Clinical Preparation as an argument against independent Practice: What about outcomes?
OPINION
As states across the country allow Advanced Practice Registered Nurses (APRNs) to practice without physician oversight or supervision; physician advocates argue that APRNs are not adequately trained to practice without physician supervision. Physician organizations consistently argue that their “deep, rigorous preparation” (1) is sufficient justification as to why APRNs need supervision. These organizations further utilize this argument of clinical preparation as justification for why physicians should lead all healthcare teams in providing care.
The Primary Care Coalition, a physician advocacy group, makes the following statement:
“Because primary care physicians throughout the United States follow the same highly structured educational path, complete the same coursework, and pass the same licensure examination, you know what you’re getting with a physician. There is no such standard to achieve nurse practitioner certification, as their educational requirements vary from program to program and from state to state.”(1)
Physicians groups further argue that Advanced Practice Registered Nurses only undergo 2,000 – 5,000 hours of clinical preparation compared 20,000 to 25,000 hours of clinical preparation for physicians.(1)
When we hear such dramatic numbers we are inclined to have a visceral, and instinctive, response that the physicians argument must be right. If the preparation is so different APRNs should be supervised by physicians!
However history has shown us that visceral and instinctive responses are often wrong! Health Policy experts have demonstrated that to improve health care outcomes health care should be guided by evidence and data, not opinion and instinct!.
This is clearly demonstrated by the United States Institute of Medicine advocating that based on research and data Advanced Practice Nurses should be allowed to practice to the full extent of their education and training unimpeded by physician supervision. This position is based on several key findings:
First; the argument that physicians undergo a rigorous standardized preparation while APRNs do not is factually wrong. All advanced practice registered nurses must pass a national certification examination to be licensed in an advanced role. To be eligible to take this certification examination the nurse must demonstrate that they successfully completed a nationally accredited advanced practice education program at the Masters or Doctoral Level. To become accredited these programs MUST demonstrate that they meet deep and rigorous criteria ensuring that students are adequately prepared in advanced physical assessment, pharmacology, health assessment and treatment.
All APRN education programs are required to meet nationally established educational requirements, just as physician programs do.
Second; physicians argue that Advanced Practice Nurses do not receive the same number of clinical hours of preparation as Physicians. Physician advocates will often cite physicians have 20,000 – 25,000 hours of clinical preparation compare to 2,000-5,000 hours for the advanced practice nurse. These numbers are often carefully selected and often do not reflect reality.
All APRN students must first complete their education and training as a bachelors prepared registered nurse. These hours of clinical preparation are often discarded as if they are irrelevant. (In comparison the majority of medical school students have little to no clinical experience when they enter medical school).
Physicians often utilize a board certified specialist with an extended post graduate preparation as their standard hours of clinical preparation. These numbers are often misleading or inaccurate. To become licensed as a physician not all states require completion of a residency program. To become licensed as a physician in Florida requires only completing the initial medical education program and 1 year of post graduate clinical experience. This preparation does not begin to approach 25,000 hours of clinical preparation.
In comparison the majority of nurses entering school to get an advanced degree have thousands of hour of real world clinical experience from practicing as a registered nurse. This provides nurses with a comprehensive, and holistic, preparation to enter into advanced practice.
Additionally when Advanced Practice Nurses graduate from their Masters or Doctoral Degree program they are required to practice under the supervision of a physician or APRN for 2000 hour, or more, prior to being granted the ability practice independently. This supervisory period helps to ensure that APRNs have the clinical skills and knowledge to practice safely. This period of clinical preparation is often ignored by physicians advocates.
Finally; research data does not demonstrate that more hours of clinical training results in better care. Multiple studies have demonstrated that the cumulative hours of clinical preparation does not correlate to clinical outcomes. Despite the different didactic and clinical preparation of physicians and Advanced practice nurses both professional groups demonstrate similar health care outcomes, patient satisfaction and safety.
Advanced Practice Nurses are prepared to practice in specific roles that include Nurse Practitioner, Clinical Nurse Specialist, Nurse Anesthetist and Nurse Midwife. Multiple studies have demonstrated that when comparing the care provided by these advanced practice providers with their physician colleagues APRNs have similar, or better, outcomes than their physician colleagues. Several studies have further demonstrated that care provided by APRNs involves more prudent utilization of expensive tests, invasive studies and prescribing of medications when compared with physicians.
Advanced Practice Registered Nurses have over 50 years of clinical data to demonstrate the quality of the care they provide with a track record of safety. This evidence has proven sufficient for 24 States and the Federal Government to remove supervisory requirements for APRNs.
In 2018 the United States Veterans Administration, after an extensive investigation and public comment period, determined there was sufficient evidence to remove supervisory requirements on Advanced Practice Nurses. The justification for this action included a comprehensive analysis of the evidence, the long history of quality healthcare provided by APRNs within the VA, and the need to increase access to care resulting from the ongoing shortage of physician providers.
As Florida begins the 2020 legislative session Speaker of the House Galvano has stated that health care is a priority for this session. Speaker Galvano recognizes that Florida faces a serious shortage of healthcare providers in key healthcare fields including anesthesia, primary care and obstetrical/gynecologic care. These shortages are most evident in rural and disadvantaged communities across the state. This lack of access to care for many Floridians has resulted in Florida becoming one of the worst states in our union for healthcare outcomes. (6)
In light of the healthcare challenges facing Florida it is essential that health policy decisions be based on evidence, and not opinion! Legislators need to crafts innovative and realistic solutions that will increase access to care and improve healthcare outcomes. An essential component of this solution must be eliminating unnecessary barriers that prevent advanced practice nurses from developing innovative solutions to meeting Floridians healthcare needs. This means allowing APRNs to practice to the full extent of their education and training.
Removing restrictive supervisory requirements for Advanced Practice Nurses in Florida will result in improved access to care, improved health outcomes and reduce healthcare costs. In states that have allowed advanced practice nurses to practice without physician oversight there has been improved access to care and cost reductions with improved health outcomes. The argument that the clinical preparation of advanced practice nurses justifies physician oversight is clearly not supported by the evidence, or experience of many Floridians.
Florida legislators need to discard the antiquated model that physicians are “Captain of the Ship” when it comes to healthcare. They further need to recognize that clinical hours does not correlate to clinical outcomes! Scare tactics that manipulate data only results in confusion and not good policy. Policy leaders need to utilize evidence and data to guide their decisions to ensure that all Floridians have access to affordable, quality healthcare.
It is time to make Florida a leader in healthcare again!
- Primary Care Coalition https://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf
- Traczynski, J., & Udalova, V. (2018). Nurse practitioner independence, health care utilization, and health outcomes. Journal of health economics, 58, 90-109.
- Institute of Medicine (2011). The future of nursing: Leading change, advancing health. National Academies Press Washington, DC.
- Sonenberg, A., & Knepper, H. J. (2017). Considering disparities: How do nurse practitioner regulatory policies, access to care, and health outcomes vary across four states. Nursing outlook, 65(2), 143-153.
- Martsolf, G., Arifkhanova, A., & Auerbach, D. I. (2015). The impact of full practice authority for nurse practitioners and other advanced practice registered nurses in Ohio. Santa Monica, CA: Rand Corporation.
- https://www.floridatrend.com/article/24498/floridas-health-care-system-ranked-48th-in-the-nation
- Roberson, J. (2012). A Comparison of Patient Outcomes Between Certified Registered Nurse Anesthetists and Anesthesiologists in a Phase One Post Anesthesia Care Unit(Doctoral dissertation, Southern Nazarene University).
