Nurse practitioner speaks out against independent practice
ICYMI: Drs. Rebekah Bernard and Niran Al-Agba are joined by Shannon Keaney, a nurse with 11 years of intensive care experience who recently graduated as a nurse practitioner. Shannon explains the differences between "brick and mortar" nurse practitioner training as compared to newer "diploma mills," and discusses why she thinks patients are best served when nurse practitioners practice with physician supervision.
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Rebekah Bernard MD 00:01
Hello and welcome to 'Patients at Risk.' I'm Dr. Rebekah Bernard and I'm joined tonight by my co-host and the co-author of our book, patients at risk the rise of the nurse practitioner and physician in healthcare. Dr. Niran Al-Agba.
Niran Al-Agba MD 00:18
Hey, good evening.
Rebekah Bernard MD 00:19
And I'm also joined by a very special guest tonight, Shannon Keaney. She is a nurse practitioner and she's here to tell her story and her thoughts on nurse practitioners in the workforce. Shannon, welcome. And thank you so much for being with us.
Shannon Keaney NP 00:35
Thank you for having me.
Rebekah Bernard MD 00:37
So, Shannon, can you tell us a little bit about yourself and your background?
Shannon Keaney NP 00:42
Yes, I actually started out in the medical field, as a CNA worked in a nursing home became an LPN while I was in nursing school, worked for 10 years as a critical care nurse in the ICU, and just graduated this past May, from Georgetown University with my master's degree. And now I'm a family nurse practitioner.
Rebekah Bernard MD 01:08
So you attended what we call a lot of times a brick and mortar school. Can you explain what that is, and how that differs from some of the newer online programs that you're seeing?
Shannon Keaney NP 01:19
Yes, a brick-and-mortar school is an established university that you attend on campus, or they offer through their university that's established distance learning program. There is a difference between an online program and distance learning through the university itself. So I actually had to attend campus as well as perform online, you know, for is our classes, they were actually via zoom, where we spoke with our professors and interacted with our classmates for lectures, but we would also have to attend university on campus for exams and whatnot.
Rebekah Bernard MD 02:04
How long did it take you to get your nurse practitioner degree?
Shannon Keaney NP 02:08
Rebekah Bernard MD 02:10
And were you able to work at the same time?
Shannon Keaney NP 02:13
No, maybe at most two days a month.
Rebekah Bernard MD 02:18
Okay. So tell us a little bit about your concerns and what you're seeing and some of the experiences that you've had with students that have graduated from some of the online programs.
Shannon Keaney NP 02:29
I actually attended some clinical rotations, in which alarm bells went off. Some of these online programs are basically diploma mills, they are basically attending clinicals but they're not being supervised to make sure that they're attending by their university. They're not being followed closely
and their documentation - I've had physicians complain that they haven't even heard from the university - most brick and mortar schools require the physician or the precepting, NP, to submit a CV and do a background check first checking their status on the perspective boards, regulatory boards. And that's not happening. I've had students that I've been in rotations with that admit that they have open-book tests. And they're still failing the boards.
Rebekah Bernard MD 03:32
So what you're saying when you say open book tests, that means that they can basically look things up while they're having an examination. They don't have information memorized.
Shannon Keaney NP 03:42
Absolutely. And I was as an NP student, I was mortified because I know that my university held us to very high standards. It was mortifying for me as well, it's embarrassing when you hear a physician that you're in rotations with express concerns that the NP profession is going in this direction. And I also hear other mid-levels. I know here, we call them mid-levels. Some places refer to us as APPs. They're also basically I want to make sure I'm not saying this in a terrible way, my apologies. But it's being said that nurse practitioners can just go online and get a degree now.
Rebekah Bernard MD 04:30
And that's something that you ever imagined being the case, I'm sure when you started out your career.
Shannon Keaney NP 04:37
No, absolutely not. Because nursing school was quite rigorous. And just to think that being a provider, you can just go online and take, you know, online exams with open books. And we're supposed to be about patient safety. How can we do this?
Niran Al-Agba MD 05:00
Oh no. Did you know about these schools and these kinds of other, like less rigorous options for nurse practitioners before you were on rotation with other students? Or did you learn about it kind of while you were working in the field?
Shannon Keaney NP 05:15
I heard of some of the schools, I will not mention any names. And I absolutely refuse to even be associated with it. I
Niran Al-Agba MD 05:26
How about the students, Had you ever come across any of the other students from these schools?
Shannon Keaney NP 05:31
Yes. And I was actually before NP school, I had completed pre-med, I was looking to apply to medical school, I was getting ready to sit for my MCAT and I had turned 40. And I just decided, I didn't want to do it. Point blank. I didn't want to finish when I was close to 50 years old.
Rebekah Bernard MD 05:54
Well, that's understandable. I mean, it's such a long course. And it's so expensive as well. So you actually have expressed to me and to other people that you really feel much more comfortable as a nurse practitioner working closely with a physician and that you don't really think that nurse practitioners should be practicing autonomously. Can you talk a little bit more about your feelings on that?
Shannon Keaney NP 06:17
Yes, I cannot understand how the nurse practitioner community thinks that it's okay. At this juncture, when we have diploma mills, putting out nurse practitioners that are not going through these rigorous programs, that they are ready to step out and practice right out of school, even some of them haven't even been nurses for that long, and think it's okay to go and care for patients in a primary care setting, unsupervised. It's patient safety there, there's no way that I am ready for that. And I can't anticipate in five years, I would even be ready for that. I just don't see how patients gain anything from this.
Niran Al-Agba MD 07:14
I was just wondering, do you think your perspective is a little bit different? Because you've been an ICU nurse, a number of ICU nurses, which, which I consider really the top, you know, group as far as seeing some difficult cases. You know, when you've worked in an ICU, I think you see things that go wrong in primary care, you end up seeing either mistakes, or you see how severely sick patients can be. A lot of my own colleagues that are ICU nurses say very similar things that you're saying, Do you think that your background work? has maybe informed that opinion differently? Or what do you think it is?
Shannon Keaney NP 07:51
It has made me aware that human beings are complicated, and that there's an intense amount of education that you must receive to autonomously care for these patients, and even in primary care where you are the eyes and ears and is supposed to be focusing on prevention, you have to be able to catch things are wrong, and I am aware of what I don't know. I'm aware, I've been in that position where you're, you're like, oh my goodness, and I just cannot advocate for NPs to be autonomous. I can't.
Rebekah Bernard MD 08:30
you know, it's something that I think about every day, I've been practicing medicine for 18 years and went through medical education and residency, and I'm still a little bit scared every single day I still look things up every single day in up to date. So I can't imagine what it must feel like to be placed in a situation where you have to be in charge when you really don't have the background and the education and the experience. And it seems to me like a lot of corporations are putting nurse practitioners in this situation that they don't necessarily want to be in Have you observed anything like that.
Shannon Keaney NP 09:04
I have seen this happen in medicine, they are utilizing nurse practitioners more, and quite frankly, it's to save money. I mean, that's the direction it goes and it's like we're having sicker patients in hospitals can't fill the positions with RNs so we're gonna put less trained LPN and that's where I get into when, you know, nurse practitioners tend to get a little bit offended on this subject, and my opinion will not be popular amongst my peers. But when you have a registered nurse that has at least four years of university you know two years or even if you go to a community college it's gonna take you four years to even get an associate's degree because it's two years prerequisites, two years of nursing school. Compare that to an LPN that gets one year of training, there is a difference. I don't care if the LPN says I can do whatever an RN can do, the training is not the same, I received much more training as a registered nurse than as a licensed practical nurse, therefore, I worked in critical care areas. It's the same thing as nurse practitioners or PAs in comparison to physicians, you know, and it's,
It's not that I want us to feel that we're inadequate, it's a different level of training, it was never meant to replace the physician. It shouldn't be used as such. We were, in essence, physician extenders.
Rebekah Bernard MD 10:43
And that's not a very popular opinion to some in the field, and I want to applaud your bravery for speaking out because I know there are others that feel this way. But there's a lot of fear and anxiety of repercussions about speaking out, you know, what are your thoughts on that? And what is it that makes you so brave that you can say what you believe is the truth?
Shannon Keaney NP 11:05
Because I think nurse practitioners are worth more than what we are presenting ourselves as. We have value. We don't have to try to equal or supersede the education of the physician to have value, we were intelligent beings, we have so much to offer patients there, the nursing model is a great model, it truly is. But what we're doing, we're going in a bad direction. First of all, we're offending physicians, we're offending PAs, this is not good. We all need to work together to take care of these patients. I just can't stand for this.
And one of the concerns that I feel that nurse practitioner groups should be focused on is the fact that we're putting out mediocre nurse practitioners from these diploma mills because it's all about money at this point. And I know professors that want to speak out about this subject, they're appalled - What's going on? And quite frankly, I don't even know the full credentialing process. But whatever process it is, it's not working. It's not working. This is ridiculous.
Niran Al-Agba MD 12:25
What would you say if I asked you because everything you're saying is really? I mean, I completely agree with you. You know, I think there are practitioners who have a real value to the system. And I think there are so many things that that they can do that are such a credit to their education and to their abilities, because you're right, they're very smart. People, they get an education, they if they there's a certain scope that I think when they're trained to do it, or they're not. And I guess the question is, what would you ideally like to see if you were designing the system?
Shannon Keaney NP 12:59
Well, I would like to see the physician lead medicine the way it used to be. And I don't mean going backwards into the old hierarchy or system. I feel that that was pretty harsh. But the team approach and to have a team, you have to have a leader, you look at the law, okay, the leader is usually the judge, and then you have the lawyers, then you have paralegals, the paralegals don't lead. The same as in medicine, it goes by years of education, it's a given. And it's not that no one has anything to offer. That's not a physician, my goodness, we all do. But this is where it needs to be. It doesn't need to be an MBA leading either. Okay, and I'm going to add that there are other reasons why nurses are leaving in droves. Okay. They can't get nurses to stay at the bedside anymore, because they're going to grad school and furthering their education to get out of that role. And of course, it's its own headache.
Rebekah Bernard MD 14:05
Yeah, I think that's the thing that a lot of times, nurses don't realize that getting an NP isn't necessarily going to make their life that much better. Because believe me, physicians are burned out left and right, nurse practitioners are burned out left and right, the answer is for us all to be treated better, and for systemic changes to happen.
Shannon Keaney NP 14:23
Right. And I just feel physicians need to be at the helm of this. Their education has to count for something right?
Rebekah Bernard MD 14:34
Tell us your thoughts about the DNP degree. You mentioned that you talked to some of your professors at Georgetown about that.
Shannon Keaney NP 14:42
Yes, I did. And without mentioning any names, but and not just professors at Georgetown. I've actually spoken to numerous professors about this, some of these online DNPs are just - They're not at the standard of which someone should be graduating with a doctorate degree and calling themselves a doctor, first of all because that's a whole other subject. But yeah,
I will not be going for my DNP. I'm just not doing it. And there, there is a big push to do this. And I feel that this is to undermine, the PAs and physicians. The nursing community feels that there's a lot more power to be gained by having more doctorally prepared nurses. There are benefits to it. But ultimately, the push was for nurses to all have their bachelor's degrees, and all these nurses have gone into debt with no increase in their pay. Same for nurse practitioners, nurses push, get your doctorate, get your doctorate, I am already over $200,000 in debt for my student loans I'm not doing another, they're pushing degrees degrees degrees. If I do go back, it's going to be for my Ph.D., I want to do in-depth research. This is just nonexistent in some of these diploma middle schools.
Rebekah Bernard MD 16:14
So hopefully, by you getting going public, telling your story, and being a voice of some of the nurse practitioners who can speak out. Hopefully, this will help move change in the right direction, because I know there are many that agree with you. Do you feel that there's any way that you can get the message out to the leadership of nurse practitioners or what can be done to make positive change?
Shannon Keaney NP 16:39
it's really difficult to have a voice because they're going to take it personally. And I'm going to be ostracized for sure. But I think that nurses ultimately feel a lack of power. And this is where a lot of lateral violence comes into play. This is where what we're seeing right now is a profession that's buying to be heard and have power. They're just going about the right way. Ultimately, I have to consider what to do next. I know that I really can't watch my profession, keep on down this path. I'm embarrassed. You know, I meet physicians all the time. The first thing they asked me was, where did you go to school? And they have a list. I have one that I just met last week that has a list of schools that he will not hire an NP from, because they're online diploma mills, and they're known to be that. And ultimately, you know, we have to hold ourselves accountable for this. I know recently, one of the largest nurse practitioner associations was actually marketing one of these diploma mills schools. So I'm rather appalled by that. We're better than this. That's the message I want to send across. But you know, if you want to go and practice medicine because that's ultimately what we're doing in the state of North Carolina. They say I practice advanced practice nursing. But I'm also governed by the North Carolina Medical Board.
And what I'm doing ultimately, I'm practicing medicine on diagnosing and treating diseases. You can call it what you want advanced practice nursing. But regardless, you are responsible for the care of these patients. You cannot go to school and take an open-book test and think that you're going to put on a long white coat and care for these patients adequately.
Niran Al-Agba MD 19:01
Are you seeing harm from this in your own work? And I'm not asking you for details. I just mean are you seeing some of the negative impacts directly.
Shannon Keaney NP 19:11
I haven't seen too much negative impact yet because I haven't seen them practicing really yet. But I've been very worried about what I saw in some of my clinical rotations.
Rebekah Bernard MD 19:25
I think it's a good thing that in North Carolina, both the Board of Nursing and the Board of medicine are able to kind of keep an eye on nurse practitioners. That's not the case in most states in most states, just the Board of Nursing and you wonder how they're able to supervise so many different nurses and nurse practitioners. It seems like maybe other states should follow what North Carolina is doing.
Shannon Keaney NP 19:48
I would think so and the catch-22 with this too and this kind of goes on to physicians as well as in my state at a nurse practitioner or a PA can own a practice, you can own it, you have to have a supervising physician though. But the supervising physician may not be present, but four times a year. So I find that to be concerning that that is allowed as well. If we're going to supervise NPS, we need to look at it from that angle to the physicians that are making a rather nice income supervising some of these APP clinics are going to have to step it up as well and ultimately play a part and reviewing these charts and being a part of the clinic.
Rebekah Bernard MD 20:41
You're 100%, right. In fact, in our book, we call out physicians who are not properly supervising, and we call it treating nurse practitioners as their own personal cash cow in the book because there are physicians that are not doing the right thing when it comes to supervision. And that needs to stop. But we know from studies that when nurse practitioners, physician assistants, and physicians work closely together, and that usually means working on-site one on one as much as possible that patients get great care. But when you lose track of that model, and you no longer have direct supervision, instead you have this loose collaboration or nothing at all, then that's when patients can really get into danger.
Shannon Keaney NP 21:24
I'm not offended by having to be supervised, I would never put myself or the patients in that position. I have not had the training where I am ready to graduate from a two-year program with a terminal degree and no residency. To be alone, tere's just no way. I'll admit that and I'm an astute clinician. I was a critical care nurse for 10 years, I've given great care to patients. I don't find any shame in that is the level of my training.
And I received the training. I don't think that that belittles my cognitive abilities or anything. I'm not a minion. I don't just follow algorithms or anything like that. And NPs are great. It's just we have a limit of our training in such a short time.
Niran Al-Agba MD 22:20
We completely agree with you. Absolutely. What you're saying resonates I think with both of us.
Rebekah Bernard MD 22:26
Absolutely. And like I was saying there's not a day that goes by that I don't feel a little nervous, despite as much as I know. And I think you're right, it speaks to understanding yourself better. And just really knowing your limits. And that's unfortunately what someone who doesn't have is perhaps never seen something go wrong or seen someone get really, really sick, they have a certain level of hubris, that's really dangerous. And we don't see that as much in people who have real-life experience like you do. And other nurse practitioners and physicians who have had that chance to really see the worst-case scenarios, it gives you a lot more respect for treating with things that seem really minor, but actually could turn out to be a life-threatening situation.
Niran Al-Agba MD 23:10
Absolutely. Can I ask you why you went back to become a nurse practitioner? Like, what's something that you've really enjoyed and loved about working in that part of the field once you've been to school?
Shannon Keaney NP 23:23
Honestly, I would have a lot of physicians come up into the ICU, and they would say, oh, 'Dr. Shannon,' and I was always, I really I studied it, I spent an enormous amount of time my own free time learning and going to extra classes and trying to be at the very top of my practice. And I was limited as a nurse, and I really loved medicine. absolutely loved it. And I was like, Well, I'm going to go to med school, why not and did all my pre-med and I don't know, it just occurred to me that I was just too old to want to do this to actually go through with it. And I felt that being an NP was the closest thing I could get to be able to expand my horizons and practice medicine, per se.
Rebekah Bernard MD 24:18
We want to thank you for your, the work that you've put in your dedication to patient care and patient safety, and also your bravery and speaking out about really what is unfortunately a controversial subject. But it's so important that we talk about it. So thank you, Shannon, so much for joining us. I want to thank you my co-host Niran. And I will encourage all of you if you'd like to learn more about the changes in our healthcare system, please get our book. It's called patients at risk the rise of the nurse practitioner and physician assistant in health care available on Amazon and Barnes and noble.com. And if you're a physician and you'd like to learn more about proper supervision and about the physicians' role in making the system better. I encourage you to join physicians for patient protection, our website physicians for patient protection.org Thank you all so much