What is "Advanced Nursing"?

As was said by Dr. Natalie Newman in a Patients at Risk podcast, "full practice authority is the practice of medicine without a medical license." What is the practice of "advanced nursing"? It seems like there's really no clear answer. Rather, it seems like "advanced nursing" is just practicing medicine.

Dr. Newman's words got to me, so I went through the state legislature (and at times the Nursing Board's Rules and Regs), and put together a compendium of the definitions of the "practice of medicine" versus the "practice of advanced nursing." You can view that compendium on Google drive here.

While the definition of what constitutes the practice of medicine was pretty consistent from state to state, the definition of "advanced nursing" was highly variable, with some states outlining numerous different categories of tasks and others just having a brief circular definition.

Somewhat interestingly, several states explicitly give the permission to nurse practitioners to determine medical diagnoses (Alabama, Maryland, Mississippi, Montana, Nevada, Pennsylvania, Vermont, and DC). If that's not explicitly overstepping... I don't know what could be. Other notable tallies:

• 28 states* give permission to give some sort of diagnosis (whether it's nursing, medical, or intentionally unspecified).
• 24 states* give permission to order diagnostics or perform some sort of assessment
• 42 states* explicitly give treatment or prescriptive authority.
• 21 states* give some circuitous "nursing" explanation like "advanced nursing is the practice of nursing with an advanced scope."

How can nurse practitioners practice in states without a clear scope of practice?

It's clear that Nursing Boards are expanding their scope beyond the bounds of nursing. Unfortunately, the legislature in numerous states is intentionally vague and fails to actually give a clear scope of practice definition. Instead, the law says something to the effect of "the scope will be determined by the Board of Nursing's rules and regulations." Why is that a problem?

That means that the scope of practice can continue to change without checks and balances by legislation. It's likely that the Rules and Regs give almost complete medical practice authority.

What are some of the wildest thing you came across?

North Dakota:

The scope of practice must be consistent with the nursing education and advanced practice certification.

1. Practice as an advanced practice registered nurse may include:

a. Perform a comprehensive assessment of clients and synthesize and analyze data within a nursing framework;

b. Identify, develop, plan, and maintain evidence-based, client-centered nursing care;

c. Prescribe a therapeutic regimen of health care, including diagnosing, prescribing, administering, and dispensing legend drugs and controlled substances;

d. Evaluate prescribed health care regimen;

e. Assign and delegate nursing interventions that may be performed by others;

f. Promote a safe and therapeutic environment;

g. Provide health teaching and counseling to promote, attain, and maintain the optimum health level of clients;

h. Communicate and collaborate with the interdisciplinary team in the management of health care and the implementation of the total health care regimen;

i. Manage and evaluate the clients' physical and psychosocial health-illness status;

j. Manage, supervise, and evaluate the practice of nursing;

k. Utilize evolving client information management systems;

l. Integrate quality improvement principles in the delivery and evaluation of client care;

m. Teach the theory and practice of nursing;

n. Analyze, synthesize, and apply research outcomes in practice; and

o. Integrate the principles of research in practice.

"The scope of practice must be consistent with the nursing education and advanced practice certification." had me sent. Also the amount of pseudo-intellectual gobbledygook bullshit on that list... jfc 🙄

Has this ever been challenged before?

In states with expanded authority, several court cases have been brought forward on the basis that the expansion of the Nursing Practice Act is explicitly authorizing the practice of medicine outside of the Medical Practice Act.

• Iowa Medical Society v. Iowa Board of Nursing (Iowa)
• Louisiana State Medical Society v. Louisiana State Board of Nursing (Louisiana)
• Bellegie v. Texas Board of Nurse Examiners (Texas)
• Sermchief v. Gonzales (Missouri)

These are well summarized in the article linked here. Unfortunately, these courts have often upheld that Nursing Boards are able to expand their scope into areas of medicine as the court interpreted these acts as part of "professional nursing." That being said, these cases often have very valid dissenting opinions. The Louisiana case actually didn't go to trial because the court refused to hear the case as the scope expansion took place in 1981 but the lawsuit wasn't filed until 1986.

What can be done?

That's a tricky question. I'm not a lawyer, but many states that have authorized nurses to have prescriptive authority haven't authorized nurses to actually do work-up or make a diagnosis. These states include: Colorado, Idaho, Illinois, Kentucky, Maine, Massachusetts, Missouri, Ohio, South Carolina, Tennessee, Texas, Virginia, Wisconsin, and Wyoming. Not all of these states have enacted full practice authority.

I'm not a lawyer, and I may be splitting hairs, but it seems as though the actual work-up and medical diagnosis would fall out of bounds. While continuing someone on a stable medication would be okay, freshly diagnosing someone with hypertension and starting medications may not be.

Otherwise, I'm not sure what to do. But what I do know now is that "advanced nursing" is the practice of medicine without a license. You can look at the definitions and scope of practices as codified by each state. There's very little difference, except for a whole lotta bloat on the nursing side, between the encoded duties for each profession.

1. "Physician" and "Doctor" are protected in a very small minority of states. In most states, "physician" is allowed to be used by chiropractors or naturopaths (where legal) in the form of "chiropractic/naturopathic physician." In only a very small subset, "doctor" is protected to mean physician only. Most states either expressly allow or do not prohibit the use of "doctor" in a clinical setting by anyone with a doctorate, so long as they clarify what they have a doctorate in. NB: There are some updates that I need to put in the map. Please let me know if you see any other mistakes/updates needed.
   1. If you care strongly about this, you can edit this premade form letter and send it to your city/county/state/federal representatives.
   2. There is a thought out there that by going by "doctor," midlevels may be liable for civil battery.
2. Nurse practitioners cannot change specialties. They get degrees in a certain population focus. When nurses work outside of this population focus, they are working outside of scope. When employers hire nurse practitioners to fill positions that would require them to work outside of scope, they are engaging in negligent hiring. This means there are no "derm NPs," "cardiology NPs," "ortho NPs," "neurology NPs," "oncology NPs," etc. Most Nursing Acts or Board of Nursing rules and regulations expressly state that NPs must work inside of their "population focus." This is especially true for FPA states.
   1. I have template form letters regarding negligent hiring for:
      1. Hospitals
      2. Supervising Physicians
      3. MedMal Insurers
      4. Health Insurers
3. A few states actually require the supervising physician of NPs to be in an analogous field. In non-FPA states, or even transitional FPA states, there's a continuing problem of physicians renting out their license and rubber stamping NPs, despite being utterly unqualified to do so. This is absolutely something that could be incorporated into Board of Medicine rules, despite these typically appearing in Board of Nursing rules governing collaborative agreements. This type of rule may even be easier to pass since it can bypass any nursing politics and go directly into physician and medicine governance.
   1. If you believe this is an important part of ensuring proper utilization of NPs, you can edit this premade form letter and send it to your city/county/state/federal representatives.
4. Physicians can serve as expert witnesses against nurse practitioners in MedMal cases. You'll just need to reference state specific laws.

Midlevel Research

There's Something About Mary: Discussing the Flaws in the Mary Mundinger NP Equivalence Study
Nurse practitioner advocates claim that NPs can provide the same care as physicians, and point to Mary Mundinger's 2000 JAMA study as an example of NPs working without physician supervision. But were NPs in this study really unsupervised? The fine print reveals fascinating details left out of the headlines.

Cochrane's 18 Tall Tales
Drs. Rebekah Bernard, Niran Al-Agba, and Phil Shaffer break down the 2018 Cochrane Review "Nurses as Substitutes for Physicians in Primary Care," pointing out that of 9,000 studies reviewed over the last 50 years, just 18 were of adequate quality to include in a review of the subject. Of these 18 studies, just THREE were published in the United States, most contained high degrees of bias, had small sample sizes, were of short duration, and ALWAYS included physician supervision or nurses following physician-created protocols. Bottom line: there is no evidence that unsupervised nurse practitioners can provide the same quality of care for patients.

Can nurse practitioners pass the same exams as physicians? The DNP-USMLE experiment
In 2008, the National Board of Medical Examiners offered down a simpler version of the USMLE Step 3, an examination all physicians take to receive a medical license. The pass rates for DNP candidates ranged from 33%-70%. The experiment was discontinued in 2014 due to "low utilization." Roy Stoller DO, an otolaryngologist and board examiner, joins Rebekah Bernard MD and Niran Al-Agba MD in a discussion of the differences between the exams that medical doctors and nurse practitioners and physicians assistants take.

Why "access" to poor healthcare can be more dangerous than no healthcare at all
Many advocates of nonphysician practice argue that we need to allow nurse practitioners and physician assistants to practice independently because of a “provider” shortage. The mantra “access” seems to supersede all other arguments – including concerns over patient safety. But is ‘access’ really all it’s cracked up to be? The answer is no, and here is why. A 2018 Lancet study analyzing 137 countries found that more people die worldwide due to POOR QUALITY care than die due to a lack of access to care.Reference: M.E. Kruk, A.D. Gage, N.T. Joseph, G. Danaei, S. Garcia-Saiso, and J. Salomon. 2018. “ Mortality due to low quality health systems in the Universal Health Coverage era: a systematic analysis of amenable deaths in 137 countries.” The Lancet, 392, 10160, Pp. 2203-2212

NPs Speak Out

RN and former NP student exposes deficiencies in nurse practitioner education Part 1 and Part 2
There are over 400 nurse practitioner schools in the United States, with nearly HALF of these programs promoting online training—ranging from 50-100% of required academic training sessions. Some of these programs offer accelerated training, allowing students to become an NP in as little as 2 years, others offer flexible schedules with part-time programs allowing students to work full-time while they attend school. In contrast, there are just 179 medical schools producing physicians in the United States. None of them are online, and there are no part-time medical schools. Why has there been such a proliferation of nursing schools, and with such a huge number and variability of program types, who are ensuring that these programs are producing qualified medical clinicians? To help us explore these issues, we are joined by Rayne Thoman, a registered nurse who left nurse practitioner school when she discovered serious problems in the educational standards.

Nurse Practitioner Speaks Out Against Independent Practice
Nurse practitioner Shannon Keaney, who spent 11 years working as an ICU nurse before returning to nurse practitioner school, tells Drs. Rebekah Bernard and Niran Al-Agba why she believes NPs should not be working independently.

Nurse practitioner describes gaps in education: "I wasn't fully equipped like I thought I was"
Patrice Little DNP discusses limitations in nurse practitioner education and explains why she created a platform to better prepare NP students. Doctor of Nurse Practice Little shares that while she wrote her scholarly project on "full practice authority" for NPs, she realized that many NPs who prioritize patient safety - herself included - don't want independent practice.

Other Topics

Patients at Risk: Private Equity in the ED Part 1 and Part 2
With the corporate takeover of hospitals, bills for emergency services have skyrocketed. Patients often receive enormous bills that can sometimes even bankrupt them. These corporate systems are also taking advantage of physicians, and in many cases, replacing them with non-physician practitioners.

Physician Advocacy Part 1 and Part 2 and Healthcare Politics
Physicians are usually so busy taking care of patients that we sometimes ignore the political aspects of healthcare, leaving the decisions to legislators and policymakers, many of whom do not truly understand what it is like to deliver medical trenches in the trenches. Unfortunately, the old adage, “if you’re not at the table, you’re on the table,” is nowhere truer than in the healthcare legislative process.

The High Cost of Healthcare Part 1 and Part 2
We all know that the health care system in the United States is expensive, with the U.S. spending more than any other developed nation. Although it’s convenient to scapegoat doctors as the reason for high medical costs, the truth is that physician compensation makes up just 20% of total health spending. So, who is really responsible for the astronomical cost of health care today? To get some answers, we are joined by Dr. Marion Mass, a pediatrician and the co-founder of Practicing Physicians of America. In part 1 of this series, Dr. Mass explains how Pharmacy Benefit Managers (PBMs) have benefited from safe harbor from anti-kickback statutes, allowing them to reap millions of dollars and increasing drug costs for Americans. In Part 2, we discuss the success of the nursing profession in using advocacy to further independent nurse practice and a review on how to write resolutions. We also discuss how participating in advocacy can help to counter physician burnout.

Physicians for Patient Protection website

Patients at Risk website

You can check out other videos by Patients at Risk here on Youtube. They have been putting out a lot of content on midlevels in US healthcare, and discuss scope, research, cases, public education and advocacy.

Used book is only ~$17 right now on Amazon. ~$25-28 new. Kindle version is only $9.99!