Welcome to Kunta Gautam, now a regular
Nursology.net Blogger and
Management Team member!
Why is there so much rumor that Nurse Practitioners (NPs) are not quite well prepared for what they have undertaken the education and training for? I am a nurse practitioner working as a front line provider and my blogpost may be biased or opinionated, but I must highlight some salient features that NPs contribute to healthcare, most notably when our practice is founded on a nursing theory.
Nurse Practitioner and AANP History
- 1965- Dr. Loretta Ford and Dr. Henry Silver developed the NP program at the University of Colorado.
- 1968- another NP program developed by a nurse & physician team in Boston.
- 1974- Burlington Randomized Trial study found NPs conduct appropriate referrals.
- 1985- American Academy of Nurse Practitioners (AANP) was established, collaborating internationally for NPs’ professional development.
- 2019- there were more than 270,000 NPs in the U.S.
- 2023- Nurse Practitioners have flourished to 355,000 nationally in the U.S.
History reflects that the NP role evolved in 1965. But why are we being treated differently in healthcare? NPs struggle to fit-in in both nursing and medical domains completely. They are sort of outcasted from the proper nursing umbrella, which could be because they have a license to practice, which is a “medical model.” My viewpoint might be a little biased because this is my personal experience working in tertiary care level specialty areas in the hospital setting. I did not feel welcomed and supported by nurses when I made rounds for inpatient consults in the hospital. I was a new graduate NP working in a specialty area, performing multiple roles: outpatient clinic, inpatient consults, and initial workup on ER admissions. The most common question that I was asked during inpatient consults by experienced nurses was: “Why are you working as an NP when you can easily make more money as an RN?” I would say the best answer I could possibly say being mindful of trying not to hurt anyone’s feelings. For me, it was a path in my career; I never counted the money, simple as that. However, over the course of time, I have seen positive changes related to this problem. RNs are more accepting and trusting of their NP colleagues. And, as a profession, that gives us (nurse practitioners) a sense of unity, strength, and belonging.
With over 13 years in an NP role and five years as a clinical preceptor, I see that our practice is an excellent way of serving humanity with complete independence and authority. I have been an NP in all areas: 3 years in specialties in a hospital setting, 7 years in primary care practice, and three years in urgent care practice. I have been through different challenges. I was thrown in the spot to make clinical decisions; which was sometimes nerve-racking, but I never gave up. I did my homework and, at the same time, never stepped back from asking questions. I had my learning curve; I made several mistakes. However, I had collaborating physicians and others who helped me learn and grow and made me feel like I was making sound decisions. I still learn, refer to resources when I need to, and seek consultation. As an NP, depending on our clinical area, we must communicate our expectations with the healthcare team. We should be allowed to make mistakes, learn, collaborate, and grow in a healthy environment as a team.
Nurse Practitioners have a unique trajectory that does not fit into other hats: nursing, medical or other allied health professions. Here are some key points that describe us, along with some recommendations for new graduate NPs:
- Nurse Practitioners complete three years of the graduate program (+/-, depending on various universities) after completing four years of Undergraduate degree BSN. They take advanced pathophysiology and advanced pharmacology courses.
Recommendation: This is only school education to build your foundation. Never stop learning. You will learn more in the real world.
- The term “mid-level” does not define who Nurse Practitioners are. We were not given this terminology from our nursing profession, and I would reject any other terminologies that define our role besides what our profession has given us. Extensive lectures, clinical hours, and training invested in preparing an NP are not mid-level people who are considered to be on the back seats, making discharge summaries and doing more “clerical, clinical work.” A competent NP would not stay longer if they were treated as a typewriter or a phone caller. In this were the case, the hospital would be at a loss, losing a graduate-level prepared professional workforce, who could have been utilized to their maximum potential at less expense.
Recommendation: Know your worth. Study, build yourself, and prove your worth to others around you. Do not let others define you as mid-level. Correct them politely to call you a Nurse Practitioner or a Provider. Do not go with “mid” or “sub”.
- Nurse Practitioners know their skills, knowledge, and scope of practice. The prescription authority is earned from demonstrating expertise and accountability in the provider role. They abide by two licenses, RN and APRN, and in conjunction with both the nursing and the medical boards.
Recommendation: Own the prescription authority given to you and what you have worked for.
- Nurse Practitioners have a different lens through which they view those they care for. When they wear a medical model hat and give treatment recommendations, they also listen to other areas of health issues. They practice a medical model which is solidified with a nursing foundation.
Recommendation: Never lose the site of holistic nursing and our core values. Remember, the unique gift you have is the combination of nursing and the medical model. Always, proudly stand out from the crowd by bringing this quality in you.
Nursing theorist, Patricia Benner, provides detailed stages of clinical competence in her book “From Novice to Expert” (1984). This theory describes how expert nurses develop skills and understanding of patient care over time through proper education, application of knowledge, and patient experiences.
Applying Benner’s stages of clinical competence in the NP model of care
- Stage 1 Novice: The NP student learning and gaining knowledge is a novice. At this stage, students are building a foundation with advanced pathophysiology and advanced pharmacology. In addition, they are learning basic steps like HPI, review of systems, physical examination, assessment, and plan. (Similar to the SOAP format seen in BSN programs).
- Stage 2 Advanced Beginner: These are new graduate NPs. They have a great deal of knowledge but not yet experienced enough to treat patients without guidance or supervision.
- Stage 3 Competent: These NPs have some mastery of advanced practice but may not have practice efficiency. However, they can make diagnoses more accurately than advanced beginners.
- Stage 4 Proficient: At this level, NPs can make clinical decisions in more than one area. In addition, they can handle multiple health problems in a patient. For example, a patient with an asthma exacerbation, ear infection, and diarrhea/vomiting.
Stage 5 Expert: These are NPs who are independent in their practice with minimal consultation needs. They can address uncommon challenges that come into the practice and be flexible as the situation demands. They can also handle emergency situations like active seizure management, respiratory distress, etc. In addition, they can identify subtle signs of illnesses that could be missed.
The purpose of this theory, as Benner states, is that these levels reflect a movement from past experiences of skills acquisition and moving forward into more concrete experiences. Transitioning from bedside to a provider role is an entirely different role description. A new graduate NP has to start the provider journey from the stage of being a Novice to an Expert. It requires a solid foundation to thrive, own the responsibility, make clinical decisions, and stand firm with the rationale for making that decision. Dr. Benner found that improved practice depended on experience and science, and developing practice skills was a long and progressive process.
I would highly encourage all new graduate nurse practitioners to embrace the program’s intensity, choose a study method that works for you, and learn every step during the clinical experience without missing any single step. I would encourage students to ask questions to their preceptors or supervising clinicians and not hesitate to say, “I would like to learn more” Remember, nobody is born an “expert.” We need to overcome the fear mindset and go through the learning curve. You will be surprised that everyone will be willing to help you grow if you seek it out. If the area you practice is not healthy for your growth, I suggest you move on and explore and find the right fit where you meet your passion and growth.
I would appreciate thoughts, comments, and constructive ideas.
References
Benner, P. (1982). From novice to expert, American Journal of Nursing, 82(3),402-407.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley Publishing Company.
Nurse Practitioner and AANP History. Retrieved from https:// www.aanp.org/history
How wonderful that you are addressing some of the challenges that nurse practitioners face as they enter into practice in their new role as NP. I would also add as a nurse practitioner and a nurse for 40 years that as I transition from an RN role to a nurse practitioner role I brought with me the nursing lens by which I see my patients holistically beyond just the episodic care moment. I lift my eyes to understand the systems that affect the individual or family that I care for and how best I can address some of those systems that impact the overall health outcomes. This is decidedly different than the medical model . I am also very grounded in the philosophy of ontology. This speaks to the individuals person hood, and how that individual developed from gestation to where they are in the moment of care respecting all that they are, and working alongside them to help them reach their healthcare goals. This approach is strongly aligned with the nursing approach to care.
Linda,
Thank you for raising an interesting insight into philosophy of ontology. Nursing ontology involves meta-paradigms and ontology itself. The meta paradigms help us include health, environment, patient as a person, and nursing as a profession while delivering care. Ontology, I would say, is more descriptive of the origin of existence. Maybe in clinical practice, we could say where is the patient coming from. Their ethnicity, cultural background, and language, which I think, extend far behind the meta paradigms. In short, ontology also can be a cumulation of worldviews from a patient’s perspective coming from their existence. Thank you.
It would be interesting to know some more thoughts on this.
Kunta and Linda, Thank you for this blog post and the comments.
Please note that there is only one metaparadigm made up of concepts–the concepts are not metaparadigms.
I wonder how using a nursing perspective (conceptual model, theory) could lead to any type of practice that would include the medical model (whatever that is–cannot find a description anyplace in the literature)?
We must be very clear that nurse practitioners practice advanced nursing, not any form of medicine. When we base our practice on a nursing conceptual model and/or nursing theory, we are clearly and explicitly practicing nursing (i.e., nursology).
Thank you, Dr. Fawcett, for taking the time to review my blog post.
I am so honored to receive your feedback on my perspectives and get corrected on my wrong assumptions, especially from you, who is a Metatheorist, an internationally recognized authority in nursing metaparadigm and conceptual models. It means a lot to me.
I took this opportunity to self-reflect and go over your extensive work on the evolution of Fawcett’s version of Nursology’s metaparadigm concepts. Thank you for leading us with your dedication in this area and guiding us to have a better understanding of what our practice is all about.
I can see how these concepts are embedded in our practice. Following the conceptual models and clinical competence based on nursing theory, we are actually wrong in saying that our practice is a medical model. I appreciate for giving me this opportunity to learn, grow and have a much better understanding of what my role is and what I do.
Thank you so much for writing this piece. As the number of NPs has grown exponentially since the role’s inception, and the APRN workforce is projected to grow by 40% over the next ten years (U.S. Bureau of Labor Statistics, 2022), this is an incredibly relevant and timely topic. As the role rapidly grows, I believe now is the time to be strategic and to reinforce nursology-specific conceptual models as a foundation for our NP practice. When we as practitioners and scholars discuss nurse practitioners we must be very intentional as to not reinforce the notion that NPs belong to anything other than the discipline of nursology.
As many do, I disapprove of the term midlevel. It’s clear in your recommendations that you also disapprove of this term. Midlevel is an unequivocally physician-centric term – it relates NP (and PA) practice to a, so-called, physician gold standard. Terminology like midlevel is just one specific example of a larger trend to center NP practice around physicians. A more subtle example of medicocentrism is a development of professional role identity that is grounded in prescription and diagnosis. These are tasks that NPs do that help to advance our practice, but our role is much greater than the tasks we do.
Advanced practice nursing is, as the name indicates, borne form nursing (nursology). As the role grows both nationally and internationally, its value has been constantly justified and critiqued using medical practice as the standard. The two practices may be in some ways related, but it is essential that we consciously and subconsciously understand that they are ultimately distinct.
A great deal of current discourse around NP practice, often unintentionally, considers the practice within context of physicians and the practice of medicine. Given the significant projected growth, it is imperative that advanced practice nurses and the nursologists who study them must shift from this comparative practice to one that re-centers APRNs within nursing conceptual frameworks. We must consciously call our practice back into the discipline of nursology. If we can’t do that we will never truly be liberated from the medical hegemony.
References
U.S. Bureau of Labor Statistics. (2022). Nurse anesthetists, nurse midwives, and nurse practitioners. In Occupational outlook handbook. https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm
Chris,
Thank you for your comments and shedding the light on the classification and how NP practice comes in Advance Practice Nursing.
But, I guess, my question is, why are we talking about this after four decades of NP practice. Why are we still struggling to define ourselves with the outside world.
I am aware, in nursing we are aware, but who is going to relate this message outside the box of nursing. Why do we have to keep defining ourselves, keep proving ourselves, day in and day out when we are tackling with the outside world?
That brings up another point, we need to publish our studies in other journals as well, why do we focus on publishing ONLY in Nursing journals. I know we should by all means, add more scientific knowledge to our journals, but flip side of this is, nobody knows what kind of researches are done in nursing, besides the nurses themselves.
I think it is time for us to come out of our own little self-made professional square and interact with other disciplines and that would take the profession into whole different level in coming generations.
Thank you for sharing your perspectives, I would appreciate more insights from others as well. I think this a topic of real-time problem which can be logically but cannot be solved.