NPs and “Full Practice Authority”

WARNING: I have been through one nurse practitioner (NP) firestorm on Facebook about the ideas presented in this post. However, Facebook fails to provide a good stage for discussion of complex issues. So here’s the whole nine yards on the issue “full practice authority” from my perspective. If you have a low tolerance for notions which may be different than yours, please skip the post. Your blood pressure will thank you.


I’m always amazed at what will set off a binge of angry, pejorative, and sometimes downright ignorant comments from Internet posts on social media. Especially now that I have inadvertently stepped into a veritable cow pie of egregiously offended nurse practitioners (NPs) regarding certification and the ability to practice without physician oversight.

My sin? In welcoming our new NP to our clinic I wanted our patients to know that he has had a lot of experience and actually had taken both NP certification exams.

The American Association of Nurse Practitioners (AANP) examination results in a certificate ending in –C (certified) after the person’s name. The American Nurses Credentialing Center (ANCC) certification results in a certification ending in –BC after the person’s name. The C stands for certified, the BC for board certified. I had made the unforgivable statement that the –BC certification, with it’s “board-certified” designation, indicated a more difficult test, in a way a little like the additional credentialing of physicians becoming boarded.

Strident yelps from all over the country about how NPs with either certification were “boarded.” Didn’t matter that one certification included “board” in the degree name and the other did not.

I couldn’t figure out where the notion that both certifications were boarded was coming from until I looked at the two difference certificates. The –C certification is given by an organization with the word “board” in it’s name arching across the top of the diploma. To me, that does not equate to “boarding.” That is, an organization with “board” in its name granted the certification. The other organization granted a certification which was not just “certified,” but “board certified.” That’s the notion I was trying to get clarified. One of the kinder responses was that both certificates meant the same thing, and I was being careless in my use of social media by spreading misinformation.

I tried getting the naysayers to address why there should be two different certifications if both meant the same thing, but I simply got increasingly vicious replies. I attempted a second time to clarify my question. And a third time. The NPs really didn’t want to address the question, but rather to insist that the –C certification was no different than the –BC certification. To my knowledge there must be a difference because I knew some physicians will hire only NPs with the –BC certification. So why wouldn’t the NP responders be up front about this.

There is a history as to why there are two entities offering certifying examinations to NPs. As a few of the reasonable responders pointed out, many NPs find this confusing and misleading. However, the reality is that the –C certificate can be had for answering fewer multiple-choice questions than the –BC exam. Plus, the –BC exam goes beyond multiple choice questions and requires responses to videos, sort of like practicums.

I was referred many times by responders to a web page describing the two examinations where the attempt to gloss over that one exam is more extensive than the other was very clear. This page only says the –BC exam includes questions on ethics. By the way, this web page was last updated in 2012. Not a good sign.

There is a reason, obviously, why the predominance of NP certifications are the –C variety. Why take a hard test to get that certified designation when one can take an easier one. One respondent said she had taken both exams and one was no easier than the other. Another respondent asked why anyone would bother taking both.

Others deemed the post as “false advertising.” These posters, and they were from all over the country, miles from our area, felt it necessary to write bad reviews of our clinic to get its rating down.

You would have thought the sky was falling.

PLEASE NOTE: I am sure there are many competent, very proficient NPs out there. I even know a few. However, this NP hysteria over my ignorance, especially the deliberate attempt to lower our clinic rating by giving bad patient care reviews, speaks to this group of NPs level of honesty and integrity.

If nothing else, this NP uproar indicates to me just exactly why NPs are incapable of providing patient care equally as professionally as physicians. They, at least the large number in this responding group, are far too invested in hyping their abilities than paying close attention to what really counts, such as their scope of practice and doing that well. Physicians don’t waste their time insisting some of their various certifications require more work than others, although they are capable of joining together to rid the profession of the Maintenance of Certification (MOC) examination when the credentialing business becomes unethically onerous.

NPs have fallen victim to their own professional organizations trying to pretend there is no difference between these two certifications. But unlike physicians who may disagree professionally over diagnoses, NPs instead try to defend politically correct labels. Time for NPs and their certifying organizations to become more honest about their differences. NPs and their two certifying organizations should be working to avoid confusion, not pretending there’s no difference between the two exams.

I recently observed an NP on Twitter politely take a physician to task for referring to “his NPs.” When the focus of attention is politically correct language, what’s really important gets left in the dust. This NP commented that he, the physician, just didn’t understand. NPs wanted to practice without false barriers.

I specifically asked for a list of what those barriers might be. Got in return a link to a white paper with all kinds of reasons NPs should be allowed to practice without physician supervision. Again, what barriers? Practicing without supervision doesn’t mean NPs are prevented from doing what they always do within their scope of practice. However, reading between the lines, it appears the scope of practice for NPs varies from state to state. To my mind, there should be consistency from state to state in what care NPs can provide. A worthy goal for NPs to collectively work toward. Instead NPs appear to be focusing on “physician supervision” which   does not interfere with scope of practice.

I am tired of listening to propaganda about how NPs are just as good as physicians in a clinic. Let’s be truthful here. NPs may be as efficient in treating colds, sinus infections, or warts. However, NPs who equate two years of book learning and 150 multiple choice questions to four years of medical school and three to four years of residency are seriously deluding themselves.

The time and energy devoted to trying to get rid of physician oversight, i.e., the carefully crafted notion of “full practice authority” would be much better spent bringing consistency from state to state on NP scope of practice. When a large group of professionals cannot understand the difference between their certificates, landing primarily on the side of ad hominem arguments, the profession has a significant credibility problem.

From my perspective, these kinds of misjudgments reflect a profession which has not matured enough to be able understand what they really are asking for—freedom with a nursing license to practice as a physician.

Some young HR person once looked at my CV and asked me, quite seriously, if I had really done everything I had listed there. Well, yes. Because I am someone who can't sit in a Morris Miller cubicle every day, much less for any great stretch of time. Once the problem is solved, I get bored and I'm ready to move on to the next challenge. This hasn't afforded me any great stability in my work life. I simply arrive in places about ten years ahead of time. So far, at least, that penchant for early arrival hasn't been accompanied with a pocketbook full of door knobs.
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