SSN on Facebook SSN on Twitter SSN on YouTube RSS Feed


Allowing APRNs to Practice Independently Better Serves Patients in Florida

April 3, 2019 - 3:30pm
Debra Diaz
Debra Diaz

I have been a certified registered nurse anesthetist, a type of advanced practice registered Nurse (APRN), for more than 20 years and am a retired Commander in the US Navy Nurse Corps, where I provided anesthesia care to service members and their families, U.S. Department of Defense employees, and members of Congress. While on active duty, I administered anesthesia care to service members who were injured during Operation Iraqi Freedom, Operation Enduring Freedom, and the Horn of Africa.  I have been the sole anesthesia provider on three aircraft carriers.

APRNs play an important role in Florida’s healthcare system. Whenever you have visited the hospital, a doctor’s office, or another healthcare facility, it’s likely you have interacted with an APRN -- and you might not have even realized it. 

Florida currently has more than 34,000 licensed APRNs who work in all types of practice settings. They provide essential primary care services and perform regional anesthesia, which includes peripheral nerve blocks, spinals, and epidurals. They also provide other anesthesia care, deliver babies, and much more. 

I recently had the privilege to stand with Sen. Jeff Brandes and Rep. Cary Pigman at the state capitol in Tallahassee to call for the passage of important legislation they have filed that would modernize Florida’s laws and allow APRNs to practice to the full extent of their education and training.

Senate Bill 972 and House Bill 821 would allow highly qualified APRNs to practice independently, without physician supervision and protocols.

Historically, our laws did not contemplate the sophisticated education and training APRNs receive today. Twenty-two other states, as well as the District of Columbia, have already removed barriers to allow APRNs to practice independently. It’s time for Florida to do the same. 

As Florida’s population continues to grow and healthcare costs continue to rise, we must look for innovative ways to modernize the healthcare delivery system in Florida.

With this legislation, we can increase access and allow APRNs to provide safe, cost-effective, quality healthcare to patients.

While we all agree the safety and wellbeing of patients is paramount, there are many independent studies which show APRNs can safely and effectively provide some of the same healthcare services as physicians. In fact, a recent report by the U.S. Departments of Health and Human Services, Labor and Treasury found that APRNs and other highly trained professionals “can safely and effectively provide some of the same healthcare services as physicians, in addition to providing complementary services.” The report went on to recommend that states “consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.”

Using APRNs would also prevent gaps in access to services in thousands of communities, especially in rural, inner-city and other medically underserved areas, while reducing the cost of health care and addressing increasing demand for health care services.

We urge the Florida Senate to take up this very important legislation. Patients’ interests are best served by a healthcare system in which many different types of qualified professionals are available, accessible and working together -- collaboratively. 

Debra Diaz is a CRNA, an adjunct professor at Barry University and a member of the American Association of Nurse Anesthetists board of directors.


The commentary here is frightening. I know many very knowledgeable NPs. They usually were senior nurses before becoming NPs. They all say that to pretend that there is some sort of knowledge equivalence is fraud. There is no knowledge equivalence because the training is different. This is an objective, demonstrable fact. Clinical judgement is where many here seem to be resting there cases, as a senior NP with many years in practice has likely memorized and repeated treatment algorithms (created by MDs) enough times to be safe in routine practice matters. The difference however is significant and to argue otherwise is fraud. The knowledge gap between a physician and an NP can be revealed within a 3 minute patient case discussion. It is obvious and apparent with most NPs. All physicians will tell you this. When I say knowledge, I mean deep knowledge about the etiology of illness and the mechanistic rationale for treatment. This may or may not be relevant because in clinical practice, physicians follow treatment algorithms also. The difference that matters is when a clinical case deviates from a well established treatment algorithm. This happens frequently. A lack of deep knowledge places the NP at risk of not recognizing this deviation from the treatment algorithm, resulting in delays in diagnosis and treatment. I have seen innumerable patients in ERs with medications and treatment regimens and histories that display this problems as clear as day. These "mistakes" while not life threatening in most cases, are the work of folks who hold algorithmic instead of deep knowledge. To attempt to equate the knowledge and skills of physicians and NPs is fraud. This is only an issue because a divide and conquer strategy on behalf of those who manage healthcare payment (e.g. insurance company lobbies, etc.). NPs deserve massive respect because they are playing an instrumental role in expanding access to healthcare, but this business about being equal is fraud.

Just go to medical school so you can play doctor short cut in life are for politician study more and be a doctor get your internship see how hard it is just to be in.

People don’t understand that the DOCTORS ARE NOWHERE TO BE FOUND!!!! The oversight is nonexistent; the only thing needed is a collab agreement. NPs are practicing independently in FL any way so they might as well pass the bill. Where’s the “oversight” in an NP working in Tampa but the collab doc lives in key west. People need to educate themselves before making comments on this subject matter

it all boils down to money. Physicians want to bankroll that medical director fee.

How is allowing a mid level with no advanced education, no residency (family and internal doctors have 3+ , psychiatrists 4+ in primary care) advanced florida to the next century as a commenter claims? Seems we are going backward. An ARNP almost killed my preceptor's father in a skilled nursing facility twice with her lack of knowledge. Almost sent him into a hypoglycemic death and gave him a medication that you never give to an elderly patient. If nurses want to be doctors, go to medical school. I was a nurse that went to medical school and now entering residency. If you want the standard of care, see a doctor

So im assuming there’s not a doctor in the US that has never made or mistake or killed a pt....I’ll wait....

Miss Rose, we should not accept the derogatory term, mid-level. Our education and the service we provide are not mid-level to any other education provided in the medical community. NPs are educated to the highest level required of an independent practice provider. We are not educated to provide care under MD direction, we are educated to provide care independent of a MD. Further, NPs are required to have thousands of clinical hours to support their understanding of patient care. We have been practicing since the 1940's and have better patient outcomes and higher patient satisfaction levels than our MD counterparts. It is unfortunate your preceptor had a horrible experience and there are those one in a million, who are, as a result, under litigation for their decisions. However, they are no more than MDs who practice. Many of us have decades of nursing practice prior to furthering our education to the MSN and DNP levels. Once we do proper data collection supporting outcomes due to the care NPs deliver and are able to look objectively at the outcomes, we are all better due to the support we provide our patients and the care they deserve. Further, there are areas of Florida physicians do not want to practice, let alone live. Independent practice provides care by NPs who are willing to be part of these communities and provide the much needed care in these areas.

Nps do not receive the level of training doctors do, often times online training and some hastily thrown together clinical work. I am a doctor and work with nps every day. not even close. if you want to be a captain go to captain school.

The knowledge level of an NP Vs a Doctor can make a world of difference. If I were to recount all the instances where the lack of knowledge of an NP could have killed a patient, I would be typing paragraphs. Seems like cost is more important than the life of the patient. If you want to play a doctor, go to a medical school.

I am an APRN. In my 25 years I have not made a mistake because I follow protocol. I have seen doctors negligent iand make mistakes because doctors do not follow protocols. They do what ever they damn well please to do, therefore putting patients in danger. Residents make mistakes and Doctors make mistakes!! The people complaining of APRN are ignorant of their education and their practice!

I totally support your thoughts! Very insightful and accurate

Using the term “mid level” shows that you are way behind the times .... probably just like everything else about you.

Just an Florida a “protocol” is just a piece of paper that the physician signs saying that an ARNP can do .... (whatever approved) like my MD, he is not at my practice, in fact he’s never set foot in my practice. If I need him I call him. I’m very quick to refer out because the fact is that if it’s something I’m not specialized in why not just send them to the specialist? So whether they change the law for NP or not the fact is that your NP may not really be overseen other than making phone calls to the MD if needed because Florida law doesn’t require a physician to sign off on our files like they do with a P.A.

Miss Mary, neither is my physician collaborator in my office. I have gone to visit with her on occasion as I respect her and her opinion as we should of any provider. She has never been in my office as you have stated in your office. I have 3 years of NP experience in my specialty: Wound Care. It is astounding the disrespect we receive from our MD counterparts, especially as a DNP and wanting to be referred to the proper degree as the university has awarded. I think the worst part is the horrible disrespect we receive by being called "mid-level" or physicians refusing to give us the consideration and respect we have earned due to the positive outcomes we deliver.

Nurse practitioners can work as primary care providers just like a primary care doctors with family practice or internal medicine residency. Experienced NPs are more qualified or equally qualified as them to work as primary care providers. PAs are not qualified like NPs, because (most of the) NPs have several years of experience as an RN. But I don't like NPs with no clinical experience. They are dangerous...!! Doctors (especially cheap family practitioners) don't like NPs because they can't steal from patients if NPs practice independently (secret truth).

YOU TELL 'EM SISTER ! ! ! You have A LOT of supporters "in your corner"! Keep up the "good fight"!

I think their practice of medicine should be limited to the extent of their training and licensure, nothing more, but also nothing less...

There is also something to be said about APRNs that are experienced over 25yrs. Many seem to have had the responsibility and experience of military service also. I’m interested to here from people who recognize an APRN with 25yrs clinical / military experience vs the medical intern (MD) just graduated an stepping out into the world. Training is different without question, the military recognize the APRN, PA and medics with our troops, so I think there is something to be said about “ independence “ of the experience, APRN and the PA.

That’s what we are fighting for. We are trained at a higher level then we are allowed to practice. We are restricted by each states rules. We can only practice what the state board of nursing allows which is the point if this bill.

From the banter back and forth on this issue, it seems clear there are hidden agendas in play here. I have been treated by ARNPs with no issues. Just like MDs/DOs who as general practitioners/family doctors refer patients to specialists (i.e ophthalmologists, orthopedics', neurologists, etc.) when needed care/treatment is beyond their capabilities, why the blowback against ARNPs? Is there somehow some innate inability on their part to recognize situations where consultation/referral to a more qualified medical practitioner is warranted? There is a real need for a variety of skill levels in the medical arts professions to render good sound medical care. Its time to disrupt the status quo and move medical capabilities into the 21st century reality

Most of the blowback comes from Doctors who have a chip on their shoulder or feel threatened.

The blowback comes from the lost revenuebthey charge for "collaboration". Its about money. Preach all they want otherwise. Its about money

Your are absolutely right on that!

There is a huge difference between Physician Assistants and APRN in both training and experience. APRN’s have to have extensive clinical backgrounds as RN’s before they become APRN’s. Would trust them as basic practitioners. PA’s have very ,mites backgrounds and training and should not be doing half of what they do. I have personally had scary incidents with several of them where they are supervised and still have made serious errors through belief they know more than they do. APRN’s are light years beyond them. BUT many Physicians insist you must see ARNP or PA as they are too busy, and that should NEVER happen.

The experience requirement is no longer true. In some cases a graduate bachelor RN can get into NP school. This is where a new problem lies. We must be knowledgeable and truthful in our writings and statements to remain legitimate

Kathy: Wow! There are no studies at all to back up your comments. They are at best misinformed and at worst........ Trying to get PAs who are excellent and NPs who are also excellent into a contest is just what is not needed. Please provide a link to the studies that show NPs are superior to PAs. Seriously.............

Seriously, a PA does not need a medical background, just a degree and be accepted into a PA program. I interacted with many of them and students applying to be PA's while getting some clinical hours to apply. My son was in the Bone Marrow Transplant Unit at Shands. The PA's were closely supervised and still made many mistakes that the Physician's had to correct., especially with medications. The students were acting as nurse aids, taking vitals and emptying bed pans. They got no clinical experience like and RN, especially in specialty units gets. 18 months of clinical training is not enough to "practice medicine." They are Physician ASSISTANTS for a reason. RN's that become ARNP's have a Bachelors Degree in Science and 5 years of clinical practice, generally in a specialty unit like ICU. They have a Masters Degree in their area of specialty. Saying PA's and ARNP's are equivalent is like saying that a nurses Aid and a Masters Degree nurse are both "nurses."

Kathy your retort is completely unfounded and You generalize too much. From the recent flooding of the NP population, most do NOT require experience to move onward. you must be counting the clinical rotations of RN training which is in no way comparable to the clinical training for an PA or NP. further more, there seems to be no standardization for NP training. Do you think the 30 years or working in an ICU is equal to a nurse working in Occ Med? Also the clinical hours could be essentially anything. For example, where i am from (both of my sisters are Fnps) they had to find their own rotations. One did adult within a hospital setting the other did outpatient primary care and vascular... interesting. Also their program did not teach how to interpret EKGs. maybe once the NP profession had standards, wonder what happened?

My point being, there are good and bad MDs, NPs, PAs. Your experience does not make a rule. Healthcare should be a team based approach for the betterment of the patient and that’s is it.

Umm NO! Nurse Practitioners are great, but I know I feel more comfortable knowing the Doctor is supervising. I’ve had two experiences with NPs, both of whom were know-it-alls. Plus the public has never been educated as to what their training involves. Neither NPs nor PAs. I have a dear doctor friend whose theory was “you want to be a doctor? go to medical school.”


Comments are now closed.



Live streaming of WBOB Talk Radio, a Sunshine State News Radio Partner.