This recent article from the NYT (on the need for RN’s to obtain bachelor degrees) got me thinking (again) about all the conversation these days regarding scope of practice and what specialty paths nurses can pursue.
Additionally, a 2010 IOM report on the future of nursing calls for greater involvement of nurses with advanced training in patient care. Not unexpectedly, reports such as those and others similar in spirit typically garner responses such as this:
“Representatives of the American Medical Association and the American Academy of Family Physicians said they agree with the need to expand the primary care work force. But they questioned the institute’s recommendation to expand APNs’ practice scope.”
Regardless of your viewpoint, APN’s (Advanced Practice Nurses) are here to stay. What can a specialty nurse actually do then?
To move beyond the basic RN degree, nurses need to acquire a Masters in Nursing (MSN)–which allows them to focus on education (Clinical Nurse Leader or CLN) or administration. They can also concentrate on clinical disciplines as APN’s.
Here is a breakdown of the clinical realm:
* Nurse-Midwives: a Certified Nurse-Midwives (CNM) function as primary healthcare providers for women and most often provide medical care for relatively healthy women, whose birth is considered uncomplicated and not “high risk,” as well as their neonate. Certified Nurse-Midwives, in most states, are required to possess a minimum of a graduate degree such as the Master of Science in Nursing.
* Nurse Anesthetists: a Certified Registered Nurse Anesthetist (CRNA) is an advanced practice registered nurse (APRN) who has acquired graduate-level education and board certification in anesthesia. Update here.
* Clinical Nurse Specialists: The CNS integrates care across the continuum and through three spheres of influence: patient, nurse, system. The three spheres are overlapping and interrelated but each sphere possesses a distinctive focus. The CNS is responsible and accountable for diagnosis and treatment of health/illness states, disease management, health promotion, and prevention of illness and risk behaviors among individuals, families, groups, and communities. In contrast with Nurse Practitioners, Clinical Nurse Specialists often function as educators and consultants to the nursing staff and experts on ensuring evidenced based practice and quality patient outcomes. Their roles are diverse:
- Population (e.g. pediatrics, geriatrics, women’s health)
- Setting (e.g. critical care, emergency room, long-term care)
- Disease or Medical Subspecialty (e.g. diabetes, oncology, palliative)
- Type of Care (e.g. psychiatric, rehabilitation)
- Type of Problem (e.g. pain, wounds, palliative)
* Nurse Practitioners; An NP has completed graduate-level education (either a Master of nursing or Doctor of Nursing Practice degree). Nurse Practitioners treat both physical and mental conditions and perform H&P’s, as well as order and supervise diagnostic tests. In the hospital they counsel patients and families, interface with community caregivers, and assist with transitions. NP’s can provide treatment for patients, including dispensing of prescription medications. NP’s can serve as a patient’s primary health care provider, and see patients of all ages depending on their specialty:
- Acute care nurse practitioner (ACNP)
- Adult nurse practitioner (ANP)
- Family nurse practitioner (FNP)
- Gerontological Nurse Practitioner (GNP)
- Neonatal nurse practitioner (NNP)
- Pediatric Acute Care Nurse Practitioner (PNP)
- Psychiatric and mental health nurse practitioner (PMHNP)
- Women’s Health Nurse Practitioner (WHNP)
The nurse practitioner population will nearly double by 2025 (128,000 in 2008 to 244,000 in 2025). As mentioned, NP scope of practice and physician supervision is also a contentious issue (see the latest IOM report). An illustrative quote below, and then a map and pie chart breakdown of state policies:
“Expanding the pool of health care providers through scope of practice changes has been controversial. Often, physicians and dentists are concerned about the ability of mid-level trained professionals to provide high-quality care and treat complex cases; some also fear increased competition for their services. Advocates for broadening the scope of practice point out that doing so expands access to much-needed services, helps leverage the expertise of physicians and dentists by freeing them to treat more complex or critically ill patients, and reduces costs for many basic services.”
Additionally, greater numbers of NP’s (verus PA’s) practice in primary care:
The current allocation of the NP vs PA vs MD/DO primary care workforce:
There are more than 330 master’s degree programs accredited by the Commission on Collegiate Nursing Education (CCNE) or by the National League for Nursing Accrediting Commission (NLNAC). Read more here.
- Advanced Practice Nursing Salary:$92,000 (Indeed.com)
- Nurse Practitioner Salary:$89,450 (American Academy of Nurse Practitioners (AANP)
- Registered Nurse Salary: $64,241 (BLS)
- Licensed Practical Nurse Salary: $40,875 (BLS)
- Nursing Aide Salary: $24,932 (BLS)
Patients are more receptive to the use of midlevels than you might have thought, at least by this recent survey. Convenience and cost is a priority, and we still have a lot to learn about quality and outcomes, but in the right setting, they might rival conventional care delivered by a physician. Folks are beginning to shift their views:
WOULD YOU SEE AN NP OR PA IF A DOCTOR WASN’T AVAILABLE?
- Millennials (1982-1994): 36%
- Gen X (1965-1981): 50%
- Boomers (1946-1964): 52%
- Seniors (1900-1945): 46%
Since physicians will increasingly have greater interaction with APN’s (about 5% are men), familiarity with their training background and titles will go a long way in making HM a superior team-based sport. Currently, almost half of ambulatory docs are working with midlevels.
Here, by the way, is the SHM policy statement on NP’s, and an excerpt defining our “scope of practice” position:
The hospitalist is responsible for oversight of Physician Assistants and/or Nurse Practitioners sharing in the care of the hospitalist’s patients. The hospitalist or designee must be available for consultation with the Physician Assistant and/or Nurse Practitioner at all times, either in person or through telecommunication systems or other means.
As the health dollar becomes more scarce, and NP’s (successfully?) demonstrate their worth (with evidence) in the hospital environment as independent practitioners, HM physicians and their response may resemble that of other medical disciplines. Something to watch.
For more info, here is the SHM link to the NP/PA section on our website.
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.
Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.
Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.
He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.