Defining Nurse Practitioners


For Nurse Practitioner World News
Jan-Feb 2010
By Carla Mills, ARNP

If NPs are to have a positive impact on health and health care, we must clearly define ourselves for the public and the media. People need to know what makes us distinct and different from doctors and other types of nurses. Ignorance about NPs has stunted our professional development and slowed our evolution as a profession.

Health challenges confront a world with a rapidly aging population and an epidemic of chronic lifestyle diseases. NPs can keep people well and manage the care for those who become sick. But in order to do so, the special talents and skills of NPs need to be clearly defined. If given the necessary authority and the opportunity, NPs are prepared to dramatically and positively change the way health care is delivered.

To define something, one must understand both the meaning of the term (in this case, “nurse practitioner”) and the nature, essential qualities, and boundaries of the words’ meaning (that is, what makes nurse practitioners different from doctors and other types of nurses). Defining our particular uniqueness is challenging because nurse practitioners are both doctors and nurses, yet we are neither.

When Organized Medicine Defines NPs

Our failure to clearly define ourselves created a vacuum that enabled organized medicine, under a pretext of protecting the public, to presume to define us. Long ago, organized medicine appointed itself arbiter of all health care and all health care providers. For years, it has defined NPs using rhetoric that is aimed at shaping public opinion and restricting NP practice.

Terms like “non-physicians,” “physician extenders,” and “mid-level providers” have been widely used to refer to both NPs and physician assistants—as if the two are indistinguishable. These labels diminish NP authority and impede the growth and expansion of NP practice. Constant repetition of these doctor-centric terms in the media has successfully wormed them into the common vernacular and misled everyone about the true nature of NPs. These pejorative terms define NPs not according to what we are, but rather according to what we are not. They obscure the quality of our expertise and deny the potential benefits we can deliver as independent providers. These terms do not protect public trust at all; rather, their use more closely resembles antitrust.

NP Titles Obscure NPs’ Nature

As nursing professionals earn additional degrees, certifications, and honors, they add more and more letters after their names until their titles become unwieldy and indecipherable. These titles are meaningless to the public and media, and they obscure NPs’ common characteristics.

Much has been written about the use of the title “doctor” by DNPs and other doctorate-educated nurses. Nurses who have earned a doctorate degree have every right to use the title “doctor.” But just because one has a right to do something, does that make it the right thing to do? Until a universally understood nomenclature is used by the nursing profession to clearly communicate to the public what distinguishes different types of nursing professionals from doctors and from each other, confusion will prevail. Creating this unnecessary confusion is a disservice we inflict on both the public and ourselves.

The public understands the words “doctor” and “nurse.” It needs to understand “nurse practitioner” better. Sticking with just these 3 titles and not cross-pollinating them would make it easier on everyone. We make more productive use of our valuable time when, instead of explaining and reexplaining what kind of nurse or doctor we are, we spend it on substantive matters that affect our patients.

NP Defined

All NPs are RNs, but all RNs are not NPs. Although both RN and NP practice is rooted in the profession of nursing, the scope of practice is different. NPs and RNs share the same core values and mission. All nurses stand up for and stand by patients suffering mental or physical illness.

As RNs, we are formally educated and clinically trained to care for the sick and the infirm. As NPs, after receiving more formal education and more clinical training, we advance our nursing practice to enable us to prevent, diagnose, and treat diseases. The term “nurse” refers to RNs and the term “nurse practitioner” refers to NPs. We all must see to it that the titles are used correctly on every occasion, and we should request a correction every time and every place they are not.

The medical profession’s expertise is disease; the nursing profession’s expertise is a patient’s experience of disease and the process of healing. NPs diagnose and treat illness within a larger context than doctors do, because NP care encompasses a patient’s whole life. Personal choices, family circumstances, community, and society as a whole all come under NPs’ scrutiny. The most expert medical care in the world cannot produce healthy citizens so long as lifestyles, the community, and society remain sick.

Compared with doctors, NPs tend to spend more time with each patient. NPs do not work more slowly or take more time because they are less intelligent or less efficient than doctors. NPs simply must spend more time, because it is the nature of NP practice. Treatment plans are not dictated to patients by NPs, as they often are by doctors. Rather, NP treatment plans are collaborative agreements reached in partnership with patients after a process that includes evaluating problems, teaching about causes, discussing options, and exploring patients’ own needs and wishes. With this extra time and the knowledge that is gained about the patient and by the patient, NPs are able to deliver care accurately, safely, and according to the patient’s own directives. NPs help patients manage the life changes that come with a chronic disease or a catastrophic event. When it is inevitable, helping patients face death with dignity and grace is intrinsic not just to NP care, but to all nursing care.

When people ask me what an NP is, the one-sentence defInition I give is: “I am a nurse who does the same thing a doctor does, but I do it from the perspective of a nurse.” Personally, I wish we had been named “nurse doctors” instead of “nurse practitioners”—it’s a title that’s less vague and more precise. But then nobody ever asked me.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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#1 | On February 28, 2010, ashley said:

Finally a wriiten article that gets to crux of our problem of perception. I agree that the titles we have been given are confusing to ourselves,let alone the public.  The public easily understands the PA role but still struggles with whether we are “practicing” to be a nurse and when “will we graduate” to not even being considered a RN.  I am still waiting for the 1982 resolution for BSN to be the entry level for nursing and yet now the profession is pushing the DrNP on us.  In the beginning of these talks, the Dr.NP was to be “clinical” based and not theorectical like the PhD yet I find nothing clinical about anyone’s DNP programs.  They were supposed to do mini residency in the field of their choice but all I see is more initials that one can add to their name to inflate their egos and allow governing agencies to charge more fees to keep each year.  I am licensed in 3 states and have 3 different titles to say I am simply an NP.  How crazy is this??  We are already experienced nurses who need to expand into the medical model to add to the nursing models.  We don’t need more “nancy nurse” theories, but more medical education so we can practice medicine which is what we do.  The PAs learn medicine and we learn more theories, who is better perceived by an employer looking for someone to provide additional medical services with their practice?
Refreshing to read an article like this when all I read is articles that just make us look more confused about who we really are.

#2 | On March 07, 2010, Carla Mills said:

Thanks for your comments. Here are emails exchanged between me and another reader (who did not want to be identified) that highlight some of the differences within the profession that need to be resolved if NPs are ever to become a unified force in the health care system:

She wrote:

I truly appreciate your efforts to get the word out to the public about nurse practitioners and agree with much of what you say in your recent “defining Nurse Practitioners” article, but I wanted to present a different perspective on titles. I am always curious as to why you discuss nurse practitioners and doctors as opposed to nurse practitioners and physicians. A doctor is someone having attained a doctoral degree and that is why you call your dentist, podiatrist, chiropractor, etc. “doctor”.

Patients understand what a doctorate is and can comprehend the difference between a physician and a doctor. When a DNP uses the title, the patient may need a brief explanation at first, but it is not complicated. If NPs don’t use the title, then we are making a statement to the public and other health care professionals that our doctoral degree is not a real doctorate. This sends a dangerous message. By not using the title doctor, we are allowing the physicians to once again define nurse practitioners, as they are the biggest opponents to NPs using this title. This short term “confusion” will lead to long term benefits for the profession.

My reply:

I think you make some excellent points here and so I want to respond. I use the terms “physician” and “doctor” interchangeably. I tend to use the term “physician” when I am trying to be politically correct (almost always a stretch for me). I use the term “doctor” when I am trying to speak plainly and from the perspective of patients. Three points I’d like to make:

Linguistically, I value plain talk that communicates to everyone regardless of educational background. The health issues people face in their lives are complicated so I believe the language we use to explain them should be very plain. I use “doctors and nurses” in the same vein as “cops and robbers” or “cowboys and Indians”. They are archetypes everyone understands. I believe NPs (which I think should include ALL advanced practice nurses by the way) should create our own archetype - not be just another kind of doctor or nurse. But this is just me and I seem to be in the minority on this.

Professionally, I am a master’s educated NP with 25 years of clinical experience - 10 as an RN and 15 as an NP. I will not be seeking a DNP or any other advanced academic degree - it would add nothing to my practice at this point. Obtaining a DNP and becoming a “doctor” would not add anything to my skills and effectiveness as a seasoned and experienced clinician. Will I one day be considered a second rate NP when I am compared to a freshly minted DNP with less clinical experience just because I’m not a “doctor”? I admit that concerns me and that I will feel betrayed by my profession if it happens. Also, I am SO, SO tired of having to waste valuable time explaining to patients what NPs are and are not. The public does not have a clue about what makes NPs unique and NPs are doing nothing to help them or ourselves find clarity where this matter is concerned.

Politically, I believe if there is to be any chance at all for NPs to become real forces in health care reform and any new health care system that comes out of that reform we MUST be a unified profession. Historically this has never been the case and, if we fail to make ourselves relevant, it will be because of our lack of unity. NPs using the title “doctor” just further fragment the profession when we should be unifying it.

All that being said, one can’t put the genie back in the bottle and though my views on this may be in the minority I will continue to express them.

#3 | On March 13, 2010, Jose Rosales, NP, DNP Resident said:

As I read these threads I see a lot of negative remarks about the word “Doctor.“  I do support the move that ALL NPs obtain their DNP.  What I do not understand, is why are people, who have not been through the DNP program, putting the DNP programs down.  The AANP/ANA has determined that all should have it.  Period.  That will help us now and in the future.  I used to thnk the same way two years ago.  Once I started the DNP, I then knew I was wrong.  The patients are not confused when they are treated by an NP, DNP or MSN, they both provide excellent medical care.  But, we must move forward.

#4 | On March 13, 2010, Jose Rosales, NP, DNP Resident said:

Carla, excellent point.  I strongly agree with you!  We should not be ashamed for using the word Doctor.  We are the pathfinders and must continue moving foreward.

#5 | On March 13, 2010, Carla Mills said:

Thanks for your comments, Jose. I am interested - you seem very certain that “ALL” NPs need to go back to school for a DNP - how long have you been practicing as an NP?

#6 | On March 13, 2010, Jose Rosales, NP, DNP Resident said:

Sorry Carla, I thought it was you who supported the DNP programs.  However you look at it, we must support each other, and educate patients on what we do.

#7 | On March 13, 2010, Carla Mills said:

No apologies necessary, Jose.

For the record I DO support the DNP programs - just not for “ALL” NPs. I’ve been a practicing NP for 15 years - you emailed me that you have been practicing as an NP for 5 years. If I, too, were 5 years into my NP practice I’d be looking at the DNP programs, too. But for me, at this stage in my career, it’s not an appropriate use of either my time or money.

I think grandfathering in NPs like me with DNPs is probably the answer to problem. With or without a DNP – I still don’t want patients to call me “doctor” and I will continue to correct them whenever they do. I want to be known as an NP and I want NPs to be known as our own class of provider which, in many ways, I believe is superior to the class of providers known as “doctors”. But, as I’ve already conceded, I realize I am probably in the minority in holding this opinion.

On one thing we both agree completely – all NPs must support one another and educate patients about what we do.

#8 | On January 04, 2011, jen said:

I love this article. You make and clearly articulate so many points.

I’ll throw my hat in on the DNP though. After 12 years of NP practice I went back for a DNP. I knew I would not be a different clinician necessarily but I knew I was going to support the AANP/ANA on this and as 2015 is going to intersect with health care reform catapulting legislative changes favoring autonomous NP practices I find it was a brilliant move on the AANP/ANA’s part.I agree though, that is was not until I started my DNP journey that i truly realized what it was. It is not designed to make practicing NP’s clinically stronger, it is designed to make practicing NP’s better at practicing in a complex system with countless wolves snapping at our heals. For me it puts me in a much different position, a unique one. I feel i can walk onto the playing field feeling it has just leveled. While the physician vocals rage against it, they do so to the backs of health care administrators, policy makers and board members, and that is all I need to know. The truth is we have always been on a level field, only WE did not know it. I am now intolerant to skewed rules, bias’s and prejudices. And when we all become intolerant of them then perhaps we won’t need a DNP, for me I did/do.

I posted an editorial suggesting physicians become more comfortable introducing themselves as physicians, this will help a vulnerable patient avoid mistaking them as a doctor (of nursing, PT, audiology etc) and we would not want to mislead them. I think the time has come for them to be physicians, a noble calling, perhaps one of the noblest. Of course they rage against sharing a title except it really isn’t their truest title, nor is it ours. It defines a level of education, not a level of clinical expertise. Physician and Nurse Practitioner define our areas of expertise as you have so eloquently described. (I really love that description) 

You have a great voice and I understand why you like ‘cops/robbers’ and ‘nurses/doctors’, but i do believe holding so firmly to ideology such as this only makes the obstacles in defining ourselves larger.

I challenge you to partake the DNP journey, not to change your ability to be a clinician but to perhaps change your ability to understand. I think you would have a shift in perspective (maybe it will make you more solid in your current opinion, who knows).

Unification, in my opinion, will come from supporting the leadership in the profession. The leadership has studied this issue for over a decade, published a position paper in 2004, years after they started the journey of looking at this, and they made a decision. Unification will come when we stop trying to buck, and argue against a forged path by a leadership that does not have a track record of running us astray on tangents fraught with self serving decisions.
Unification can come if we can direct gifts like yours toward it.

Thank you for your work, it was a pleasure to read and I have posted the link on other sites to raise awareness of all these issues.

#9 | On January 04, 2011, Carla said:

Thanks for your thoughtful reading of this article and for sharing your comments.


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