Getting Lost: My Former Profession is Being Led Astray (Practicing to the Full Extent…… Clinical Supervision a Barrier …… Nonsense!)

An Institute of Medicine (IOM) (1) report two years in the making guides the Campaign in its efforts to build healthier communities through nursing (2).

            But the report has been bastardized to fit a narrative and rhetoric. A conclusion in the IOM report has merit, but it’s been spun to fit this narrative and rhetoric of the current Campaign for Action (2). The conclusion states:

“The current conflicts between what APRNs can do based on their education and training and what they may do according to state and federal regulations must be resolved so that they are better able to provide seamless, affordable, and quality care (5).” 

This is true. However, the Campaign for Actionstates “Nurses must be allowed to practice to the full extent of their education and training” (which is code for full practice authority independent of physicians) and is purported as being a factor in access to care. This manipulation of IOM conclusions is dishonest.   

I love my NP/PA brethren. On Physician lead Multi-Disciplinary Health Care Teams – a well functioning team with NPs/PAs is a great tool. Especially with quality physician collaboration/supervision; an item I use to really enjoy as an NP. Getting free knowledge, suggestion, and advice from someone with more education, and training was awesome (collaboration/supervision is not a barrier!) However, my former profession is being lead astray, and the dishonesty of a few is killing the reputation of a good many mid-level providers. I believe the majority of NPs/PAs are out there doing the daily grind trying to do good, but the profession as a whole is getting lost and going down the proverbial rabbit hole. I already referenced the aforementioned IOM report in a prior blog (3): https://authenticmedicine.com/a-commentary-on-as-nurse-practitioners-try-to-shake-free-of-doctors-kansasphysicians-resist/. It’s not evidence nor does it cite evidence, rather it appears more of a consensus opinion of supposed health care experts (I didn’t verify the authors). As such, as a guiding force in the Campaign for Action, it’s bogus. This is where the lies and dishonesty needs to stop from my former profession. I was an RN for 15 years then became an NP for 8 yrs before becoming and MD. I am fed up with the dishonesty and push for power by zealots within my former profession. Stop it! Here’s an example from The Campaign website:  

This statement “Nurses must be allowed to practice to the full extent of their education and training”is purported as being a factor in access to care. I wrote about this previously too (4) and debunked this outright lie that it affects access to care: (https://authenticmedicine.com/straw-man-the-dishonesty-needs-to-stop/). It’s a straw man that somehow practicing to the full extent of education and training improves access to care, thus there must be full practice authority. This statement seems to be influenced from the IOM report, but it didn’t define exactly what the barriers were nor did they define exactly what is practice to the full extent of their education, training, and competence (5):

“Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence.(5)”

The inference supposed to be made is twofold and it is nothing more than a swipe at physicians and effort towards power and practice of medicine by individuals who have not gone to medical school: (a) practicing to the full extent of education, training, and competence, and top of one’s license will increase access to care, and (b) clinical collaboration with physicians and physician supervision is a barrier towards practicing to the full extent of ones education and license. Interesting though, the IOM report seems to address the issues of scope of practice and barriers vaguely without bona-fide operative definitions, but these issues have been again spun to suit the narrative. The actual IOM report states:

“Scope-of-practice regulations in all states should reflect the full extent not only of nurses but of each profession’s education and training (5).” 

“Elimination of barriers for all professions with a focus on collaborative teamwork will maximize and improve care throughout the health care system.(5)”

            It brings up the following points:

  1. it doesn’t specifically state that the full extent of education and training is the practice of medicine such as being pushed today.
  2. It is a general statement that includes all healthcare providers not exclusively NPs.
  3. It doesn’t state that collaboration and supervision is a barrier, in fact it states the opposite that there may be inherent barriers, but the focus on collaborative teamwork will maximize and improve care throughout the health care system.
  4. Thus, the concept of scope of practice to include the practice of medicine, supervision as a barrier, and collaboration as a barrier is false narrative. 
  5. These two aforementioned conclusions (scope of practice and barriers) of the IOM report have been bastardized to again suit the narrative of a zealous few. 

Clinical collaboration/supervision has never been proven to be a barrier nor has there been a viable description as to just how it is a barrier. Nor does the statement of practicing to the full extent of ones clinical training increase access. These are nothing more than talking points. I wrote about this previously too (6,7): (https://authenticmedicine.com/wheres-the-beef-2-impact-of-state-scope-of-practice-laws-another-straw-man/https://authenticmedicine.com/clinical-supervision-a-positive-thing-for-all-practitioners-and-physicians/). So my counter is that no one has been able to define “practicing to the full extend of education, training, and competence, and top of one’s license”and this will not increase access to care. Nor have I found a description that pin points just how supervision and collaboration are barriers towards practicing to the full extent of ones education and training. As a former NP, I don’t even know what this means and haven’t been able to figure it out. In addition, I will also counter that as stated before and I can’t state it enough that clinical collaboration/supervision IS NOT a barrier. I have never encountered any barriers in my former 8 yr NP practice in both FPA states and collaboration states. In fact, just the opposite – I worked in a couple organizations in a FPA state that required clinical supervision, and what a gift that was. It would be hubris to think I wouldn’t have anything to gain from someone with much more education, training, and clinical hours. So much to learn, and I had clinical supervision with willingness to give me that. Something about when the student is ready, the teacher will appear. 

The Campaign for Action and my former profession as a whole needs to become much more honest in the promotion of the profession. I will stand by the good NPs and PAs just as the good physicians (who were teachers, mentors, collaborators, and supervisors for me) stood by me. But I am frustrated and fed up with the bold face lies being told by entities and my former profession. Citing poor evidence or evidence that doesn’t exist. Moreover, don’t even get me started on the concept of evidence as will be touted by my former profession. All in all, I am not against mid-level providers promoting their profession and careers. I just disagree with the direction they are taking it, and the means by which they are doing it. This dishonesty needs to stop. 

Have a great day. 

REFERENCES:

  1. http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
  2. https://campaignforaction.org/issues/
  3. https://authenticmedicine.com/a-commentary-on-as-nurse-practitioners-try-to-shake-free-of-doctors-kansasphysicians-resist/
  4. https://authenticmedicine.com/straw-man-the-dishonesty-needs-to-stop/
  5. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Scope%20of%20Practice%202010%20Brief.pdf
  6. https://authenticmedicine.com/wheres-the-beef-2-impact-of-state-scope-of-practice-laws-another-straw-man/
  7. https://authenticmedicine.com/clinical-supervision-a-positive-thing-for-all-practitioners-and-physicians/

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Robert Duprey MD

Robert P. Duprey Jr studied medicine as a 2nd career medical student who went to medical school in his 40’s after honorable discharge and ‘retirement’ from 25 years in the US Military (USCG & US Army). He was a registered nurse (RN) with specialty training as a psychiatric RN in the US Army for 15 years. During this time he also became a Master’s level psychotherapist in 2002. While on US Army active duty he also became a Psychiatric Nurse Practitioner while working full time in 2011. He served as a Psych NP on active duty, to include a combat tour in Iraq, until his ‘retirement’ in 2014 and moved to Philippines with his 3 children. At this time he started medical school overseas at Oceania University of Medicine based out of Samoa accredited by Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). He continued to work as a Psych NP throughout medical school to support his children and to not have to take out loans for medical school tuition. Originally from Rhode Island, he completed medical school clerkship rotations throughout the USA with a graduation in May 2019 earning the esteemed credential of MD. He has successfully completed USMLE Steps 1, 2CS, and 2CK. He will take Step 3 this September as he applies for Psychiatry Residency. Having been and RN, NP and now MD, he is a believer of Physician led multidisciplinary healthcare teams 

  1 comment for “Getting Lost: My Former Profession is Being Led Astray (Practicing to the Full Extent…… Clinical Supervision a Barrier …… Nonsense!)

  1. Diane Haugen
    July 4, 2019 at 12:51 pm

    Excellent coverage of what few recognize as a serious problem, especially in rural medicine where NPs are seen as perfectly O.K. substitutes for MDs. The misguided hype about “full practice authority” has certainly muddied the waters as to what the good NPs should really care about (my perspective on this: http://bit.ly/2q2qRgb).

    Another problem physicians should really be concerned about is that NPs, at least in North Dakota, is that NPs are overseen by the nursing board whereas MDs are overseen by the medical board. Their standards are very different. So not only are we giving “full practice authority” to significantly less educated persons, but they are being held to a vastly less stringent level of practice by their professional board.

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