Avoiding Liability Bulletin – July 2023

Doctoral-prepared nurses are on the rise. From 2014-2018, for example, the numbers almost doubled, from 3,065 to 6,090. 

Nurse practitioners have sought doctoral degrees in nursing as well.  Whether a nurse practitioner or not, using the title “Dr.” in one’s NP practice has been controversial at best.

Although the American Association of Nurse Practitioners (AANP) does not have an “official” position on whether to use the title or not, in its Discussion Paper: Doctor of Nursing Practice, it states:

“The transition to the new title must be handled smoothly and seamlessly to avoid negative impact on NP practice and sound patient care and to maintain parity.”

In the following 2022 case against a nurse practitioner with a Doctor of Nursing Practice (DNP) degree, the “transition” with the new title did not go smoothly or seamlessly.

Brief Facts

Sarah Erny was properly licensed as an RN and NP under the nurse practice act in her home state of California.

Sarah established “Holistic Women’s Healing” wherein health care services and medications were offered to patients in a physical office and on-line.  In addition, she had several social media accounts.

In all of these sites, she used her name as: “Dr. Sarah”, or “Dr. Sara Erny”.

Sarah’s “supervising and collaborating” physician was an obstetrician-gynecologist.

District Attorney Files Complaint against Sarah

The District Attorney (DA) files a complaint on behalf of the people of the State of California seeking “Injunction, Civil Penalties, and Other Equitable Relief.”

Specifically, the DA alleged that Sarah:

  • Failed to obtain and file a fictitious business certificate for her business, “Holistic Women’s Healing” as required by the California Business and Professions Code
  • Holding herself out as “Dr. Sarah Erny” in violation of the California Business and Professions Code and California Code of Regulations
  • Engaged in “unlawful, unfair, and fraudulent acts, omissions, and practices” that constitute “unfair competition” within California’s Business and Professions Code, including the use of “Dr. Sarah Erny” on her social media platforms which unfairly elevated her position among other NPs who properly identified themselves as an NP on those platforms and which misled the public to believe she was a medical doctor
  • Violated the False Advertising section of the California Business and Professions Code by knowingly advertising her business or” which by the use exercise of reasonable care should be understood, to be untrue or misleading.”

Order of the California Trial Court

In a stipulated (agreed), final Order, the California trial court held that the plaintiff (People of the State of California) was entitled to a judgment against Sarah Erny and ruled:

  • Sarah was “now and permanently enjoined and restrained ”.. from doing directly or indirectly, by any manner or means whatsoever” referring herself as a doctor, using the letters or prefix “Dr.”, the initials “M.D.” “or any other term or letters indicating or implying that she is a physician or surgeon” when advertising or providing medical treatment to the public
  • For five (5) years from the entry of the Order, Sarah must conduct electronic searches of “Sarah Erny” to determine if any advertising or listings exist with her name and the title “Doctor” or “Dr.” and make “diligent efforts” to remove the references on a monthly basis the first year and at least twice a year afterward.
  • Promptly prohibit any supervising physician or staff from referring to her as “doctor” in any and all settings of providing medical services to the public
  • Promptly correct any patient who refers to her as “doctor” when providing medical services or medicine to patients and advising said patients that she is a registered nurse or a nurse practitioner
  • Pay a civil penalty of $19,750.00, $16,000 allocated to the Consumer Protection Trust Fund Account and $3,750 allocated to the District Attorney’s Office

In addition, nothing in the final judgment limits, alters or otherwise affects the “rights, procedures, and protections” afforded to Sarah under the California Business and Professional Code.  And, a minor violation that is cured by Sarah is not to be considered a violation of this Final Judgment.

Discussion of How This Case Decision Affects Your NP Practice

Sarah was not prepared for the results of her entry into her own NP business.  For whatever reason(s), she did not seek, or follow, advice that would have avoided the outcome she experienced.

If you are thinking of establishing your own NP nursing practice, there are  sources you need to consult with. 

One consultation needed is with a nurse attorney or attorney who works with health care providers establishing their own business. The attorney you select will share with you the following:

  • The need to register an assumed name (such as “Holistic Women’s Healing”) with the appropriate state agency if you use one
  • Other obligations and limitations under your state business and professions code (or similar name)
  • If hiring employees, requirements under state workers’ compensation laws, unemployment insurance, and applicable labor laws

A second consultation needed is with a nurse attorney or attorney who represents nurses in professional licensure proceedings in order to determine what your state nurse practice act says in terms of your NP practice. 

One important aspect of this consultation will be how you can utilize your educational degrees in relation to your NP practice, your business, and in advertising.  Title protection in the act will determine how you can advertise yourself.

Most likely, utilizing the designation “Dr.” will not be allowed in any clinical setting, for this term is reserved in state medical practice acts only to be used by an individual who has a license as a physician or surgeon.   Rather, “NP”, “APRN”, “RN, NP”, and “APRN-CNP” can be used if approved in your nurse practice act.

This does not mean you cannot let the public know you have a Doctor of Nursing Degree on your website, your letterhead, or on your business cards.  An example of an acceptable designation could be:

                Mary Smith, DNP, APRN-CNP

Moreover, correcting patients and staff if they refer to you as “Dr.” in your NP practice would also be essential. Give them your correct title—nurse practitioner.

Know, too, that if you violate your obligations in relation to the correct use of your credentials, civil fines may be assessed against you, as occurred in this case.

If you find yourself in a situation like Sarah’s, be certain to retain a nurse attorney or attorney to represent you in the judicial proceedings.  Because the allegations are based on your NP practice, the first call should be to your professional liability insurance carrier to determine if your policy covers similar allegations.

You may have very strong feelings about the limitations placed on you as an NP with an earned Doctor of Nursing degree.  Those feelings are valid.  However, until the controversy over the use of “Dr.” is settled, placing yourself in a situation where recourse is sought by your state in a judicial proceeding against you is unwise.

The best use of your time at this juncture is to education your patients and the public about advanced nursing practice generally and how you can provide quality nursing care to them.

Also important is the need to advocate for change at the legislative level surrounding the current title designations in both your state nurse practice  and medical practice act.

This information is for educational purposes only and is not to be taken as specific legal or other advice by the reader.  If legal or other advice is needed, the reader is encouraged to seek such information from a nurse attorney, attorney or other professional.

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About the Author

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Nancy Brent

NANCY J. BRENT, MS, JD, RN, received her Juris Doctor Degree from Loyola University Chicago School of Law. Ms. Brent has been in practice for over 40 years and concentrates her solo law practice in education and consultation for nurses, nursing organizations, and health care delivery systems. She also defends nurses before the Illinois Department of Financial and Professional Regulation. Ms. Brent has published and lectured extensively in the area of law and nursing practice.