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Allowing APRNs to Practice Independently Better Serves Patients in Florida

April 3, 2019 - 3:30pm
Debra Diaz
Debra Diaz

I have been a certified registered nurse anesthetist, a type of advanced practice registered Nurse (APRN), for more than 20 years and am a retired Commander in the US Navy Nurse Corps, where I provided anesthesia care to service members and their families, U.S. Department of Defense employees, and members of Congress. While on active duty, I administered anesthesia care to service members who were injured during Operation Iraqi Freedom, Operation Enduring Freedom, and the Horn of Africa.  I have been the sole anesthesia provider on three aircraft carriers.

APRNs play an important role in Florida’s healthcare system. Whenever you have visited the hospital, a doctor’s office, or another healthcare facility, it’s likely you have interacted with an APRN -- and you might not have even realized it. 

Florida currently has more than 34,000 licensed APRNs who work in all types of practice settings. They provide essential primary care services and perform regional anesthesia, which includes peripheral nerve blocks, spinals, and epidurals. They also provide other anesthesia care, deliver babies, and much more. 

I recently had the privilege to stand with Sen. Jeff Brandes and Rep. Cary Pigman at the state capitol in Tallahassee to call for the passage of important legislation they have filed that would modernize Florida’s laws and allow APRNs to practice to the full extent of their education and training.

Senate Bill 972 and House Bill 821 would allow highly qualified APRNs to practice independently, without physician supervision and protocols.

Historically, our laws did not contemplate the sophisticated education and training APRNs receive today. Twenty-two other states, as well as the District of Columbia, have already removed barriers to allow APRNs to practice independently. It’s time for Florida to do the same. 

As Florida’s population continues to grow and healthcare costs continue to rise, we must look for innovative ways to modernize the healthcare delivery system in Florida.

With this legislation, we can increase access and allow APRNs to provide safe, cost-effective, quality healthcare to patients.

While we all agree the safety and wellbeing of patients is paramount, there are many independent studies which show APRNs can safely and effectively provide some of the same healthcare services as physicians. In fact, a recent report by the U.S. Departments of Health and Human Services, Labor and Treasury found that APRNs and other highly trained professionals “can safely and effectively provide some of the same healthcare services as physicians, in addition to providing complementary services.” The report went on to recommend that states “consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.”

Using APRNs would also prevent gaps in access to services in thousands of communities, especially in rural, inner-city and other medically underserved areas, while reducing the cost of health care and addressing increasing demand for health care services.

We urge the Florida Senate to take up this very important legislation. Patients’ interests are best served by a healthcare system in which many different types of qualified professionals are available, accessible and working together -- collaboratively. 

Debra Diaz is a CRNA, an adjunct professor at Barry University and a member of the American Association of Nurse Anesthetists board of directors.

Comments

it all boils down to money. Physicians want to bankroll that medical director fee.

How is allowing a mid level with no advanced education, no residency (family and internal doctors have 3+ , psychiatrists 4+ in primary care) advanced florida to the next century as a commenter claims? Seems we are going backward. An ARNP almost killed my preceptor's father in a skilled nursing facility twice with her lack of knowledge. Almost sent him into a hypoglycemic death and gave him a medication that you never give to an elderly patient. If nurses want to be doctors, go to medical school. I was a nurse that went to medical school and now entering residency. If you want the standard of care, see a doctor

Using the term “mid level” shows that you are way behind the times .... probably just like everything else about you.

Just an FYI....in Florida a “protocol” is just a piece of paper that the physician signs saying that an ARNP can do .... (whatever approved) like my MD, he is not at my practice, in fact he’s never set foot in my practice. If I need him I call him. I’m very quick to refer out because the fact is that if it’s something I’m not specialized in why not just send them to the specialist? So whether they change the law for NP or not the fact is that your NP may not really be overseen other than making phone calls to the MD if needed because Florida law doesn’t require a physician to sign off on our files like they do with a P.A.

Nurse practitioners can work as primary care providers just like a primary care doctors with family practice or internal medicine residency. Experienced NPs are more qualified or equally qualified as them to work as primary care providers. PAs are not qualified like NPs, because (most of the) NPs have several years of experience as an RN. But I don't like NPs with no clinical experience. They are dangerous...!! Doctors (especially cheap family practitioners) don't like NPs because they can't steal from patients if NPs practice independently (secret truth).

YOU TELL 'EM SISTER ! ! ! You have A LOT of supporters "in your corner"! Keep up the "good fight"!

I think their practice of medicine should be limited to the extent of their training and licensure, nothing more, but also nothing less...

There is also something to be said about APRNs that are experienced over 25yrs. Many seem to have had the responsibility and experience of military service also. I’m interested to here from people who recognize an APRN with 25yrs clinical / military experience vs the medical intern (MD) just graduated an stepping out into the world. Training is different without question, the military recognize the APRN, PA and medics with our troops, so I think there is something to be said about “ independence “ of the experience, APRN and the PA.

That’s what we are fighting for. We are trained at a higher level then we are allowed to practice. We are restricted by each states rules. We can only practice what the state board of nursing allows which is the point if this bill.

From the banter back and forth on this issue, it seems clear there are hidden agendas in play here. I have been treated by ARNPs with no issues. Just like MDs/DOs who as general practitioners/family doctors refer patients to specialists (i.e ophthalmologists, orthopedics', neurologists, etc.) when needed care/treatment is beyond their capabilities, why the blowback against ARNPs? Is there somehow some innate inability on their part to recognize situations where consultation/referral to a more qualified medical practitioner is warranted? There is a real need for a variety of skill levels in the medical arts professions to render good sound medical care. Its time to disrupt the status quo and move medical capabilities into the 21st century reality

Most of the blowback comes from Doctors who have a chip on their shoulder or feel threatened.

There is a huge difference between Physician Assistants and APRN in both training and experience. APRN’s have to have extensive clinical backgrounds as RN’s before they become APRN’s. Would trust them as basic practitioners. PA’s have very ,mites backgrounds and training and should not be doing half of what they do. I have personally had scary incidents with several of them where they are supervised and still have made serious errors through belief they know more than they do. APRN’s are light years beyond them. BUT many Physicians insist you must see ARNP or PA as they are too busy, and that should NEVER happen.

Kathy: Wow! There are no studies at all to back up your comments. They are at best misinformed and at worst........ Trying to get PAs who are excellent and NPs who are also excellent into a contest is just what is not needed. Please provide a link to the studies that show NPs are superior to PAs. Seriously.............

Seriously, a PA does not need a medical background, just a degree and be accepted into a PA program. I interacted with many of them and students applying to be PA's while getting some clinical hours to apply. My son was in the Bone Marrow Transplant Unit at Shands. The PA's were closely supervised and still made many mistakes that the Physician's had to correct., especially with medications. The students were acting as nurse aids, taking vitals and emptying bed pans. They got no clinical experience like and RN, especially in specialty units gets. 18 months of clinical training is not enough to "practice medicine." They are Physician ASSISTANTS for a reason. RN's that become ARNP's have a Bachelors Degree in Science and 5 years of clinical practice, generally in a specialty unit like ICU. They have a Masters Degree in their area of specialty. Saying PA's and ARNP's are equivalent is like saying that a nurses Aid and a Masters Degree nurse are both "nurses."

Umm NO! Nurse Practitioners are great, but I know I feel more comfortable knowing the Doctor is supervising. I’ve had two experiences with NPs, both of whom were know-it-alls. Plus the public has never been educated as to what their training involves. Neither NPs nor PAs. I have a dear doctor friend whose theory was “you want to be a doctor? go to medical school.”

Your comment really doesn't hold water. You are erroneous to say the public has never been educated on what we do. What are you basing this comment on? AANP, our national organization, and other NP organizations on the state and local level have spent many years and dollars educating the public. We are very transparent on what our education involves and I had excellent training and education as an NP. As for your comment "if you want to be a doctor go to medical school?" I did not want to be a physician, I wanted to be what I am--a highly educated nurse practitioner that can provide high quality, cost effective health care to my patients and have been doing so for 27 years. I don't have to be a physician to do so. Nineteen of those practice years have been with the same physician who knows the quality of care I provide and respects my profession. We work together as a team to provide excellent patient care--he knows his limits and refers when needed, as well as I know my limits and refer when needed. He is extremely supportive of lifting the supervision requirements because he knows how I practice, my patient outcomes are excellent, and that I am not a threat to him, like most physicians feel we are. My patients love me and choose to see me, they are not forced to. Being in the same office with the physician does not make me practice any differently. I practice evidence based medicine based on my own education and training, not the physicians.

Well pretend you are a Lawyer, if a Nurse were to "miss something" you can't hold them accountable they did not know about that, it was not covered in the training [one can't "miss" what they don't know]. The MD on the other-hand did learn everything "in theory" if they miss something they should have known, and most don't miss much.

Wow are you misinformed. Nurse Practitioners are just as accountable for missing something as a doctor.

"Pretend I am a lawyer"..?!?!? If I did THAT, I'd DEFINITELY need a doctor; but a Nurse Practitioner would do just fine ! ! ! (You've heard the old adage: "Doctors bury their mistakes"... and lawyers "keep their 'mistakes' safe"...)

Actually your statement is not accurate. In the state of Florida physicians are actually allowed to “go bare”. That means they do not have to have malpractice insurance. CRNAs have the deep pockets and are held accountable for all their decisions apart from the surgeons. This means the CRNA’s decisions, based on evidence and research, stand on their own. We are held to the same standard.

If I am reading your post correctly you are sadly mistaken and/or misinformed. The APRN is held just as much accountable as the physician. “ I didn’t know or I wasn’t taught that” is not a legal defense or a get out of jail free card. In this instance it would be an admission of guilt

Even a lawyer gets sick and must seek medical help, when all is said and done, the medical practitioner should do less harm and the lawyer should be thankful.

Sounds like a great idea, please try not to screw it up with burdensome regulations.

Nurse Practitioners are very good, but they are NOT doctors. Letting them practice "independently" just means a way to cheap out on health care for many less affluent Floridians, and Floridians in rural areas. Also, the APRN's will get paid more when they work "independently." Nice for them. These folks need to be supervised by physicians and to work closely with them. They many times don't know what they don't know. And it is nice that this woman has served in the military, but that still doesn't give her the same skills as a physician.

Your comment "a way to cheap out on healthcare" sickens me. As a practicing NP for 27 years I can guarantee you I don't provide cheap healthcare. I provide high quality healthcare to all. What does practicing independently or practicing in a protocol with a physician under general supervision have to do with this? You obviously do not know what you do not know!

I am a lay person who happens to know several highly skilled nurse practitioners. Firstly, I would like to ask you from where do you derive your position? In my line of work, I have witnessed many ARNPs, who are very much expert in their fields, AND often possess BETTER bedside manner than the physicians who they work with! Most of the NPs I know are highly specialized as well. First earning a Bachelors of Science in Nursing, then working in their field of choice. And finally, earning a Masters of Nursing in that field! They are very ethical as well, they know their limits, which is more than I can say for many other professions. If a patient presents with a condition that is beyond their knowledge, the majority would rather refer the patient than risk the consequences. I for one believe that NPs deserve the rright to practice on their own accord.

Had a serious misdiagnosis from PA who told me three times I had pneumonia despite clear chest X-ray. Turned out to be Angina. PA sent husband home from E.R. with vasovagal diagnosis. Begged her to query monitoring device but she knew better and refused, turned out when cardiologist checked monitor he had asystole episodes and needed immediate pacemaker. Third one prescribed heavy duty Med not needed for condition, fortunately MD saw orde and changed it. They are very scary to me.

PAs are totally different than ARNP/APRN...you go to an ER generally you are seeing a PA

You are quite mistaken .... many ER’s are staffed with nurse practitioners as well.

Please educate yourself between the difference between P who are certified and ARNPs who are licensed providers. PAs cannot practice independently. Refer back to and Diaz’s article.

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