As healthcare reform evolves, nurse practitioners (NP) will play key roles in improving health outcomes of diverse populations. According to the Institute of Medicine (IOM) 2011 report, The Future of Nursing: Leading Change Advancing Health, nurses should be change advocates by caring for populations within complex healthcare systems. The IOM reports asserts, “advanced practice registered nurses (APRNs) should be able to practice to the fullest extent of their education and training” (IOM, 2011, s8). However, existing barriers in the healthcare arena limit APRN practice. This article will discuss some of these barriers and provide suggestions for possible ways to decrease the barriers.
Key words: Nurse Practitioner, Nurse Practitioner Education, Nurse Practitioner Practice
In the 1970’s NP education moved from a certificate program to programs that offered bachelors or masters degrees. In 1965, to meet the demands of underserved populations, Loretta Ford and Henry Silver began the first certificate program that provided nurses with the skills to deliver primary care to children in community settings. In the 1970’s NP education moved from a certificate program to programs that offered bachelors or masters degrees. In addition, the population focus was not only pediatric and families, but also began to include adult/gerontology, women’s health, neonatal, and other specialty roles. These early nursing pioneers revolutionized advanced practice nursing. Present-day NPs assume various roles that include caring for ethnically diverse, underserved populations within an aging society and across many healthcare settings. The rapid growth of NPs since the initial certificate programs has been astounding and contemporary NPs have emerged as leaders in healthcare (Sullivan-Marx, McGivern, Fairman, & Greenberg, 2010). Despite many positive expansions to the NP role, there continues to be many barriers requiring attention of national and state leaders in order to achieve the Triple Aim of healthcare... The NP role in the 21st century looks much different than it did in 1965.
Today, NP practice is impacted by four significant policy and regulation initiatives 1) the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (APRN Joint Dialogue Group, 2008); 2) the Doctor of Nursing Practice movement; 3) the IOM report (2011); and 4) the Patient Protection and Affordable Care Act (PPACA). Despite many positive expansions to the NP role, there continues to be many barriers requiring attention of national and state leaders in order to achieve the Triple Aim of healthcare: 1) better care; 2) better health; and 3) lower healthcare cost (Berwick, Nolan, & Whittington, 2008). The next part of this paper will discuss some of the barriers to NP practice.
State Practice and Licensure
NP practice is regulated by state licensure...only about one-third of the nation has adopted full practice authority licensure and practice laws for NPs. State licensure regulates NP practice and is a barrier to NPs practicing to the fullest extent of their education and training. Licensure and practice laws for NPs vary per state, despite a main goal of full practice authority. What does this mean? Full practice authority is “the collection of state practices and licensure laws that allow for NPs to evaluate patients, diagnose, order, and interpret diagnostic tests, initiate and manage treatments-including prescribing medications-under the exclusive licensure authority of the state board of nursing” (American Association of Nurse Practitioner (AANP), 2014, p.1).
The problem is only about one-third of the nation has adopted full practice authority licensure and practice laws for NPs. The remainder of NPs in the U.S either have: 1) reduced practice and licensure which means the NP has the ability to engage in at least one element of the NP practice and is regulated through a collaborative agreement with an outside health discipline in order to provide patient care; or 2) restricted practice and licensure which means that NP has the ability to engage in at least one element of NP practice and requires supervision, delegation, or team-management by an outside health discipline in order to provide patient care (AANP, 2013).
IOM report has recognized that overly restrictive scope-of-practice regulations of NPs in some states as one of the most serious barriers to accessible care. Full practice authority is also referred to autonomous practice or independent practice. Under full practice authority, NPs are required by their licensing state to meet educational and practice requirements for licensure, maintain national certification, consult and refer to other healthcare providers per patient/family needs, and be accountable to the public and state board of nursing for meeting the standards of care in practice and professional conduct (AANP, 2014). The IOM report (2011) has recognized that overly restrictive scope-of-practice regulations of NPs in some states as one of the most serious barriers to accessible care. NPs with the same educational preparation and national certification may face a compendium of restrictions when relocating from one state to another, thus limiting their scope of practice (Safriet, 2011). Variation of scope-of-practice across states has an indirect impact on patient care because the degree of physician supervision may affect practice opportunities and payer polices for NPs (Yee, Boukus, Cross & Samuel, 2013).
Physician Related Issues
Some physician professional organizations, including the American Medical Association, believe that because physicians have longer and more rigorous training than NPs, nurse practitioners are incapable of providing quality, safe care at the same level as physicians (American Medical Association (AMA), 2010; Fairman, Rowe, Hassmiller, & Shalala, 2011). However, other physicians recognize that the education and training is not the same as their own, yet continue to value nurse practitioners. In 2009, the American College of Physicians published a position paper identifying the important role NPs play in meeting the growing demand for primary care (American Colleges of Physicians, 2009). This may contribute to the confusion among many physicians regarding the role of nurse practitioners.
At a time when healthcare reform is rapidly evolving, it is critical that NPs and physicians collaborate to achieve best practices. In preparation for this article, local nurse practitioners were queried about what they see as physician related barriers. One common thread was lack of physician and other healthcare professionals’ knowledge of NPs scope-of-practice (Hain, Personal Communication, February 15, 2014). At a time when healthcare reform is rapidly evolving, it is critical that NPs and physicians collaborate to achieve best practices. Although, physicians and NPs possess a similar goal of improving patient outcomes, barriers to successful collaboration exist. Lack of knowledge of NPs scope-of-practice has been identified as a barrier to successful collaboration (Clarin, 2007; Phillips, Harper, Wakefield, Green, & Fryer, 2002). The traditional medical hierarchal model of practice contributes to ineffective teamwork. This model promotes physician dominance over the healthcare team. As the shortage of primary care providers looms in the distance and healthcare providers struggle to care for an aging population, this type of medical model will no longer suffice. It is critical to establish collaborative models of care that embrace the gifts of all members of the healthcare team (IOM, 2011). Accomplishing this may be difficult if some physicians believe that nurse practitioners lack competence to provide quality care. This belief can be one of the major obstacles to independent NP practice (Clarin, 2007).
In Florida, nurse practitioners have struggled for years to move from restrictive practice and licensure to full practice authority but have consistently been met with opposition from some medical organizations. Recently, a “fact sheet” was sent to members of the Florida Medical Association opposing the current Independent Advanced Practice Registered Nurse bill. The reasons cited were: 1) major differences in educational preparation between NPs and physicians; 2) concerns regarding NPs ability to safely prescribe controlled substances and narcotics; 3) shortage of physicians (should support initiatives to increase the number of physicians in the state); 4) shortage of nurses (NPs will affect the future nursing workforce); and 5) inability to control healthcare costs (expansion of role may lead to NP reimbursement same as physicians); and 6) lack of physician oversight (concerned about the danger of less qualified RNs practicing without supervision (FMA Fact Sheet, 2014). Heated debates regarding these topics have brought the scope-of-practice issue to the forefront with some legislators supporting the expanded role of NPs and others standing strong with physician organizations who oppose broadening the scope-of-practice for NPs.
A recent study (Donelan, DesRoches, Dittus, & Buerhaus, 2013) suggests that, despite a shortage of primary care providers, primary care physicians are not likely to support expansion of the roles and supply of nurse practitioners. The findings from this study indicate that the majority of physicians in the sample (70% of the 505 physician respondents) agreed that nurse practitioners should practice to the “fullest extent of their education and training.” Nonetheless, many physicians didn’t agree with NPs leading medical homes or receiving equal pay for providing similar service as them. On the other hand, NPs felt they were capable of leading medical homes and there should be equity in compensation for services. In addition, physicians thought they provided better quality care to patients then NPs which was incongruent with the beliefs of the NPs in this study and similar studies exploring this concept.
A Cochrane review of substitution of doctors by nurses in primary care settings indicated that similar to physicians, nurse practitioners provided high quality care that leads to improved health outcomes (Laurant et. al, 2004). Patient satisfaction was higher with nurse-led care; however, this didn’t mean that patients preferred NPs to doctors. In fact, there were mixed results with some patients preferring nurses and others preferring physicians. The findings of this review should be viewed carefully because there were several methodological limitations across the various studies. Regardless if care is delivered by an NP or a physician, the goal should be to meet the Triple Aim of healthcare. However, payer polices related to NP practice may present challenges in meeting these goals.
Restrictive scope-of-practice may lead to stricter payer policies limiting NPs ability to practice independently. Many NPs report that payer polices have a significant impact on their ability to practice to the fullest extent of their licensure and training (Yee, Boukus, Cross, & Samuel 2011). Payer policies are often linked to state practice regulations and licensure. Restrictive scope-of-practice may lead to stricter payer policies limiting NPs ability to practice independently. They are essentially forced to be in practice as employees of physician practice, hospitals or other entities (Yee et al., 2013). Commercial health plan payment policies may vary and often don't recognize NPs as primary care providers. In addition, these payers may be resistant to credentialing or directly paying NPs for services they provide. In some practices, NPs have to bill ‘incident-to’ a physician's services which means the billing for care delivery is under the physician's name. The Centers for Medicare & Medicaid Services (CMS) state that billing incident-to require that the physician establishes the initial plan of care and the nurse practitioner performs follow up care with the physician on site. Once again this type of practice may limit practice sites to only those associated with physicians. Even in states where NPs have full practice authority, some public and private payers impede NPs from practicing independent of a physician by not paying directly or reimbursing at a lower rate (Yee et al., 2013).
State insurance mandates are important to NP practice because they affect nurse practitioners’ ability to independently practice and bill for services. State insurance mandates are important to NP practice because they affect nurse practitioners’ ability to independently practice and bill for services. Health insurance mandate “is a command from a governing body, such as a state legislature, to the insurance industry or health plans to include coverage of a particular healthcare provider, benefit and/or patient population” (Bunce, 2013, p. 3). This mandate legislation varies from bill to bill and from state to state and can substantially increase the cost of health insurance. The problem is some states have not set mandates for specific reimbursement for nurse practitioners as primary care providers.
For decades nurses have “been ‘revenue invisible,’... which may promote the belief that nurses are not ‘revenue generators.’ For decades nurses have “been ‘revenue invisible,’ meaning that nursing services are not separated from the institutional room fee or other professional fees on the billing statements,” which may promote the belief that nurses are not ‘revenue generators.’ This may contribute to the underrepresentation in or exclusion from the decision-making processes that determine the metrics upon which costs, value, pricing, and payment are based” (Safriet, 2011, pg. H-2). Nurse practitioners historically receive lower wages and reimbursement fees as compared to their physician counterparts. These lower payments make it difficult for NP’s to financially sustain a primary care practice (Chapman, Wides, & Spetz, 2010).
Nurse practitioners hold prescriptive privileges in 50 states with the ability to prescribe controlled substances in 49, which has allowed NPs to prescribe medications for patients in need. Despite having prescriptive privileges, barriers may exist preventing NPs from following their patients when they are admitted to acute care facilities which ultimately may impact patient outcomes. Continuity of care is an important aspect of providing the best care for patients. At a time when care coordination has drawn national attention, obtaining admitting privileges to a hospital poses a significant obstacle to continuity of care (Brassard & Smolenski, 2011). The reasons for not allowing NPs to have admitting privileges is unclear; however, recognizing the potential contribution of NPs, some hospital organizations are hiring nurse practitioners to increase physician productivity, improve continuity of care, and improve patient safety and quality (Brassard & Smolenski, 2011).
Another barrier to NP practice is job satisfaction and intent to leave. As the demand for more primary care providers increases, NPs can be expected to have an active role in meeting primary care needs. The impact of experienced NPs leaving their job can have a negative effect on meeting the goals of the Triple Aim. The authors of a recent study (De Milt, Fitzpatrick, & McNulty, 2011) reported that NPs (n = 254) who attended a national nurse practitioner conference were more satisfied with their job if they had “intrapractice partnership and collegiality” (p.47) and that benefits didn't play a significant role in job satisfaction. Those with the intention to leave their current position had lower job satisfaction scores as compared to who didn't have plans to seek new employment. The most common reasons for planning to leave current positions were having little control over practice and limited career advancement opportunities. Even though there are study limitations, this research provides further evidence of the importance of NP independent, collaborative practice.
The continued dialogue about whether nurse practitioners are prepared to provide quality, cost effective healthcare reduces the ability to have meaningful conversations about strategies to address the growing need for primary care providers and decrease healthcare disparities. State legislative reforms continue to focus on NPs issues such as state scope-of-practice and payer polices. National nursing organization such as the American Nurses Association (ANA) and the American Association of Nurse Practitioners (AANP) are leading advocates for allowing NPs to practice to the fullest extent of their education and training. In addition there are many state and local NP organizations that continue to struggle to move legislative initiatives forward.
The level of physician supervision appears to have the greatest impact on NPs ability to practice the fullest extent of their education and training (Devi, 2011). Despite physician organizations opposition, certain consumer groups like AARP (2013) have shown support for the independent NP practice. The ‘call to action” is loud and clear; nursing organizations are not able to move policy and legislative initiatives forward without the financial support of its members. Becoming an active member of nursing organizations at the national, state, and local levels is a major way to address the barriers to NP practice.
Eliminating variances in state licensure and scope-of-practice and removing barriers to independent practice are necessary elements of providing superior primary care. The Consensus Model for APRN Regulation (APRN Joint Dialogue Group Report, 2008) recommends having a single-advanced practice RN license, allowing independent practice with no regulatory mandates for physician supervision or collaborative agreement (a formal agreement that is submitted to state boards of nursing). Standardizing APRN regulation may promote nationwide consistency and quality of NP educational programs so that there is uniformity among the graduates (Round, Zych, & Mallary, 2012). NPs have demonstrated the ability to provide quality, cost effective care, therefore are deserving of equitable pay for services rendered. In alignment with the concept of quality care, NPs should be held accountable for contributions to “high-value primary care” by including performance measures of NPs who are independently practicing or in a collaborative practice in the Agency for Healthcare Research and Quality Health Care Quality Report Card (Naylor & Kurtzman, 2010, p. 897).
An essential step to advancing the role of NPs is to rethink how to deliver quality, efficient primary care in an environment with a projected workforce shortage. Newhouse et al. (2012) suggest having an integrated workforce in which NPs establish relationships with primary care and specialty physicians. Primary care providers could refer to NPs with the expertise in chronic disease management. In accordance with the IOM (2011) report, NPs should take an active role as a member and/or leader of interprofessional teams. In this dynamic healthcare environment, NPs should take an outcome driven approach to care, by showing that innovative NP models of care may lead to improved health outcomes of populations.
Collaboration between physicians and NPs is a fundamental part of healthcare transformation. Paying attention to gaps in quality may provide a focused direction for areas needing improvement. The implementation of the Doctor of Nursing Practice (DNP) degree has allowed opportunity for nursing inquiry and quality improvement. These areas include but are not limited to: 1) practice management, 2) health policy, 3) use of informatics, 3) risk management, 4) evaluation of evidence, 5) advanced diagnosis and management of disease process (Apold, 2008). It is anticipated that DNPs will make substantial contributions to healthcare redesign. Healthcare redesign must include payer policy reform. Restructuring should support interprofesional teams and promote independent NP practice (Newhouse et al., 2012). Collaboration between physicians and NPs is a fundamental part of healthcare transformation.
Collaboration between physicians and NPs as members of interprofesional teams is an important aspect of achieving the Triple Aim of healthcare. As NPs strive for independent practice, collaboration can be used as a tool to educate physicians about the role of NPs and help strengthen relationships to achieve best practice (Maylone, Ranieri, Griffin, McNulty, & Fitzpatrick, 2009). Collegiality, respect, and patient-centered care are principle attributes of physician-NP collaboration (Crecelius et al., 2011). Taking an intellectual approach instead of allowing one’s emotions to take control when confronted by conflicts with physicians is congruent with the concepts of interprofesional collaboration (Gegaris, 2007). One way to increase knowledge and understanding of NP roles is through interprofessional education.
Advanced Practice Education
Future of Advance Practice Nursing Education
In 2008, The Robert Wood Johnson Foundation (RWJ) and the IOM (2011) began a 2 year initiative to respond to the need to assess and transform the nursing profession to meet the needs of the very drastically changing healthcare environment (IOM, 2011). The IOM report reveals and recommends an urgent need for highly educated advanced practice nurses. Guided by the Consensus Model for APRN Regulation (Joint Dialogue Group Report, 2008), the Master’s and DNP Essentials of Advanced Practice Nursing (American Association of Colleges of Nursing (2011; 2006) and National Organization of Nurse Practitioner Faculty (NONPF), nurse practitioner educational programs are required to provide the necessary skills (competencies) for NPs to meet future population healthcare needs.
Since the initial release of core competencies in 1990, NONPF has published updated and revised core competencies to guide NP educational programs. In response to a need for further guidance for NP programs, NONPF and the American Association of Colleges of Nursing collaborated to facilitate the development of population-specific competencies; the first competencies were completed in 2002 (NONPF, 2013). In 2008, The Consensus Model for APRN Regulation stipulated that APRN must complete a minimum of three core competencies which are: 1) advanced physiology/pathophysiology; 2) advanced health assessment; and 3) advanced pharmacology. The Consensus Model for APRN Regulation made changes to the population foci for NP educational tracks, most notably the adult and gerontology foci were merged and are either primary care or acute; pediatric foci as both primary or acute care, and psychiatric-mental health across the lifespan (APRN Joint Dialogue Group Report, 2008) . A task force of representatives from various organizations convened to develop competencies related to these changes. In addition, NONPF endorsed the “transition of NP education to the doctoral level and an integration of previous Master’s level core competencies with the practice doctorate NP competencies” (NONPF, 2013, p. 7). Leadership, health policy roles, business, economics, evidence-based practice, interprofessional team approach to patient-centered care are among the other required NP skills (Aleshire & Wheeler, 2012). Many schools and colleges of nursing, in the midst of faculty shortages, are struggling to address the demands of a dynamic U.S. healthcare system by assuring that nurses are prepared to be essential members of the healthcare team.
The IOM and Patient Protection and Affordable Care Act have identified the need to increase primary care providers in the redesign of the healthcare system. The IOM (2011) and Patient Protection and Affordable Care Act have identified the need to increase primary care providers in the redesign of the healthcare system. Through formal education and training NPs are uniquely positioned to fulfill primary care needs. Many educators are working to create new models to prepare NPs for practice. NONPF (2013) is committed to enhancing the level of NP and DNP competency–based education. Competency-based model of care is a way to demonstrate that NPs are skilled to meet contemporary healthcare challenges (Sroczynski & Dunphy, 2012). To achieve the best outcomes it is critical that all professionals have knowledge and competence to engage in collaborative, non-hierarchal team approach (Golden & Miller, 2013).
Interprofessional education (IPE) is deï¬ned as “an intervention where the members of more than one health or social care profession, or both, learn interactively together, for the explicit purpose of improving interprofessional collaboration or the health/well-being of patients/clients, or both” (Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013, p. 2). A systematic review indicated that IPE interventions compared to no education had positive outcomes such as improved patient satisfaction, health outcomes of people with specific chronic diseases, and reduction in medical errors. These promising findings should be carefully considered because many of the studies were small and lack generalizability. There is a need for more research exploring the benefits of IPE on clinical outcomes and the effect on collaboration between NPs and physicians.
Through IPE nurse practitioner students can help others recognize the importance of Care vs. Cure. This metaphor has been used by Barbara Safriet, J.D. who has represented NPs in legislative testimony regarding the many regulatory obstacles and restrictions that impede the full realization of NPs practicing to the fullest extent of education and training (2013). The paradigm shift from focusing on treating disease to one of health promotion is not new to nurses. NP students are uniquely positioned to demonstrate this to other members of the educational team.
Expanded healthcare coverage mandated by the Affordable Care Act (ACA) will impact healthcare providers, policymakers, and payers as the demand for services escalates. Healthcare professionals will be challenged to meet needs of an aging and diverse population within an emerging primary care workforce shortage. Through education and training, NPs are prepared to serve in roles of primary care providers with the potential to make a substantial impact to improve clinical outcomes. The role of nurse practitioners is defined by their scope-of-practice and ultimately their employment agreement which is often disregarding the extent of their education and training. These along with other barriers discussed in this paper limit the contribution NPs can to achieve the Triple Aim of healthcare: 1) better care; 2) better health; and 3) lower healthcare cost. Addressing the barriers to practice demands attention from NPs, nursing professional organizations, educators, policymakers, and payers.
Debra Hain, PhD, ARNP, ANP-BC, GNP-BC
Dr. Hain is a board certified adult/gerontological nurse practice with 29 years of nursing experience, working in various areas of nursing, mostly in nephrology. She is an Assistant Professor at Florida Atlantic University (FAU), Christine E Lynn College of Nursing in Boca Raton, FL, and works part-time as a nurse practitioner at Cleveland Clinic Florida, Department of Nephrology and at Louis and Anne Green Memory and Wellness Center a nurse-managed center at FAU. Her scholarship focuses on improving health outcomes of older adults with chronic kidney disease and/or cognitive impairment.
Laureen M. Fleck, PhD, FNP-BC, CDE, FAANP
Dr. Laureen Fleck is a Family Nurse Practitioner from Boca Raton, Florida. She is the owner of a family practice serving over 7,000 patients including children, adults and geriatric patients. She serves as a clinical preceptor for nurse practitioner students and is associate graduate faculty in both the Nurse Practitioner program and DNP/PhD programs at Florida Atlantic University in Boca Raton, FL. Her areas of special interest include obesity, metabolic syndrome, insulin resistance and diabetes.
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© 2014 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2014
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