AANP president weighs in on full practice authority laws

By | 2022-10-10T14:24:35-04:00 September 10th, 2019|22 Comments

It’s no secret our healthcare system is needlessly complex and full of mounting challenges that often make it complicated for patients to navigate and get the care they need.

full practice authority


Outdated nursing licensure laws are one of those challenges — and one we can address together.

Each state issues individual nursing licenses that are just like driver’s licenses, which authorize individuals to drive automobiles — except for the fact that authorization for practice can end at the state line.

Imagine for a moment what it would be like if you owned your car and had a state-issued driver’s license, but had to obtain a permission slip from a neighbor before you could drive?

These permission slips also could limit your ability to drive on the highway or even make right-hand turns. Sounds pretty ridiculous, right?

We’d end up with traffic jams and kids late for school. As far-fetched as this sounds, a version of this happens to nurse practitioners (NPs) in states around the country every day.

Full practice authority rules and regulations

It’s illegal for nurse practitioners in 28 states to practice their profession without a “permission slip” — a collaborative agreement with a physician.

This creates bottlenecks in the workforce, increasing healthcare costs and, even worse, leaving patients with unmet healthcare needs.

Healthcare providers and policymakers need a clear understanding of the impact of outdated scope of practice licensure laws and the benefits full practice authority offers patients, communities and our entire healthcare system.

The benefits of full practice authority include:

  • Helping states better address challenges to accessing primary care that impacts millions of patients.
  • Lowering the costs of healthcare in states that embrace the model.
  • Increasing our nation’s capacity to combat the opioid crisis by expanding the pool of providers authorized to prescribe medication-assisted treatments.

As state legislators gear up to consider full practice authority bills in 2020, the American Association of Nurse Practitioners (AANP) is calling on lawmakers — and partnering with our nursing colleagues — to recognize the value of embracing the National Council of State Boards of Nursing’s APRN Model Practice Act as the gold standard for implementation.

For those pondering what it all means for our profession and patients in your state, below are some key points to know in the effort to secure adoption of full practice authority nationwide.

Definitions matter

First, it’s important to understand how scope of practice laws are defined and classified by each state. The AANP has created a helpful map for easy visual reference that shows you where each state stands.

On the map, states are coded:

  • Green for full practice authority
  • Yellow for reduced practice
  • Red for restricted practice

State practice and licensure laws permit all NPs to:

  • Evaluate patients
  • Diagnose, order and interpret diagnostic tests
  • Initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing

Reduced and restricted practice states have any number of regulations that prohibit NPs from engaging in some aspect of their practice, even though they are educated, trained and licensed to provide care for patients.

These states also often require NPs to maintain some form of a collaborative, supervisory or delegation agreement with a physician to treat patients. This career-long obligation also might limit the type of care and setting in which an NP can practice.

Full practice authority can address pressing challenges

One of the most profound ways outdated laws affect patients is in geographic health disparity areas or health provider shortage areas.

Full practice authority helps remedy this because it’s about allowing patients full and direct access to NP-provided care wherever they seek care.

When 60% of states fail to modernize their scope of practice laws, patient access and satisfaction goes down. At a time when America faces such serious health challenges such as the opioid crisis, ongoing physician shortages and lack of access to primary care services, it’s hard to justify keeping these outdated laws in place.

According to my recent op-ed published by TheHill.com, I noted that states with full practice authority have healthier residents and consistently rank higher on state health report cards.

In fact, eight of the top 10 healthiest states — Colorado, Connecticut, Hawaii, Iowa, Minnesota, Rhode Island, Vermont and Washington — have full practice authority laws, which enable patients to directly access NP care without restrictions.

By contrast, the 11 lowest-ranking states have laws that directly limit NP practice.

That’s a pretty stark contrast considering patient populations’ overall health, but it also applies to other mounting challenges such as the opioid epidemic.

In a recent Time magazine article, former Secretary of the Department of Health and Human Services and Governor of Wisconsin, Tommy Thompson, and AANP CEO David Hebert rightly noted failing to enact full practice authority has negatively impacted NPs’ ability to prescribe critical treatments to combat opioid use disorder.

“These restrictions don’t just impact medication-assisted treatment prescribing, they deter NPs from practicing at all,” the article said. “In fact, states with laws that limit NPs’ scope of practice have 40% fewer NPs per capita than states without. That’s why they make so little sense — particularly in states where the opioid epidemic is especially dire.”

NPs are uniquely qualified to take on these challenges — and others — while also providing high-quality, comprehensive and cost-effective care.

But it is also important we work together to show policymakers at the federal and state levels that taking the necessary steps toward full practice authority will help ensure all Americans, regardless of where they live, have access to the care they deserve.

Significant support exists for full practice authority

As we dig deeper into the reasons full practice authority is so vital to our healthcare system, it’s important to consider the breadth and diversity of agreement among industry leaders.

AANP — along with more than 40 nursing organizations, the National Academy of Medicine, AARP and several other national health leaders — support full practice authority as the pinnacle standard for licensing and regulating nurse practitioners.

Adopting this model nationwide would end the patchwork, streamline regulations and decrease unnecessary regulatory costs states incur from needless requirements and improve overall healthcare access.

South Dakota, for example, now saves an estimated $70,000 a year since adopting full practice authority in 2017.

Professional development and growth potential

By granting NPs full practice authority, they have greater mobility to practice in new communities where the patient demand is highest. They may even consider opening their own practices and/or choose to work in primary care.

And with the majority of NPs practicing in primary care — more than any other provider — reinforcing our critical role and value to underserved areas is a central component to our advocacy of full practice authority in the states still lacking adequate patient access.

Modernizing licensure isn’t just needed for NPs. Updating our nursing licensure laws ensures RNs and other advanced practice registered nurses (APRNs) can practice at the top of their education and certification to transform and improve healthcare.

The capacity of the nursing profession to radically address the challenges of chronic disease and an aging population and reshape a healthcare system to better promote whole-person health is only possible when our laws permit us to bring all of our nursing expertise to every patient encounter. That’s the bottom line.

During my presidency at AANP, I pledge to explore ways to elevate our collective nursing voice and contribution so we can get back to doing what we do best — treating our patients as if they were friends or family, with the kind of care and attention they deserve. That’s what helps make a healthy and prosperous society.

While this is a brief overview of the scope of practice landscape for NPs, there is so much more to discuss and share from each of our states.

I look forward to traveling to full practice authority and non-full practice authority states over the coming two years to listen and learn from NPs about the challenges they face and how our continued effort to bring about full practice authority will help them treat more patients.

We welcome and appreciate opportunities to showcase a growing body of evidence indicating NPs are increasingly important to our healthcare system and why more patients are choosing NPs as their provider of choice.

Explore Your Higher Education Options at Nurse.com/Schools.

Take these courses related to full practice authority:

Protect Yourself: Know Your Nurse Practice Act
(1 contact hr)
Nurses have an obligation to keep abreast of current issues related to the regulation of the practice of nursing not only in their respective states but also across the nation, especially when their nursing practice crosses state borders. Because the practice of nursing is a right granted by a state to protect those who need nursing care, nurses have a duty to patients to practice in a safe, competent, and responsible manner. This requires nurse licensees to practice in conformity with their state statutes and regulations. This course outlines information about nurse practice acts and how they affect nursing practice.

Advanced Practice Nurse Pharmacology
(25 contact hrs)
This course will help advanced practice nurses meet the new ANCC 25-contact hour pharmacology requirement for re-certification beginning Jan. 1, 2014. Written and rigorously peer reviewed by pharmacists and advanced practice nurses, this course features a wide range of medical conditions and the medications associated with them. Chapter topics include hypertension, diuretics, GI, critical care, sexually transmitted diseases, asthma, oncology, non-opioid analgesics, diabetes, weight loss, mental health conditions such as anxiety, bipolar disorder, depression and much more. The chapters highlight clinical uses, dosing, interactions and adverse effects for the common medications used in your practice. APN tips are featured throughout the chapters to help you in your prescribing practices.

Team-Based Healthcare: Helping to Improve Patient Outcomes
(1 contact hr)
Use of the interprofessional team approach has led to improved outcomes in some patient populations and disease states. Many different models exist and all can be adapted to fit specific population needs. As healthcare reimbursement continues to evolve, team-based approaches may be warranted to optimize patient care.

Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, is a licensed nurse practitioner (NP) in the state of Louisiana and president of the American Association of Nurse Practitioners (AANP).


  1. Avatar
    Lee September 16, 2019 at 4:33 pm - Reply

    I have all the respect in the world for NPs; but in no uncertain terms should they be used in place of a licensed physician. Physicians spend many more hours of classroom, clinical and research time to learn to effectively analyze symptoms, diagnose and treat illnesses. A nurse-practitioner may get approx. 650 hours of clinical instruction during their entire education which is less than what a physician receives during their first year of a three year residency. And I don’t want to hear the argument that NPs have spent many hours working as nurses before becoming nurse-practitioners. That in no way equates to any part of a physician’s education and training. In no way do I deny the hard work it took for someone to become an NP; but it is not the same as going to medical school. The bottom line is that they are not qualified to make medical decisions as an MD or DO and should never be utilized in that manner and should not be allowed to practice without a collaborative physician agreement .

    • Avatar
      Dr Carron C Cherrie September 29, 2019 at 7:28 am - Reply

      Dont contribute to the health care crisis. Let nurses practice their profession which is different from medicine. APRNs have demonstrated their competency. It is time to improve health and well being of the population which has too long been held hostage.

    • Avatar
      Elizabeth Dougherty September 30, 2019 at 9:27 am - Reply

      We practice Advanced Practice Nursing- Not Medicine.
      Your comments are equating NPs to MDs- of which we are not. Practicing in Boston Massachusetts- where there is fabulous health care, my practice and ability to earn an income is inhibited by the State Medical lobbies. However, this state is surrounded- by RI, NH, Vt who all have full practice authority. I understand your meaning- personally I see an MD and an NP for my primary. NPs have improved the healthcare across this Nation and it is just that they should be able to practice independently and be able to earn their own reimbursements. Also, collaboration is taught to NPs in their graduate curriculum- this fact teaches them to bring all health care providers to the table to improve the outcome of care to their patients.

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    Cheryl September 17, 2019 at 1:57 am - Reply

    Lee, even as a Registered Nurse, who graduated 40 yrs ago (in the dark ages), when you were actually required to spend time in a classroom & with an instructor, I agree with you 100%! I have met many wonderful CRNP’s & no doubt they often have more time than the physician. However, I, like you, don’t believe that s CRNP should be practicing without benefit of a collaborative agreement. In fact, in some states, they have people who monitor how well the doctors & CRNP’s are following the collaborative practice rules! What a smart idea!

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    Diane Bruessow, PA-C September 17, 2019 at 7:29 am - Reply

    Lee misses the point. One does not need the extensive training of a physician to work within their education and training. Every other licensed profession does it. It’a Time that NP and PAs do it too.
    The good news is that Lee and other physicians get a pony when their state’s NPs and PAs practice restrictions are removed: they no longer are held liable for the autonomous actions of the NPS and PAs they’re affiliated with. Especially now that most physicians are institutional employees and not employers.

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    Wendy Fletcher September 19, 2019 at 5:17 pm - Reply

    Nurse Practitioners are not physicians. They are Nurse Practitioners. They aren’t “playing doctor,” they are practicing advanced nursing.
    The above comments come from the (false) assumption that physicians somehow own the practice of healing in all forms. This is completely egocentric and grossly biased. NPs are well trained in what they do, and they do it well.
    The comparisons are misdirected, and intentionally manipulative.
    When a plumber and a carpenter use a drill, they may use it the same way, to drill the same size and shape hole for the same size and shaped screw—but doing so doesn’t make the plumber anymore a carpenter, or vice versa. Interestingly, both are needed to complete construction, yet I never hear one telling the other they need their “permission” to drill a hole while doing their respective jobs.
    NPs are NPs. MDs are MDs. DOs are DOs. And the house of health we all need to build together is for our patients is plenty big enough; there’s plenty of “sick” to go around.
    It’s time to stop the turf wars, start opening access to patient-preferred and patient-centered healthcare, and cut the red tape that binds all of is from doing what we were educated, certified, licensed, and perhaps called to do.

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    Lee September 24, 2019 at 12:15 pm - Reply

    Exactly, NPs are practicing advanced nursing and should always work within that scope. I’m simply saying that if I am going to a doctor’s office, I wouldn’t mind seeing an experienced NP; but I want a licensed physician on staff also. That would be especially if I were looking for a diagnosis.

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      Jillian October 11, 2020 at 7:12 pm - Reply

      What is unfortunate, Lee, is how little you value nursing experience. If only you knew how many times nurses had to correct the physician because they ordered a lethal dose of a medication. And despite the extra hours that physician put in, the NURSE, was the one who actually knew the correct dose, by heart, without letting medical informatics fill in the script order.

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    Mischelle September 28, 2019 at 11:42 pm - Reply

    The problem is that there are not enough providers. There are fewer and fewer physicians going into primary care/family medicine. I am going in to my 11th year as an FNP in the state of Missouri, prior to that spent 14 years in the ER. Our state has some of the strictest laws in the country. It is this belief that we are all trying to be physicians. We are not trying to be physicians. We are trying to provide primary care for patients who desperately need someone to take care of them. I will say in my 25 years of healthcare I have many wonderful docs and some terrible docs. I have worked with great nurses and terrible nurses. I have never met an NP whoever believed they were practicing like a Dr. I think one of the things gs I never expected when I was young is how greedy some drs are. I’m not saying that is what is fueling this feud. But there are so many who need help and you would think drs would embrace NPs who want to help take care of all of the patients.

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    Hunter Deluca September 29, 2019 at 3:55 am - Reply

    Lee, “looking for a diagnosis?” NP’s diagnose and treat. Is it your observation that an NP is a only a data collector? That the job of a nurse practitioner is just to give their assessment to the “doctor” and relinquish the coveted Diagnosis to the physician?
    I am sure that’s not what you meant. In fact, Many studies show that despite all the hours that physicians perform In training, their are a significant number of NP’s that correctly come to a diagnosis that a physician missed. Of course this goes both ways.
    There are many studies performed by physician scientist, that have compared NP practice to MD/DO practice. In many areas NP’s out perform MD/DO’s.
    Let’s be clear, the NP’s are doing it as NP’s through the practice of advanced practice nursing, not as an MD imposters or under the veil of medical practice.

    Let’s get to the argument at hand, the training hours of MD’s are higher than NP’s. That is true if the MD/DO is trained in the US. How many MD’s go to foreign medical schools? The answer is a large number. Most foreign medical grads start their training straight out of high school with a total of 6 years or less.
    An NP, has a 4 year undergrad, a minimum of 2 years for their masters and another 2 1/2 or 3 years for their doctoral degree. You get the math. So the argument that all doctors have more hours and training is not always a valid argument.
    I did not include those NP’s that have 2 years of specialty fellowships beyond their doctorate.

    Fact of the matter is that for the most part the care is equivalent. This is not MY opinion. This is the opinion of multiple high impact studies, not to mention the Institute of Medicine, which is one of the highest authorities in standard of care.

    This is an educated guess, but I bet that the majority of nurse practitioners defer to a higher level provider in any situation that they are having difficulty treating a patient or feel uncomfortable with the situation. They do care about their patients and want the best for them. That may mean deferring to an MD/or DO at times.
    Ironically, physicians perform the same
    way and defer.
    Example, a family practice physician or internal medicine physician who encounters a patient with a difficult pulmonary issue refers to pulmonary, surgical issue, refers to surgery, uncontrolled diabetes refers to endocrinology, gastroenterological issue, refers to a gastroenterologist and so on.

    Don’t get hung up on the title, concentrate on the quality of care delivered. Moreover, appreciate that there is an army of competent providers that care for vulnerable populations that otherwise would not have access to care.

    By the way, I am a US trained physician who is grateful and privileged to work with the NP’s in my practice as a Hospitalist and Critical Care provider.

    Great discussion

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    Elton September 29, 2019 at 10:11 am - Reply

    Here in CA, clinics are unable to expand because they can’t find a “supervising” physician, even someone totally “out of commission” (basically a VERY old guy/gal who comes once a week to tell at MAs and sign the charts). On the other hand, in many clinics, asking to see/sign a collaborative agreement (which is the Law) will disqualify a potential NP/PA from the job. In other words, you want a job, keep quiet and take chances. We try to “break free” … every year. But MDs have better lobbyists.

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    Alex October 1, 2019 at 12:43 am - Reply

    I wish Lee the best of luck in the future. The shrinking number of physicians, and the growing US population will dictate that he will either see NPs, or get sick and die while waiting for an appointment with the physician he is so convinced he must see.

    As the education system for healthcare providers evolves, medicine (the MD/DO variety) is rapidly becoming 150 years of tradition, unimpeded by progress. Reality is that distance education has a role, as does hands on, in person classroom time. Just because a program is longer doesn’t mean it is better, it just means its longer. Lee’s feelings are probably hurt because after 8 years of education plus a paid apprenticeship (aka residency), he finds himself writing the same prescriptions as NPs and PAs. Sorry Lee…but this isnt the venue for a pity party, or a temper tantrum. There are AMA meetings for that.

    NPs and PAs are solving tomorrow’s problems, such as access, doing education and prevention, and are doing it with little of the protectionism that the physicians do. Apparently we are more interested in helping patients, and less interested in protecting our little cash cow.

    Good luck Lee. The NP/PA ship has sailed, and I hope you are either very healthy, or have a huge disposable income to spend seeing your physician colleagues exclusively.

  10. Avatar
    Margaret October 1, 2019 at 11:58 am - Reply

    While I agree in breaking down barriers where necessary to expand freedom of well qualified and trained NP’s to practice at full capacity, I am still against blanket authority to NP without regard of their background to practice across the board because this field is still lacking standardization.
    Nurse Practitioners and as a matter of fact all APRN need a standardized entrance and certification exam like Medicine and Pharmacy. No short cut education. NP as a whole Nursing education in America is highly monetized. It is a million dollar business. Nurses must ask themselves, Why is medicine not monetized and made easy like Nursing. How many online medical schools do you have. Please share if you know one.
    It was very despising to see a pharmacist friend whose daughter was not doing well after her Masters degree in whatever she studied and could not get into any medical school or pharmacy school and she said casually without regard to NP profession I will send her to NP school. Seriously, the redeeming profession. Today she is a practicing NP. Mind you, this is someone who could not do much 3years prior.. How did that happen? Because of the loopholes in US Nursing education. Nursing education in the US is unstandardized and too watered down. Nursing is marketed as a profession where any Tom, Dick or Harry is accepted and somehow rewarded with a license to practice messing it up for the diligent conscientious ones. I see so many redeemed souls in Nursing and you want to arm these persons with unlimited authority, Not so quickly!
    Take a look at the origin of a good number of Nurses including their leaders, most did not go to 4yr college, several are redeemed products of failures in other professions. How many got a clean 4yr degree? Several hopped around from part time half baked education up to where they are today. How do you feel safe letting these persons have unencumbered license to practice. Some are opportunists who took the easier road to success, of course, Nursing. Nursing has become a watered down to a profession where entrance sometimes can be by lottery, change of schools a few times or whatever it takes and in a few years achieve your aim. Several started as Nursing Assistants or housekeepers and moved up to where they are today. That shows you the type of people the profession attracts, not intellectual minds . How many were intellectually endowed or college material from the get go.
    This convoluted entry is rare in the field of Medicine and Pharmacy. Yet you want more authority, fix the loophole and elevate the profession before seeking to be unleashed.

    NP need to have a standardized education requirement that is comparable to medicine with faculty that are comparable to that found in medicine if same authority is sought. There need to be a standardized General NP education and then specialization. This would eliminate specialized NP fields from practicing in a scope above their training. I see Women’s Health NP and Geriatric NP practicing Internal Medicine or field beyond their training and expected to thrive. The education and internship need to match the authority endowed.

    • Avatar
      Penny Myers October 17, 2019 at 5:59 pm - Reply

      Margaret, I do agree that the greed to rake in the NP student money is causing many sloppy and less selective programs to pop up, or creating well-padded but useless DNP programs that are rehashes of MSN level courses. I’m for standardization, too. Many are set up to fail the majority of students the first year to get that easy money, too. (The first year of prerequisites is so automated that the teaching staff is not needed in the numbers they will be later.)

      But keep in mind that young woman might have been immature and/or lazy, or lacking in confidence–something that just did better in the nursing climate. However, the person who said s/he’d just send her to NP school has appalling judgment. If they thought she was that stupid or unmotivated and that the program would be easier–they are still willing to unleash her on patients?


      As for online schools in general, the didactic portion may be recorded or in real-time, but I haven’t seen any evidence that a teacher droning on in person is any better. I remember doodling when I was bored, and some teachers were boring! If anything, online schools make you prove and prove and prove you know something to make sure your education is not compromised. There’s more work and you can’t hide behind little quizzes, necessarily, nor get by on cramming, any more or even as much as a brick and mortar school. The clinical hours need to be increased in all schools, but given the time already required and the huge bill, when NPs already have a large % of med school costs in some mpore expensive schools, who will accept NP pay after that?

    • Avatar
      Annelise June 19, 2021 at 12:18 am - Reply

      Let me tell you, my brother and I are 8 years apart. We are both Cubans, came to the US when he was 5 and I was 13. My first job was at 13 years old at the flea market, from 8am to 6pm Saturday and Sunday for $30/day because it was 1995 and because I wanted to work, learn English out of school and learn customer service. No AC, heat of 100 degrees under those tarps. My parents were poor because we had just gotten here. My brother, 5 year old. My father, surgeon in Cuba, my mother, engineer. I became a MEDICAL ASSISTANT in 2001, after years of working in all kinds of stores, Dandy Bear, Jewelry stores, etc and going to high school and college, driving an old car and having sometimes $17 to my name. I became an LPN and then an RN. then got my BSN and now my Masters. My brother, from the same struggled family, same food, same everything, different BRAIN, different paths, became a Medical Doctor, Physician or however you want to call it, since its so special. We love each other. We are both in medicine. He had the “convoluted entry” into medicine and I…… ” Several started as Nursing Assistants or housekeepers and moved up to where they are today. That shows you the type of people the profession attracts, not intellectual minds”….I’m one of these, “non intellectual minds” you refer to, a soon to be Family nurse practitioner. Now I ask myself, how did my brother and I have different paths and came from the same “kind of people” you also refer to. You need extensive help. I feel sorry for you as a human being, your life must have been very painful. You can reach out for help if you ever need any. God bless you.

    • Avatar
      Kieu November 12, 2021 at 2:37 am - Reply

      I don’t know where you got the idea that anyone can get into nursing and graduate school to become an NP. Certainly getting into medical school is much more difficult but it is not easy to get accepted to a nursing program. I believe it is required across the board that anyone wishing to enroll in an NP program must first obtain his or her RN license, graduated from a BSN nursing program and a certain number of hours working as a RN. Not all nurses are great, the same goes for other professions, but assuming anyone can become a nurse or NP, you must be kidding. NPs are NPs and MDs are MDs, they aren’t the same level for sure but NPs do not need babysitters to watch everything they do. It’s best to have physicians in the same practice to consult difficult cases or for a second opinion but NPs are competent to treat and diagnose.

  11. Avatar
    Gerald Lebel October 1, 2019 at 4:36 pm - Reply

    When updating laws pertaining to Nurse Practitioners please consider grandfathering those that have been practicing successfully for many years. I have an unrestricted license to practice as an independent NP in Maine but unable to practice in other states since I am not board certified. I am proud of the many years I have successfully and compassionately served my patients and wish to do so in other states. My record is spotless and my decision making has always put my patient first.
    Please let me know if you wish to discuss this further.
    Gerald Lebel NP

  12. Avatar
    S October 13, 2019 at 3:17 am - Reply

    Your opinionated comments are clearly from a disgruntled individual. Great way to use evidence to support your argument.

  13. Avatar
    Penny Myers October 17, 2019 at 5:47 pm - Reply

    Thank you, those who did not try to say that NPs are “just as good at doctoring as any physician”, or call physicians “doctors” as if they alone had doctoral degrees. (Never mind DNPs, chiropractors, English professors.) It is pure backward, outdated sociology regarding the origins of nursing that has some physicians and too many others still seeing nursing as something that exists only in conjunction with and subordinate to the practice of medicine.

    That’s no more true of nursing (since decades ago!) than physical therapy, respiratory therapy and many others. Even Registered Dieticians were once part of the RN role. No one thinks these off-shoots from what was everyday nursing care should still be subordinate to nurses forever, no matter what advanced knowledge and degrees they might hold IN THEIR OWN FIELDS. Nursing still supports medicine, but so do these other disciplines, and if there is any sincerity behind the team approach, collaboration being best and so on, medicine should support them as well.

    If an APRN is doing something and doing it well, that care is not “doctoring” but advanced-practice nursing.

    I have yet to hear an MD or DO gripe about how cocky or foolhardy or territory-stealing an advanced-degreed Physical Therapist or Dentist has gotten to be. Few seem to notice that many chiropractors are selling all kinds of medicines as supplements with alleged medicinal benefits. I don’t hear them complaining about having to call professors “Dr.”.

    Why do they and some nurses themselves want to continue acting as though there is no level of nursing education that would make nursing a real profession in its own right? Why does medicine need to own this branch and only this branch of health care for eternity? I think it is about gender and predominantly or traditionally feminine professions.

    Once upon a time, only MDs could start IVs or insert a catheter! It’s not rocket science, folks, to examine, diagnose and prescribe about 70% or even 90% of what you see in some settings. Most important is to know when care has come to the edge of your scope and is now in someone else’s. Do they need a respiratory therapist? RD? MD? Knowing it, and when, is a big part of any care, arguably one of the most important parts. Nurses in advanced practice are quite able to judge this and take the right action when they have left the modern-day advanced practice nursing zone. They may be referring to any of these disciplines, not only medicine.

    I’m not so sure many MDs don’t realize when they have left their lanes and gone into PT, RD, nursing, and psychology. The idea that your family doctor is a qualified counselor is ludicrous, but you will still see articles telling you to discuss may things with “him” first, even though no medical component is suspected. And I can’t tell you how many routinely make pseudo-psychiatric diagnoses such as what used to be called “hypochondria” or “frigidity”.

    Nurses can sometimes make faster and more accurate diagnoses because we have extensive training about listening to patients…and I do not mean hand-holding and making murmurs of sympathy/empathy–although those are sometimes indicated. I mean specific observations, verbal techniques, awareness of typical issues, knowledge of context and what and how to ask and examine. These skills taken together are powerful. They allow them to gather what the patient and family know, to know the socioeconomic risks are, and so on.

    It’s much easier to choose an area of focus with all this additional information. I have diagnosed rare and hard-to-diagnose conditions outside my NP specialty in myself and others, sending them to the right specialist to inquire about that diagnosis while of course allowing him/her to do their jobs. (Obviously, I didn’t make a formal diagnosis or say I knew any such thing…but I sent them to the right place–or took myself there for myself–with the right questions, and so a diagnosis was finally made.) I spent some time reading up, and I refused to give up when it was elusive, but the listening and observation were key.

    There are many aspects of nursing care that may appear to the unschooled to be hand-holding or minor technical skills, but a whole lot more is going on. It may be based on a ton of research and so is actually very important. One of the most powerful things you can do to help people stay well and out of the hospital is to call them during the week after discharge. Simple, right? But based on nursing research, and backed by evidence. (Just watch “Nurse Jackie” for the ton of wasted knowledge that isn’t part of our schooling, but is learned through lengthy observation and reading, too. But that’s another subject.)

    Nursing forks off from medicine fairly early on, but the part we can do and do well includes the overlap that is so resented and mocked. Most NPs no more want to be MDs than dentists do. However, a lot of what we know is not paid for nor recognized, and NPs end up willy-nilly functioning as junior residents for so many hours per day that there is no room left for the non-billable NP-specific part. The exam/interview skills are seen as warm touchy-feely hand-holding WASTED time. Thise skills go unused and compromise that part of our ability to diagnose, so we learn more didactic info to take up the slack, too. This pushes us further into MD/DO margins.

    The NP who feels demeaned and bored and frustrated is likely to give up and use his/her brainpower to learn more about medicine. Certainly many MDs and DOs like for us to do that, so we can do more for them or without their input, but only if we don’t start thinking we actually do know something.

    It’s tiresome. Thank goodness for the ones smart enough to see through the BS and treat us like professionals with some billable overlap, but valuable beyond that.

    • Avatar
      Pamela M. Conry March 27, 2021 at 5:36 pm - Reply

      Wow…! Well reasoned, thoughtful response. Thanks for taking the time to respond to the eternal ongoing dialogue. Let’s hope it gets resolved someday.

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    Addison May 13, 2020 at 12:15 pm - Reply

    I like the NPs I have seen for follow up, but I want a physician to diagnose me. It isn’t a matter of intelligence or empathy, it comes down to training. I want to know my care is always being overseen by a residency-trained physician. It matters. I think NPs are already practicing at the top of their license, and the concept of opening their own clinics without having done a residency just baffles me. I’ll keep my care with a physician-led team, and happily see the NP for routine things.

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    Camille W January 22, 2022 at 11:17 pm - Reply

    I see where you are coming from, BUT as a nurse, I can’t tell you the number of times I have caught a diagnosis in the NICU that the neonatologist missed. I am not talking about one physician or one instance. I am talking about multiple instances in different organizations. I have also caught so many medication errors from physicians who completed a residency and fellowship. It is scary how many errors nurses have caught. I understand why you would feel that APRNs are not equipped to diagnose, but many of them have thousands of hours of clinical training under physicians. For instance, I am working on my advanced degree and my clinical rotation next Fall is 650 hours. I have already had 200 hours. That doesn’t include my other upcoming semesters. I choose to work under one of the med school professors, who also practices, 2 days per week (16 hours of my own time per week) so that I can learn how to accurately diagnose and treat. After I complete my DNP, I plan to specialize in Internal Medicine which will put me in a fellowship with more clinical. In the end, I will have more clinical hours than a third year resident with many of the hours completed under the supervision of a wonderful med school professor. She has won many awards for her work around the globe. She feels that I am already fairly well-equipped to work independently and I don’t even have that many clinical hours. I can tell you she would never tell me that if she didn’t truly believe it. I still have a lot to learn and so does everyone else. A residency trained physician does not equal quality. I have met many who I wouldn’t let touch me or my family.

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