specifics of prescribing (which I admit I'm not well-versed in) and other more particular points are hidden behind their membership wall: http://www.aanp.org/legislation-reg...ctice-environment/1380-state-practice-by-type.

 

[PikminOC]

The AANP offers a breakdown by state, but the specifics of prescribing (which I admit I'm not well-versed in) and other more particular points are hidden behind their membership wall: http://www.aanp.org/legislation-reg...ctice-environment/1380-state-practice-by-type.

Thanks that was what I was referring to.
Look at the states they have full practice in.
In New Mexico, even chiropractors prescribe.

 

[Promethean]

APRNs are very different than CRNAs and NPs. Agree with recommendation to research further on allnurses. Large portions of the information presented here isn't reflective of current nursing practice and doesn't account for significant regional differences.

No, those are categories of APRNs. It was my profession. I think that I know whereof I speak.

http://en.wikipedia.org/wiki/Advanced_practice_registered_nurse

Usually when you try to correct someone, it helps if you are correct.

 

[Ray D. Ayshun]

The answer to the question OP meant to ask is another question: what's the worst that could happen?

 

[Yadster101]

Why do I sense you guys are less frustrated with PAs than with NPs? PAs do the same job as NPs and genreally have a higher salary cuz of the specialties they go into

 

[W19]

Why do I sense you guys are less frustrated with PAs than with NPs? PAs do the same job as NPs and genreally have a higher salary cuz of the specialties they go into

The answer is here:

http://www.nova.edu/chcs/pa/fortlauderdale/timeline.html

http://nursing.fau.edu/?main=2&nav=478

If you compare the curricula, you can see why some med students think NP is a joke

 

[darklabel]

Why do I sense you guys are less frustrated with PAs than with NPs? PAs do the same job as NPs and genreally have a higher salary cuz of the specialties they go into

PAs also fall under the jurisdiction of the Board of Medicine. NP and DNPs fall under the American Association of Nurse Practitioners (AANP). There isn't a lobby for PAs to be seen as equivalent to physicians (or at least it isn't nearly as strong as nursing's) and their education is suited for their role they take in healthcare, which is an important one. NPs have a strong lobbying group and are fighting for equal practicing rights as physicians without needing the education of one.

 

[Promethean]

PAs also fall under the jurisdiction of the Board of Medicine. NP and DNPs fall under the American Association of Nurse Practitioners (AANP). There isn't a lobby for PAs to be seen as equivalent to physicians (or at least it isn't nearly as strong as nursing's) and their education is suited for their role they take in healthcare, which is an important one. NPs have a strong lobbying group and are fighting for equal practicing rights as physicians without needing the education of one.

This.

I was just talking privately with someone, saying that it really isn't a protectionism thing with me. I don't care about having my salary potential affected by a whole new class of nurse-doctors, if only they were really prepared for the roles they are stepping up into. The public is being sold on the idea that they are equivalent to physicians, maybe even better, and cheaper, too. But the education isn't equivalent, not remotely. And patients will suffer from unnecessary harm when their NP fails to properly diagnose or treat what a DO/MD would have picked up on.

I expect that when enough such harm occurs, and when physicians get their own lobby together enough to force the issue, higher educational standards will be imposed upon DNP granting institutions. Possibly, there will be a special separate licensing pathway. Eventually, there may be three flavors of physicians: DO/MD/DNP. I think that is the endpoint that the nursing profession is pushing for, and I don't think it has to be a bad outcome, if educational rigor achieves parity between them.

It happened before. There are many parallels to what is going on with NPs now and DOs several decades ago. Their training was spotty, but they filled a need, especially in rural areas. They convinced the public that they were as good, if not better. The allopathic profession wasn't able to get rid of osteopathic medicine despite trying, so instead, they insisted that the educational standards be raised, for the protection of the public health. I really don't see any other endgame for our current situation. NPs aren't going away, and they aren't going to back down on any of the ground they have gained with regard to independent practice. The only thing to do now is to make them accept the full responsibilities that accompany the privileges they have assumed.

However, making that happen will require physicians to collaborate their efforts to educate the public and the legislatures regarding the problem. It will be interesting to see if we can summon the collective will.

 

[Mad Jack]

Clicky clicky

That link contains all of the nurses.

 

[NickNaylor]

This.

I was just talking privately with someone, saying that it really isn't a protectionism thing with me. I don't care about having my salary potential affected by a whole new class of nurse-doctors, if only they were really prepared for the roles they are stepping up into. The public is being sold on the idea that they are equivalent to physicians, maybe even better, and cheaper, too. But the education isn't equivalent, not remotely. And patients will suffer from unnecessary harm when their NP fails to properly diagnose or treat what a DO/MD would have picked up on.

I expect that when enough such harm occurs, and when physicians get their own lobby together enough to force the issue, higher educational standards will be imposed upon DNP granting institutions. Possibly, there will be a special separate licensing pathway. Eventually, there may be three flavors of physicians: DO/MD/DNP. I think that is the endpoint that the nursing profession is pushing for, and I don't think it has to be a bad outcome, if educational rigor achieves parity between them.

It happened before. There are many parallels to what is going on with NPs now and DOs several decades ago. Their training was spotty, but they filled a need, especially in rural areas. They convinced the public that they were as good, if not better. The allopathic profession wasn't able to get rid of osteopathic medicine despite trying, so instead, they insisted that the educational standards be raised, for the protection of the public health. I really don't see any other endgame for our current situation. NPs aren't going away, and they aren't going to back down on any of the ground they have gained with regard to independent practice. The only thing to do now is to make them accept the full responsibilities that accompany the privileges they have assumed.

However, making that happen will require physicians to collaborate their efforts to educate the public and the legislatures regarding the problem. It will be interesting to see if we can summon the collective will.

I've posted this elsewhere, but I read an article a couple of months ago with an interview of the president of a state medical association. The interviewer specifically asked him about the topic of "midlevel creep," and his response was, to paraphrase, that while it was certainly something physicians should be aware of, it wasn't a big problem with his constituency. He postulated that this is because fewer and fewer physicians are going into private practice and more are being employed by large group practices or hospitals, this the "competition" from midlevels wasn't a concern. From his perspective, it was not an issue his organization was going to take up for the time being.

I thought that was a pretty interesting insight. There isn't the political will for most physicians to deal with midlevels becoming independent providers because many physicians don't see it as a problem that affects them. I think this is especially true of our peers. I made a post on Facebook that included a link to a story about NP practice with my contradictory but not pejorative opinion, and one of my classmates jumped on it and said that "we shouldn't put down other providers - we're all on the same team." I imagine that her opinion isn't unusual. And, to a certain extent, I agree. But the major issues, I think, are exactly those that you address - which is that if you want to equate the one training pathway with another, then the competencies necessary to demonstrate those things should be equivalent. Whether that means raising the bar for midlevels (the ideal in my world) or lowing the bar of physicians, they need to be equivalent. I don't think it's unreasonable to expect people to take identical certification steps regardless of the training pathway. Introducing different exams with different requirements just obfuscates the argument that's actually being made: that the training (and therefore the final result) is "identical."

 

[W19]

This.

I was just talking privately with someone, saying that it really isn't a protectionism thing with me. I don't care about having my salary potential affected by a whole new class of nurse-doctors, if only they were really prepared for the roles they are stepping up into. The public is being sold on the idea that they are equivalent to physicians, maybe even better, and cheaper, too. But the education isn't equivalent, not remotely. And patients will suffer from unnecessary harm when their NP fails to properly diagnose or treat what a DO/MD would have picked up on.

I expect that when enough such harm occurs, and when physicians get their own lobby together enough to force the issue, higher educational standards will be imposed upon DNP granting institutions. Possibly, there will be a special separate licensing pathway. Eventually, there may be three flavors of physicians: DO/MD/DNP. I think that is the endpoint that the nursing profession is pushing for, and I don't think it has to be a bad outcome, if educational rigor achieves parity between them.

It happened before. There are many parallels to what is going on with NPs now and DOs several decades ago. Their training was spotty, but they filled a need, especially in rural areas. They convinced the public that they were as good, if not better. The allopathic profession wasn't able to get rid of osteopathic medicine despite trying, so instead, they insisted that the educational standards be raised, for the protection of the public health. I really don't see any other endgame for our current situation. NPs aren't going away, and they aren't going to back down on any of the ground they have gained with regard to independent practice. The only thing to do now is to make them accept the full responsibilities that accompany the privileges they have assumed.

However, making that happen will require physicians to collaborate their efforts to educate the public and the legislatures regarding the problem. It will be interesting to see if we can summon the collective will.

It ain't going to happen. Physicians are too busy fighting each other. You have been a SDN member for a while now and I am sure you have seen different specialties crapping on each other. It seems like physicians have the mindset: 'If it does not affect my specialty, it ain't my problem'. Look what is happening to anesthesia. Nursing schools are flooding the market with CRNA making difficult for MD/DO anesthesiologists to get a decent job.

 

[Mad Jack]

It ain't going to happen. Physicians are too busy fighting each other. You have been a SDN member for a while now and I am sure you have seen different specialties fighting crapping on each other. It seems like physicians have the mindset: 'If it does not affect my specialty, it ain't my problem'. Look what is happening to anesthesia. Nursing schools are flooding the market with CRNA making difficult for MD/DO anesthesiologists to get a decent job.

Or primary care. Or psych. Everyone is like "eh, not my problem" unless it's their specialty.

 

[W19]

Or primary care. Or psych. Everyone is like "eh, not my problem" unless it's their specialty.

It boggles my mind that physicians are like that... I think it's a mindset that need to be changed. Sooner or later NP will demand to do 'minor' surgeries as I already saw them in some nursing sites advocating for that privilege.