Notable Works
Co-contributors: Kunta Gautam, Ralph Klotzbaugh, Christopher Reeves
Carter and Haji Assa (2023) have written an intriguing and thought-provoking paper about the “curious” historical and continuing comparison between the practice of nurse practitioners (NPs) and that of physicians (MDs). They contended that the ontology and epistemology of NPs and MDs are so different “that comparisons are illogical” (p. 1).
Their review of literature is a summary of the continuous contentions that NP practice results in equal or better patient outcomes than MD practice. They noted that, “These comparisons were unusual in that Silver and Ford [who first described the role of NP in the 1960s] never suggested that the work these nurses performed equated to medical practice” (p. 1).
Differences Reside in Ontology and Epistemology
Their analysis of the philosophical foundations of NP and MD practice indicated that ontological differences focus on what is considered real:
- NPs practice within an ontology of multiple realities that take the observer and their context into account,
- whereas MDs practice within an ontology of a single reality that does not consider the observer and the context.
Epistemological differences focus on how knowledge is perceived and applied:
- NPs practice within an epistemology of lack of need of theory being expressed mathematically or symbolically logical; theories do not have to be tested axiomatically,
- whereas MDs practice within an epistemology that requires theories to be expressed in mathematical and symbol logic terms and must be axiomatic to be considered scientific.
- NPs practice within an epistemology of the importance of all sciences, all of which provide estimates of probabilities and do not predict any phenomena,
- whereas MDs practice within an epistemology of physical sciences as basic and its purpose, as well as all other sciences, is to predict phenomena.
- • NPs practice within an epistemology of the criticalness of discovery for evaluation of outcomes,
- whereas MDs practice within an epistemology of the unimportantness of discovery.
- • NPs practice within an epistemology of use of many methods of science to gain the understanding needed for scientific progress,
- whereas MDs practice within an epistemology of reduction of “less basic to more basic sciences” (p. 5) using only one method of science.
Jacqueline Fawcett (JF): Carter and Haji Assa (2023) maintained that nursing’s basic philosophy is that of holism. Holism is inherent in most, if not all, nursing conceptual models and theories. However, as Parse (2023) pointed out, many nursing PhD programs no longer include a course about nursing’s extant conceptual models and theories in the curriculum. I share her concern that our existing knowledge is an “endangered species” (p. 109). More specifically, and especially relevant to our discussion of Carter and Haji Assa’s (2023) article, Parse (2023) asked, “What is the uniqueness of nursing as a discipline when medical science content has replaced the nursing theories and frameworks in [nursing] PhD programs? . . . What is the meaning of a PhD in nursing, if the focus is on medicine and other ancillary content?” (p. 109). Thus, we might want to ask whether holism really matters to nursologist or do nursologists, including NPs, prefer to practice within the context of the reductionist philosophy of medicine?
JF: My understanding of NP practice (I am not a NP) is that some tasks may appear to be similar to tasks performed by MDs but the so-called NP tasks are performed within an entirely different conceptualization of the nursologist-patient relationship, a relationship that is grounded in a nursology conceptual model or theory (see nursology.net for an entire repository of nursology conceptual models and theories). Hence, the tasks only appear to be similar. I defer, however, to my colleagues who are NPs and engage in nursology practice. Their thoughts follow here.
Christopher Reeves (CR): An historical consideration is the envelopment of osteopathic doctors (DOs) into the larger allopathic-dominant physician group. To a large extent DOs have, over time, disconnected from their own philosophical and theoretical perspectives to align with the biomedical and allopathic medical hegemony. To find a DO who practices osteopathic manipulative technique after their initial medical training is almost completly unheard of. Thomson and MacMillan (2023) suggest that a weak theoretical basis is an active threat to the practice and propose that more deeply developing and reinforcing the theoretical underpinnings is critical for professional maturation. As we consider advanced practice nurses, this history should serve as a strong warning to NPs who, similarly, are encouraged directly and indirectly to assimilate into the medical model. Without a clear and internalized understanding of the philosophical tenants that underly nursing practice and set that foundation for expansion into advanced clinical practice, NPs are at risk for similarly abandoning their professional identities in favor of the dominant, reductionist biomedical perspective.
CR: Even if we accept, as Carter and Haji Assa (2023) suggest, that NPs and MDs are fundamentally philosophically different, current policy, both public and organizational, prevents the NP from fully realizing this truth. Historically, NPs have required a written agreement with a physician to “supervise” their practice of advanced nursing. Guidelines and oversight that are conceived through a reductionist, medical lens do not, and cannot, allow for NPs to practice fully from their true philosophical grounding.
Over time, NPs have begun to separate themselves from direct physician oversight through state-based legislation granting of full-practice authority (FPA), but this independence continues to be unachieved in many states. Currently, FPA has been achieved in only 32 states and Washington, D.C., leaving 36% of states with ongoing restricted NP practice (AANP, 2023). Concerningly, even in states where NPs have been granted FPA, such as Massachusetts, implementation has been slow with many still retaining practice agreements with physicians (O’Reilly-Jacob et al., 2023). For NPs working in larger systems, hospital bylaws often lag and continue to restrict authentic practice.
Ralph Klotzbaugh (RK). Some thoughts that I have on reading the philosophical foundations put forth by Carter and Haji Assa (2023) are based on the holistic approach unique to nursing in that “nursing science involves understanding the physical science[s]…but focuses more on understanding the whole person’s experience” (p. 6)
I think that over time this holistic approach ascribed to nursing has reduced itself to window dressing (unfortunately). I say this in response to the myriad specialties and certifications within advanced practice nursing. For example, how holistic is our unique approach to patient care when we have (most importantly in my practice) divorced physical from mental health? Further, what does it mean when places like Columbia University are offering post masters certifications in care of the LGBTQ+ client? This fractionalization of human bodies and experiences within APRN education is directly following a medical perspective (but it makes money). The DNP might have been an opportunity to address (at the very least) body/mind disconnect in other health science practices…but chose instead to follow a quasi-administrative degree with quality improvement projects.
RK: Carter and Haji Assa (2023) point to APRNs’ attention to patients as individuals and yet fail to also recognize providers as individuals from both medicine and nursing and how that affects patient care regardless of the philosophical foundations of either. For example, some MDs I have worked with have a far more holistic approach than some NPs I have worked with. Additionally, I believe the authors are remiss in not discussing the overlying business model structure that has replaced professional ethics with business practices and how that affects patient care…and not for the better.
CR: It is instructive to understand that the dominant billing model in the US encourages the fragmentation and medicalization of whole people, which further drives nurse practitioners away from an authentic practice of holism.
Kunta Gautam (KG): Historically, NP practice generated concerns regarding stepping out of the professional boundaries. Both allopathic medicine physicians and members of some nursing organizations were suspicious that this type of advanced nursing practice was not clearly defined as nursing (Carter & Assa, 2023).
KG: Advanced practice nursing and medicine originate from different philosophical bases and are not interchangeable. Carter and Assa (2023) analyzed these differences based on the extensive work done by three highly privileged professionals such as Florence Nightingale, Osler, and Flexner.
KG: Nightingale argued that symptoms of suffering are not produced by the disease itself but by other elements surrounding the disease, which are not adequately addressed. Nursing is practiced to address all the surrounding areas that can promote disease recovery. Her theories contrasted medicine with environment-based assumptions. Nursing, therefore, focuses on the whole person being more than the sum of the parts.
KG: The NP role was initially created for community-based primary care rather than hospital-based practice. Leaning on this philosophy, advanced practice nurses provide holistic care focusing on well health promotion, illness and disease prevention, and health education.
KG: However, modern nursing has a strong understanding of the science used by medicine. With the evolution of advanced practice nurses in different specialty areas, the holistic view of nursing has been segmented into different practice areas. This paradigm shift in advanced practice in modern nursing has generated more in-depth knowledge and skills. It has successfully invaded different specialized areas that were not considered in the initial phase of the evolvement of the NP role.
KG: This rapid evolution of advanced nursing practice in NP roles needs a supportive network to flourish. NPs have a specialization, but specialty information is not listed on their licensure data and is inferred based on the medical specialties (Harrison et al., 2021). Although both advanced nursing and medical pathways have evolved over several decades, we have to have specialty licenses to have autonomy in our philosophy of practice.
KG: NPs are identified by their National Provider Identifier Number (NPI). NPI numbers are 10-digit numeric identifiers the federal government assigns to all healthcare organizations and providers for billing (Harrison et al., 2021). NPs can add value to the nursing profession by generating revenue. The findings of several studies have revealed that NPs can perform effectively in acute and primary care settings if they have adequate knowledge and training. The National Sample Survey of Nurse Practitioners (NSSNP) needs to include survey data for specialized NPs and primary care survey data to better understand NP distribution and contributions to healthcare. It is time for the respective licensing boards and the American Association of Colleges of Nursing to come together and strengthen NP practice by providing specialized licenses, which will empower NPs in different areas to practice with more autonomy on top of their license and make a more significant impact in healthcare as a whole.
KG: In addition, I urge the American Association of Colleges of Nursing to revise the NP curriculum by adding a mandatory course regarding the origin of NP practice, where we stand in the modern nursing era, the evolution of practice, and how we are embedded in advanced practice nursing roles.
JF: I wonder whether NP specialties should be the same as medical specialties. If yes, would that complicate the differentiation of NPs from MDs other than philosophical origins? If not, what might the basis of NP specialties be?
RK: I wonder, if given the overarching business practice model (in both MD/NP education and practice) if it is even possible/necessary to discuss the impacts of philosophical foundations related to patient care and practice for either MD/DO/NP. It is worth noting that the referenced article is from this year 2023. In my mind this is important in that it woefully omits the reality of the great resignation among RNs, APRNs, MDs, DOs, etc. This is post-pandemic, where the failings of administration have been graphically displayed (repeatedly in grey literature) and have overwhelmingly fueled this great resignation. These overarching business practice models (that have been in place well before the pandemic and place profit over people) that have occluded professional ethics (and the philosophical foundations of said professional ethics) render this comparative discussion (right, wrong, or indifferent) put forth by the authors as irrelevant. My philosophical foundations of practice, for example, have been occluded by measured patients per hour, changing billing codes, procedural notes, preliminary readings, etc. such that what my approach to patient care is or ever was is rendered meaningless. This has become such a problem that ethical debates are being had over strikes among physicians and nurses and the continued provision of patient care. I also think about the window dressing that is “culturally competent patient care”. How do ‘one size fits all’ patient appointment times address the need for translation services for example? If I have 15 minutes allotted to an acute patient visit and 10 of those minutes are spent reaching the appropriate translator to even start that visit, how is that in any way culturally appropriate and/or considerate? This continues to be the case even though all relevant data have shown that demographics are changing in the US to becoming more culturally and linguistically diverse. In fact, many state demographics already reflect a minority majority. In their article, Carter and Haji Assa (2023) most disturbingly avoid any kind of larger political consideration, discussion, and/or confrontation.
KG: I totally agree with you Dr. Klotzbaugh about the pressure the business model puts on our practice. Given clearly that our ontology and epistemology foundations are different – Why are we still assigned along with Medical Boards- we have our own NPI, why are we still having to co-sign with collaborating physicians. We say we come from different foundations. But, why is our foundation attached to medicine? I would not care to compare my practice with medicine. I always look at myself as a professional, giving my best efforts in my practice, within my boundaries and license scope. I regard the issues that need addressing by our higher authority in NP practice to be:
- NP licensure recognition in specialty areas.
- An advanced nursing practice role that can sustain the pressure of the business model in healthcare.
- NP provision of culturally competent care, with a clear pathway for advanced nursing practice in different areas.
- Action in the form of bold leadership to make our own practice model.
References
American Association of Nurse Practitioners. ([AANP]2023). State Practice Environment. https://www.aanp.org/advocacy/state/state-practice-environment
Carter, M. A., & Haji Assa, A. S. (2023). The problem of comparing nurse practitioner practice with medical practice. Nursing Inquiry, e12551, 8 pages. doi: 10.1111/nin.12551
Harrison, J. M., Germack, H. D., Poghosyan, L., & Martsolf, G. R. (2021). Surveying primary care nurse practitioners: An overview of national sampling frames. Policy, Politics & Nursing Practice, 22(1), 6–16. https://doi.org/10.1177/1527154420976081
O’Reilly-Jacob, M., Zwilling, J., Perloff, J., Freeman, P., Brown, E., & Donelan, K. (2023). Early implementation of full-practice authority: A survey of Massachusetts nurse practitioners. Journal of the American Association of Nurse Practitioners, 35(4), 235-241. doi: 10.1097/JXX.0000000000000853
Parse, R. R. (2023) Are the extant nursing theories endangered species? Nursing Science Quarterly, 36(2), 109. doi: 10.1177/08943184221150254
Thomson, O. P., & MacMillan, A. (2023). What’s wrong with osteopathy? International Journal of Osteopathic Medicine, 48, 1-6. doi: 10.1016/j.ijosm.2023.100659
About the contributors
Kunta Gautam, RN; MPH, NP, is a pediatric nurse practitioner in community urgent care clinics at Texas Children’s Hospital, Houston, TX. She has been an NP for 14 years and has experience in different areas, which include outpatient specialty clinics, in-patient acute care settings, primary care clinics, and urgent care clinics. She is a clinical preceptor for nurse practitioner students from various universities at her practice site. She loves to mentor students and believes in establishing a strong clinical foundation to thrive as an independent practitioner. She advocates NP practice to be able to practice with knowledge and skills on top of their license. She also is a PhD candidate at the Nelda C. Stark College of Nursing at Texas Woman’s University. For more information, please follow her on LinkedIn.
Dr. Ralph Klotzbaugh, RN; PhD; FNP-BC is an assistant professor at Duquesne University, Pittsburgh PA. His research relates to the role of nursing in the equitable health care of lesbian, gay, bisexual and transgender populations. More specifically, his research focuses on the intersection of sexual and gender minorities within a rural context. He is a nationally certified family nurse practitioner and a recipient of the Maureen Oh Eigartaigh Excellence in Nursing Practice Award for his work with transgender clients. He has been an invited lecturer on the care of sexual and gender minorities in primary practice. Dr. Klotzbaugh has been active in the establishment and development of the nursing section of the Gay and Lesbian Medical Association and a longstanding member of the World Professional Association for Transgender Health.
Christopher (Chris) Reeves, RN; MSN; CNP is an adult-gerontology acute care nurse practitioner working in nursing professional development with an ongoing advanced nursing clinical practice in neurocritical care. He is currently enrolled in a PhD program at the University of Massachusetts Boston. His research interests include the initial transitional experience of the novice nurse practitioner and outcome measurement of post-graduate transition to practice programs, namely residency and fellowships. He serves on the board of directors for the Massachusetts Coalition of Nurse Practitioners (MCNP) as well as the Massachusetts Chapter of the National Associated of Pediatric Nurse Practitioners (NAPNAP).
This article demonstrates the problematic nature of the white, Western, Eurocentric, colonial “binary” discourse that leads to ontological imperialism. Eisenstein (2020) describes two levels of ontological imperialism: 1) “we’re right and you’re wrong, and 2) “Only one of us could possibly be right, as our views are in contradiction. It’s either-or”. Thorne, Hendersen, McPherson, and Pesut (2004, p.208), discussed the “problematic allure of the binary in nursing theoretical discourse”. One half of that binary is uncritically adopted, leading to “othering” that prevents “healthy and critical engagement with ideas” (Thorne, et al., 2004, p.208).
I know very few NPs that “practice within an ontology of multiple realities” but I have worked as an NP, nursing professor, and social medicine educator with hundreds of physician, resident, and medical student colleagues from all over the world in the past 10 years, many whom are dually educated as anthropologists, sociologists, historians of science, or political economists, who “consider the observer and the context”, a context that broadly considers the social, cultural, economic, political, and historical context in which illness is created and perpetuated.
Do any of the authors (article or blog) teach in a medical school or teach medical students in other settings? If not, where does their knowledge about biomedical epistemology and ontology come from? Are they familiar with the work of physicians, many who are also social scientists, whose holistic, broadly contextual scholarly work is fundamentally changing the face of healthcare?
The bio-psycho-social model, that many nurses believe comes out of nursing, actually comes from biomedicine, psychiatrist George Engel, MD in 1977. Other important holistic, broadly contextual concepts and models , developed by physician scholars, that are changing the face of medicine, and other healthcare disciplines willing to engage with their work, includes: 1) cultural humility ( Melanie Tervalon, MD, MPH; Jann Murray-Garcia, MD, MPH, 1998), 2)narrative medicine (Rita Charon, MD, PhD- English literature, 2006), 3) social determinism; effects of neoliberal economic policies on health (Howard Waitzkin, MD, PhD- sociology), 4) structural competence (Helena Hansen, MD, PhD- medical anthropology; Seth Holmes, MD, PhD- medical anthropology), 5) anti-racism allegories for health equity (Camara Jones, MD, MPH, PhD-Epidemiology), 6) historical scientific racism, structural racism inherent in racial correction of physiological measures (Lunde Braun, MD, PhD- Africana Studies), 7) structural violence, liberation medicine (Paul Farmer, MD, PhD- medical anthropology), 8) effects of neoliberal economic policies on health (Salmaan Keshavjee, MD, PhD- medical anthropology), 8) social suffering (Arthur Kleinman, MD, PhD- medical anthropology), 9) non-universal nature of autonomy and self-determination in healthcare ethics (Scott Stonington, MD, PhD- medical anthropology), and 10) molecular and cellular consequences of colonialism (Rupa Marya, MD).
Should we also reject other ideas that could fundamentally change how we care for patients but do not come from a nursing perspective such as: 1) Social epidemiology, social embodiment (Nancy Krieger, PhD- epidemiology), 2) allostatic overload, weathering hypothesis (Arline Geronimus, ScD- public health), or 3) the ACES Plus framework?
Will nursing continue to engage in ontological imperialism, rejecting everything that comes from biomedicine as “wrong”, or embrace the transdisciplinary, epistemic plurality that is necessary to solve the overwhelming problems we face within healthcare?
rastaus. Thank you for your comprehensive comment, which is best directed to the authors of the article, Carter and Haji Assa.Perhaps you could contact the authors at mcarter@uthsc.edu to discuss ontological imperialism It seems to me that the major point of their article is to not compare NP and physician practice, which is common in studies of their practices. If there is no philosophic or conceptual model-guided difference in practice, one has to wonder why NPs do not also hold a physician license and physicians do not also hold a RN/NP license. Or, perhaps we should devolve or evolve to a generic health care worker. Please let us know your name and email address so that we might continue this dialogue. Thank you, again.
Philosophy, from which epistemology and ontology flow, is not a binary world but one of both…and as well as ‘on the other hand’ and ‘let’s consider a more expansive definition of x” or “a more refined one.” Philosophy also includes other studies e.g, ethics and logic. The philosopher of human well-being, Kant, saw care and respect as inexorably linked: one does not exist without the other. Dillon beginning in 1992 until today ties respect and caring as essential elements of moral integration, which I must say is so lacking in our neoliberal conservative dominated Supreme Court decision reversing affirmative action. Caring and respect for The Other and for one another, including among our nurse colleagues, is deficient it would seem to this not so unobtrusive observer. Let us hope it is not missing in terms of the ‘respect’ and in terms of the basic as well as advanced nursing ‘care’ we extend to all clients across all settings. I, for one, hope that theoreticians and diagnosticians, representing the ‘full’ expresión on nursing epistemology and ontology can come together and grow in their understanding of nursing. The theory I espouse? Jean Watson’s ‘caring’ and/or ‘caring and respect’ model because, as Kant indicated, one does not exist without the other. And I would not be walking in the same path as Nightingale did I not also hold that undergirding caring and respect is vigilance, described in at least one publication as the ‘essence of nursing’ (Meyer & Lavin, circa 2005? 2998?).
Sorry about the 2998 typo
Mary Ann, Thank you for your comment.
I started the study of Nursing in 1969, almost concurrent with Ford and Silver’s nurse practitioner role emergence. It was definitely created as a “physician extender” practice, and was openly called that (conjointly with the Physician Assistant role). So while many in Nursing, primarily as I experience it, Nursing educators, try to conceptualize and “sell” the idea of “advanced nursing practice”, it seems to continue to live as originally conceptualized, as a physician extender practice. Granted, there are a few NPs who intentionally practice as Nurses in their NP roles, the majority seem to practice the physician extender role.
I get the most severe migraines when i read material produced by people with no real grasp of science or scientists. I didn’t learn about holism by going to nursing school. I already figured that all out through my life experiences, and my studies of engineering, physics, mathematics, philosophy, the social sciences and the much maligned probability and statistics. I chose nursing because of the holistic views I already held, but I was quite disappointed by what I experienced in nursing school where I stood out like a sore thumb precisely because of my pre-existing holistic orientation.
Real scientists aren’t foes of holism, nor are MDs as limited in their worldviews as this article suggests. Most of the NPs I have met, or worked with, have been completely at home playing junior MDs without the slightest trace of the holistic views the article suggests ought to guide their practices.
An exemplar: During my MSN/PhD studies I had a classmate who was an NP. She applied for, and got, a job that was pretty much along the lines of what the article presumes would be an appropriate practice: Going out of the hospital, meeting patients in their communities, in their homes, and in their workplaces. Understanding their lives, the context of their lives, and the impact of their lived experiences on their health, their health challenges, and their care.
It was the sort of job I’d have really enjoyed and I understood exactly what the grant funded position was meant to achieve. But she wanted no part of that, and basically refused to leave the comfort of her “office-based practice,” blaming the patients she was supposed to do outreach with for not complying with her desire to have them schedule office appointments and show up for the appointments. She should have been fired, but instead she prevailed, and never had to leave the office. Her patients didn’t show up for appointments, just like they hadn’t been showing up for their appointments with the MDs.
Yes, there may be a tiny fraction of all NPs that fit the narrow description in the article, just as there may be a tiny fraction of MDs who fit the narrow description in the article. The world bears little similarity to what the article describes. When you get right down to it, if our theories and accumulated knowledge fail to describe the world we might as try to drive to work while ignoring everything we intuitively understand about mass and velocity on highways.
We have the luxury of living in an age brought about by disciplined scientists intent on creating a better world. We tamed illnesses, increased food supplies, developed antibiotics, invented X-Rays, Cat Scans, MRIs and on and on, The authors would do well to approach their knowledge of medicine, medical science, and science in general with a more appreciative perspective.
Savina, Thank you for your comment. The Ford and Silver program was, I understand, called PRIMEX, meaning primary care extender, which at the time referred, as you correctly point out, mean physicians, as they then, I think, were the only primary care providers. Perhaps of interest is the AACN (2006) Essentials for DNP education Essential VIII-Advanced Nursing Practice. This essential states, in part : “All DNP graduates are expect to demonstrate refined assessment skills and base practice on the application of biophysical, psychosocial, behavioral, sociopolitical, cultural, economic, and nursing science as appropriate in their area of specialization” (p. 16).The issue for me is putting nursing science at the end. I would not separate nursing science from the other areas listed in the essential, as my understanding is that nursology knowledge, at least in the form on conceptual models, already includes all the others (although perhaps not economic).
As we discussed the professional roles, holistic nursing, and understanding of Nursology knowledge, I questioned myself- why do we talk about righteousness, and what is the righteous way of everything?
In the olden days, knowledge was disseminated as a blessing by the wiser ones to the novices.
The academic area is considered to be the sacred place of knowledge. No matter which generation of people we are, we pursue education as a framework of righteousness, growth, wisdom, and skills that prepares us to holistically live our lives as better human beings.
We all know the real world consists of so-called good and bad in professional and personal roles. But despite this knowledge, we strive to be good in every area. When we discuss theory, philosophy, and other work that holds a high value of integrity, morals, and knowledge, we are talking about the ideal framework and the guiding principles.
It is our responsibility, and we are accountable for how we perform these roles and maintain our core values, moral ethics, and integrity in nursing and other areas of life by demonstrating kindness and respect to every human being.
Diversity of perspectives and how we do things in specific ways could be a combination of formal education and lived experiences. This diversity leads to the growth of humanity.
I appreciate the discussions and sharing of different perspectives.
Kunta
Thanks for providing a detailed blog on the problem of comparing nurse practitioner. Being a professional nurse we also provide nursing assignment writing services.
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