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Letter to the Editor: Term ‘mid-level provider’ outdated, offensive :

May 24, 2016

An article titled “How to manage liability risks when supervising mid-level providers,” by James P. Scibilia, M.D., FAAP, a member of the AAP Committee on Medical Liability and Risk Management, was published in the February issue of AAP News, For an association courting a favorable relationship with the National Association of Pediatric Nurse Practitioners (NAPNAP) and its members, the article's language, tone and content were unfortunate.

The author repeatedly used the outdated and offensive “mid-level provider” terminology. This term incorrectly implies that pediatric-focused advanced registered practice nurses (APRNs), including pediatric nurse practitioners (PNPs), are not capable to provide pediatric care and require supervision.

“In fact, the standard of care for patients treated by an NP is the same as that provided by a physician or other healthcare provider, in the same type of setting,” according to a position statement from the American Association of Nurse Practitioners (AANP).

NAPNAP agrees with this statement and appeals to all health care stakeholders to refrain from using “mid-level provider” terminology.

Dr. Scibilia falsely claims that “In some states, the NP does not have an additional scope of practice beyond the usual registered nurse (RN) scope and must rely on standardized procedures for authorization to perform medical functions that overlap with those of physicians.” The truth is nurse practitioners in every state have a scope of practice that is expanded well beyond that of registered nurses.

Those with PNP certification graduate from a master's or clinical doctorate program from an accredited university. The PNP then must pass a national board certification exam focused on acute or primary care practice before being licensed as a pediatric-focused Advanced Practice Registered Nurse (APRN). Pediatric-focused APRNs are first educated, licensed and employed as RNs. Therefore, they have thousands of hours of professional practice caring for children.

The article notes, “Mid-levels care for less complex patients...” and “When delegating authority to provide care, pediatricians should determine the proper means of oversight.” Again this is misleading. In 21 states and the District of Columbia, nurse practitioners can practice independently per statute, and the number of states passing full practice authority legislation is increasing.

The article focused on physician risk when collaborating with nurse practitioners (and physician assistants). While it’s understandable that legal liability is of concern in our litigious society, the article insinuates that nurse practitioners are risky health care providers requiring physician oversight to protect pediatric patients. The data cited are incomplete and one-sided. According to Nurses Service Organization, one of the largest professional liability insurance companies for APRNs and RNs, in a five-year closed claims analysis, the average total incurred for malpractice closed claims for nurse practitioners was $290,935. That’s a far cry from $431,974 cited by the author. NAPNAP encourages all pediatric nurse practitioners to carry professional liability insurance.

Pediatric-focused APRNs are knowledgeable, trained and capable of providing high-quality care to patients and families. As the U.S. health care system turns to team-based and patient-centered care, inaccurate and paternalistic articles such as this perpetuate misinformation and outdated thinking. It’s time to realize that different providers have different — not inferior — skill sets.

-- NAPNAP President Cathy M. Haut, DNP, CPNP-AC, CPNP-PC, CCRN

AAP National Affiliate Member

To submit a letter to the editor email Anne Hegland at

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