There was a session during the 2019 Winter Fellows Meeting titled "Coffee Talk with Loretta Ford: An Interview with the Original NP" in which Dr. Ford was asked about her views on the current struggle for full practice authority (FPA) for nurse practitioners (NPs). With concern, she told us of the implications of the misuse of the term "independent practice", and that what NPs have been seeking is more accurately termed "autonomous practice". She pointed out that no health care provider practices independently, nor ever has. Words matter.
What makes nursing or any discipline a profession? The key components of any profession include responsibility, accountability, a basis founded in a body of knowledge, institutional preparation, a moral/ethical foundation, and autonomy. The International Council of Nursing provides one of the best definitions of nursing: "Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings" (Nursing Definitions, 2002). Professional autonomy means having the authority to make decisions and the freedom to act in accordance with one's professional knowledge base. Collaboration means we work with other disciplines. We are not under their control.
Back in the 1980s when I was working with the New Hampshire Nurse Practitioner Association for FPA, I testified before the House of Representatives and was asked why I wanted to be an independent NP. Did I want my own practice? I replied that I did not want to be an independent NP because all health care providers work together for a common goal. I started to use the language of nursing to describe our unique body of knowledge, skills, experience, and philosophy. At that point, the audience was tired, and I was losing their attention. I rephrased it and said while every team has a captain, it takes the whole team to win the game. The captain could be the quarterback or any member of the team. It is not about who the player is but what the player's skill set is. And yes, I did want the ability to be self-employed and to be regulated by my own profession. The struggle was not about whether we were safe and competent providers as stated. It was and still is about whether we are competition or not. New Hampshire was one of the first states to be granted FPA.
Words matter in everyday parlance. I do not say I am going to advanced practice nursing conference for my Continuing Medical Education (CME) this year. As an NP, I go to conference for continuing education (CE) for my contact hours for relicensure and recertification. Sometimes, I go to an interdisciplinary conference and they may award me CME credit (because they did not apply for contact hours from an NP organization) but I am continuing my education in nursing as an NP. Continuing Medical Education is designed for physicians and rarely includes nursing content. Accrediting bodies for NPs do not use the term CME for CE programs for NPs.
With the increase in the number of states with FPA, more and more NPs say they want to start their own practices. Many call themselves entrepreneurs, but they are actually business owners (Sahut, 2014). The definition of an entrepreneur is someone who has a novel idea that has not been tested or worked through yet (Joseph, 2019). An entrepreneur develops a new product or service rather than using an existing business model. An NP who wants to open a primary care practice, urgent care center, house call practice, cosmetic practice, mental health practice, or health coaching practice is a small business owner. Why is this distinction important? Capital and risk. An entrepreneur needs plenty of capital (often millions) and needs to obtain it from outside sources. A small business owner also needs capital but a lot less and so the risk is less. If NPs want to be taken seriously in the business world, we need to be sure we call ourselves the right thing.
Speaking of calling ourselves the right things, there is no such thing as a mid-level provider (Nursing Definitions, n.d.). Health care is not a continuum with the endpoint being a physician (Position Statements, n.d.). It was a term used by bureaucrats who did not understand NPs and physician assistants and looked for a simple way to lump us together and distinguish us from other health care professionals. I do not use the term, and I challenge it wherever I see it. Some of my colleagues think it does not matter, it is not important, we have bigger battles to deal with. I disagree. It belittles our professional integrity and identity and demeans us to the public. If we, as NPs, do not fully embrace that we are advanced practice nurses and that that is of great value to society, it will be hard to convince anyone else of this. Some NPs say they do not understand why we must have Registered Nurse (RN) licenses and then NP licenses. We are RNs first and then advanced practice nurses. Dr. Ford also said in her interview that we cannot forget that we are first and foremost nurses.
Legal titles are defined and protected by law but what about words. Especially, the word "doctor.". According to Johnson's Dictionary Online, the primary meaning of doctor refers to a person who holds a doctoral degree. Anyone. Prior to the 19th century, the only fields of study that awarded doctoral degrees were divinity, law, medicine, and music. Currently, there are 88 different doctoral degrees available in the United States. If you earned your PhD or DNP, you can and should be called doctor. I know the argument that doctoral prepared nurses will confuse everyone because only physicians should be called doctors. But the implication is that we are not "real doctors." Think about the subtle implications of that.
When women started entering medical schools in force, many people got confused and assumed that any female in health care was a nurse. They explained they were not and people got it. Our patients and colleagues are educatable, too. They will come to understand that optometrist, chiropractors, osteopaths, physical therapists, psychologists, physician assistants, etc., can all have doctoral degrees and be called doctor. Every health care provider should be clearly identified by name, title, and job. I introduce myself as "Hello, I'm Dr. Nancy Dirubbo, a family NP." Then I can answer any questions they may have. It is a golden opportunity to dispel myths and promote our profession.
Another observation I had from the Winter Fellows meeting was the undercurrent of discord, disillusionment, and frustration. It is a feeling that health care is doomed, that we are all exhausted and will never catch up. It is certainly all over social media NP groups. New NPs are terrified, feel unprepared, and are wondering how they can feel burnt out when they are just starting. I hear the term burned out so often. Then, on the plane home, I watched a video on social media by Zubin Damania, MD (ZDogg MD) called "It's Not Burn Out, It's Moral Injury." And it was one of those light bulb moments. In a few minutes, he articulated what so many of us are feeling and he introduced me to the work of Dean and Talbout (2018).
Burnout implies something is wrong with us. We are the problem. We are not strong enough, committed enough, resilient enough. Dean and Talbot tell us that moral injury happens when we are forced to be a part of or bear witness to events that go against our moral values to provide the best possible health care to all. It is not our fault. Words make us feel like it is. Calling it by its rightful name, moral injury, stops placing the blame on us and will help us to refocus our energies on identifying the problem so that change can actually start to occur.
Where do we go from here? Here are some things you can do. Do not use the term "independent practice" when you mean professional autonomy and correct people who misuse it. Get involved with your professional organizations even if it is just being a member and writing carefully crafted emails of support for legislation. Do not use the term "CME". Want to start your own practice? Call yourself a business owner. Want to revolutionize the health care industry? Be an entrepreneur. Challenge anyone who uses the term mid-level, including other NPs who do not think it matters. Write letters to ask it to be changed when you see it in documents. Got your DNP? PhD? Congratulations, doctor. Be proud and use your title. And when someone tries to imply that you are inadequate because you can not see 45 patients in a 12-hour shift in urgent care and get all your charting done, remember you are not burned out, you are burnt up and it is moral injury. But most importantly, remember: words matter.
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