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News: Are NPs and PAs Taking EP Jobs?

Phillips, Andrew W. MD, MED

doi: 10.1097/01.EEM.0000522209.68828.c1
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Dr. Phillipsis a clinical fellow in the division of critical care at Stanford (CA) University and an emergency physician with the Permanente Group in Redwood City, CA. Follow him on Twitter @warejko.

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If the recent past is any indication, all 50 states will eventually grant nurse practitioners unrestricted scope of practice without any physician collaboration, much less supervision. States that allow unrestricted NP practice already have nurse-managed health centers for primary care—outpatient clinics that are entirely staffed by NPs without any physician. (Nurse Pract 2006;31[2]:5; Am J Nurs. 2010;110[9]:23.)

The logical next step is emergency medicine staffing groups composed entirely of nurse practitioners. At their current rate of progression—there are already approximately 300 nurse-managed health centers nationally—and with unrestricted practice in an increasing number of states, it is reasonable to expect that such a group will exist within the next 10 years, if not sooner. Perhaps it already exists, but has not been described in the literature. Future regulations for physician assistants' scope of practice are much less predictable because the American Academy of Physician Assistants (AAPA) only recently established its members' preferences on the matter.

How did we get here?

The number of advance practice providers (APPs) has risen sharply over the past two decades in the United States, with approximately 70 percent of emergency departments incorporating them into their staffing models. (CJEM 2013;15[3]:134.) With that has come growth and changes in PA and NP education and advocacy, including complete autonomy and unrestricted scope of practice by NPs in 22 states. (AANP. NP Fact Sheet. http://bit.ly/AANP-NP.)

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Current and Future PA Roles

PAs trace their roots to military field medics and midwives, formally recognized in the 1960s, and, as a result, were always considered dependent practitioners working with the physician. (Physician Assistant History Society. http://bit.ly/PAHxDuke.) Because of their origin, PAs are primarily regulated by state medical boards, but regulations vary greatly by state and often are not specialty-specific. It is worth noting that only Virginia requires an on-site physician for PAs caring for ED patients. Six states (12%) require physician review within a week, and 16 states (31%) do not specify what “physician review” means. Nonetheless, PAs are still currently considered dependent practitioners in all 50 states. (J Emerg Med 2015;48[2]:e49.)

The past few years have seen an increase in PA advocacy, and a hot-off-the-press survey of PAs in all specialties in the United States clarified many of their perspectives. (AAPA Research Department. 2017 Full Practice Authority and Responsibility Survey Report. 2017.) The executive summary is an important read for every physician (http://news-center.aapa.org), but some highlights of note:

  • Ninety-six percent of PAs support the “team-based” practice model with physicians.
  • Eighty percent support establishing autonomous PA state boards for licensure, regulation, and discipline on which some physicians would still sit.
  • Sixty-three percent want to eliminate specific relationship requirements with physicians, and this was associated with the 62 percent who reported a perception that employers thought NPs were easier to hire because they do not have collaboration requirements like PAs.

It is particularly striking that the majority of responding PAs want autonomy at least in part because they think it is necessary to compete with NPs for jobs while the overwhelming majority still support the team-based model with physicians. To be sure, some PAs want autonomy for other reasons, but the report's authors stated that they believe that the drive is largely political, driven by NP lobbying, according to their 67-page analysis. (AAPA Research Department. Full Practice Authority and Responsibility Survey Report. 2017.)

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Current and Future NP Roles

The NP role in any specialty was formalized in 1966 by a nurse, Loretta Ford, and Henry Silver, MD, at the University of Colorado to increase the supply of primary care providers in underserved urban and rural areas. The initial concept was for NPs to provide care for the straightforward presentations, allowing the physician to focus on more challenging cases. The NP model at its inception was designed for independent providers with a limited scope. (The Development of the Nurse Practitioner and Physician Assistant Professions; http://bit.ly/2rW6m9g and Adv Emerg Nurs J 2006;28[3]:198.)

NPs are regulated by state nursing boards without any physician oversight, in contrast to PAs. All states historically required a “collaborative agreement” with physicians for NPs, but 22 states currently have no collaborative or other legal restrictions. Only 13 states require a collaborative agreement or restrict scope of practice in some way. (AANP-State Practice Environment. http://bit.ly/2s5bAk5.)

NP advocacy has been strong for at least a decade, and has been clear about its goals for practice regulation, especially emergency NP advocates. Several years ago, the Association for Advanced Practice Nursing released the Advanced Practice Nursing Consensus Model, which called for full practice independence for NPs in the United States. The editors-in-chief of the Advanced Emergency Nursing Journal strongly supported the consensus model, writing that it would “remove APRN [Advanced Practice Registered Nursing] scope of practice barriers (e.g., prescriptive authority limitations, physician collaboration issues).” (Adv Emerg Nurs J 2011;33[2]:107.)

One of the editors later wrote that “nurse practitioners are not ‘intermediate’ providers of care. Nurse practitioners are licensed independent practitioners who practice in a variety of settings (e.g., hospitals, urgent care, primary care).” (Adv Emerg Nurs J 2012;34[2]:93.)

A position statement from the Emergency Nurses Association in 2003 is also worth noting: “[A]n advanced practice emergency nurse is uniquely prepared to develop and apply theory, conduct research, and develop standards of care that enhance patient outcomes.” (ENA. Position Statement: Advanced Practice Nurses in Emergency Care. 2012.)

These statements are not contingent upon extra education or training, but include even new nurse practitioners after a two- or three-year graduate degree and no residency education.

The NP societies' lobbying efforts are too extensive to cover in this article, but interested readers may wish to review the robust website dedicated to NP lobbying (including a map that defines which states have the most and least regulations; http://bit.ly/2s5bAk5), a joint article with the AARP that presses legislators to remove “barriers” to NPs fully practicing (http://bit.ly/2qXdoap), and an article encouraging NPs to apply for job positions for PAs to increase the proportion of NPs in emergency practice. (Adv Emerg Nurs J 2014;36[4]:291.)

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Contact AAEM and ACEP

Both practitioner groups are formally just over 50 years old, but the role of PAs and NPs in U.S. health care, including emergency medicine, has increased exponentially, while regulations for NP care have decreased dramatically. NP societies appear to be driving the lobbying efforts to have the same legally unlimited practice scope as physicians despite significantly less education and training, which is thought to be driving PA societies to lobby for the same scope of practice to compete for jobs.

Emergency physicians should be asking what training and education are really necessary for safe patient care. Increased scope of practice for providers who have less education than physicians may be reasonable if they can provide safe and appropriate care. If that is the case, emergency physician societies should reconsider the length of required residency. Conversely, if increased scope of practice for providers with less education and training than physicians occurs simply because NP societies are spending more money and time on lobbying than physicians, emergency medicine as a specialty—composed of various types of providers—needs to re-evaluate the care offered to patients who find themselves in the ED on the worst day of their lives.

Physician lobbying opportunities for this issue are relatively limited, unfortunately. The American Medical Association has grassroots efforts nationally (http://bit.ly/2rJrgrx), but the two major EM society websites for advocacy pale in comparison with the online, grassroots presence of the NP societies, but concerned physicians can reach out to emergency medicine societies at http://www.aaem.org/advocacy and https://www.acep.org/advocacy. Interested physicians do not have to be members of these organizations to contribute to advocacy. Indeed, all three organizations invite everyone to join them to advocate for patient safety—and we should.

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