NR 510 Week 1: Barriers to Practice Discussion

NR 510 Week 1: Barriers to Practice Discussion

NR 510 Week 1: Barriers to Practice Discussion 

Advanced practice registered nurses’ roles include nurse midwife, nurse anesthetist, nurse practitioner, and clinical nurse specialist. The main practice barriers for these role in Florida include scope of practice since they have reduced practice environment, portability of their license, and need for supervision. The lack of full practice authority for nurse practitioners in Florida and even across several states at the national level is a core practice barrier (Fealy et al., 2018). Further, clinical nurse specialists in Florida and even across the country face prescriptive barriers that hinders their ability to practice to full authority and training.

Nurse practitioners have been practicing in various healthcare settings in states but face varying scope of practice laws across the states. The implication is that APNs have varying levels of practice from one state to another implying that the various creates a competitive pressure in states that allow them to practice to full authority (O’Reilly-Jacob et al., 2022). As such, they compete with physicians, nurse assistants, and nurse practitioners who enjoy changing levels of autonomy in practice. APNs are considered as quality, cost-effective and competent providers who can fill the physician shortage gap in care provision (Schirle et al., 2018).

Key lawmakers at the state level, Florida, include Ben Albritton who is the majority leader in the Senate, Lauren Book who is the minority leader and a Democrat, and Kathleen Passidomo who of the president of the Senate (The Florida Senate, 2023).

Interest groups on state and national level impact policy reform for APNs. These include professional nursing organizations like the Florida Nurse Practitioners Association at state level. The American Association of Nurse Practitioners (AANP) is a professional interest group at the national level that advocates issues concerning the NP specialty. Influencing policy change in terms of competition, state legislative and executive branches of government as well as interest groups entail using a raft of approaches that include lobbying, provision of education and training for nurses, and regulations (Schirle et al., 2018). These approaches ensure that nurses understand the legislative approach to providing patient care.

References

Fealy, G. M., Casey, M., O’Leary, D. F., McNamara, M. S., O’Brien, D., O’Connor, L., … &

Stokes, D. (2018). Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers. Journal of Clinical Nursing, 27(19-20), 3797-3809. https://doi.org/10.1111/jocn.14550

O’Reilly-Jacob, M., Perloff, J., Sherafat-Kazemzadeh, R., & Flanagan, J. (2022). Nurse

practitioners’ perception of temporary full practice authority during a COVID-19 surge: A qualitative study. International journal of nursing studies, 126, 104141. https://doi.org/10.1016/j.ijnurstu.2021.104141

Schirle, L., Norful, A. A., Rudner, N. & Poghosyan, L. (2018). Organizational facilitators and

            Barriers to optimal APRN practice: An integrative review. Health Care Management

            Review, 45(4): 1-10. DOI: 10.1097/HMR.0000000000000229

The Florida Senate (2023). 2022-2024 Senators. https://www.flsenate.gov/Senators

Much of this week’s reading by Authors DeNisco & Barker (2015) focused on your very question! Since the inception of the advanced nurse practitioner in the 1960’s universities, institutions and organizations have been advocating for the expansion of role development, increased competencies in clinical knowledge, leadership and administrative roles.  As the author’s note, NP’s make up one of the largest groups of advanced nurses, but are still facing barriers almost sixty years later.  According to the Institute of Medicine, a major goal of was to increase the amount of and capacities of NP’s to meet the needs of people who not have access to healthcare (Institute of Medicine,  2010). Given the initial goals of what an NP is and our current medical needs in our society (especially since the passing of the Affordable Care Act), I do not believe the entry level for practice should be at the DNP level. I feel increasing the credentials of the specialty will create additional barriers. First off, the development of the DNP was to clear up confusion that had arisen from nurses who held PhD in education and other nursing sciences that hold the title Dr. with a focus on research. DNP was created to have more clinical practice with a higher level of education which require an additional 500 to 600 clinical hours and align with more recommendations from the Institute of Medicine (DeNIsco & Barker, 2017).

While, I always commended and advocate for higher level of nursing, I do not DNP should be the minimum required entry until the present barriers that exist be resolved. First, not all NP’s have equal licensing privileges across the county and vary within the States. For example, in Vermont NP’s have full practice authority, whereas Florida NP’s must practice under the supervision of a MD. The barrier to various license capability means inability for some to seek appropriate care. Second, not all professional organizations acknowledge the capabilities of NP’s practice and professionalism. It is asserted by Hain & Fleck, (2014) that the American Medical Association for Physicians NP’s do not have the same level of training and knowledge, thereby fueling a sourced of incapable opinions. Third, a States policy of practicing rights of an NP affects how they are reimbursed financially. As a result, many insurance companies do not acknowledge NP’s as the primary provider but as providers who provide follow up services after the MD’s. Companies reimburse accordingly on a lower scale for follow up services (Hain & Fleck, 2014). On a final note, I do not believe DNP will gain more respect as compared to MD’s because the hold the word “nurse” in there title. I believe there needs to be more of a work culture shift of roles, powers and state policies shifting the differences.

Reference:

DeNisco, S.M., & Barker, A. M. (2015). Advanced practice nursing: Essential knowledge for the profession (3rd ed.). Retrieved from https://bookshelf.vitalsource.comLinks to an external site.

Hain, D., & Fleck, L. (2014, May). Barriers to Nurse Practitioner Practice that Impact Healthcare Redesign. OJIN: The Online Journal of Issues in Nursing, 19(2)

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/Rep;orts/2010/the-future-of-nursing-leading-change-advancing-health.aspxLinks to an external site.

Read the assigned Hain & Fleck article, and discuss the following:

• What are the barriers to APN practice identified in the article? Describe these barriers in your own words.
• What are your impression of the barriers to APN Practice? (Are you surprised by these barriers? Is this new information to you? Have you ever been involved at the legislative level in nursing? Do these barriers concern you or motivate you toward becoming an APN?)
• Do these barriers represent Restraint of Trade? Why, or why not?
• Your thoughts on how nurses can influence these barriers.

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The barriers identified in the articles include state practice licensure issues, physician related issues, payer policy issues, and prescriptive issues (Hain, Fleck, 2014). These issues do not come as a surprise as physicians have dominated the medical field for a very long time. It is the same concept to the work field with male dominance and women fighting for equality. We have been living in a world that aims to maintain dominance, we are seeing it today in the financial world with the United States and their protectionist views by implementing trade tariffs. If we go all the way back in time, there has been wars and attempted genocides to ensure one’s beliefs dominate the world. So, for physician dominance to occur in the medical field is not a surprise to me. On the positive note, we do have organizations that fight for nurse practitioner equality in the medical field such as the American Association of Nurse Practitioner (Hain, 2014).

I believe these barriers are occurring naturally in a world that aims to maintain dominance. But we live in a time where change needs to occur, because the fact is we are short in primary care physicians in an aging population and a work force that will be reduced with baby boomers retiring, which will only add to the shortage in primary care physicians in a world where people are requiring more medical attention. The healthcare cost is also increasing at such a fast rate, where it will not be sustainable in the future. I believe these restraints will be resolved. The main driver of this resolution will be cost.

Reference:

Hain, D., & Fleck, L. M. (2014). Barriers to NP Practice that Impact Healthcare Redesign. Online Journal Of Issues In Nursing, 19(2), 5. doi:10.3912/OJIN.Vol19No02Man02

The barriers to APN practice that were identified in the article are state practice and licensure, physician related issues, job satisfaction, payer policies and not being allowed to follow patients who are admitted to acute care facilities (Hain &Fleck, 2014).

These barriers to me mean that APN are restricted in their practice. They do not get to practice to the best of their education. I do feel that in the beginning there does need to be some guidance from a physician. The barriers can cause dissatisfaction with the job because of the amount of control taken from the APN regarding their decisions with their patients. This should be done in the first five years or so of practice. This would give the ANP the guidance needed while caring for patients. These barriers also mean the ANP does not get the same compensation as does a physician and payers will not pay at the same rate as they would for a patient being seen by a physician.

These barriers are not new to me nor do they come as a surprise. I have spoken with a few FNPs who have mentioned the fact that they are restricted to a certain extent. When working in the emergency room a lot of times the APNs would only be allowed to work on the lower acuity patients. In the event that there was someone who ended up being a higher acuity the APN would have to go to the physician for their opinion. This I did not see as a bad thing. It is always good to have the extra resource which can provide an additional set of eyes and knowledge for a situation. These restrictions do not concern me currently. I feel my motivation is seeing how certain physicians welcome the APN and are willing to work with them. Many I have seen give the APN more room to do their thing once they gain confidence in the APN.

These barriers do represent restraint of trade. They do not allow the APN to see patients and prescribe medications without restrictions. They have rules and regulations that restrict them and only allow them to practice in certain ways.

Nurses can influence these barriers by forming organizati0ons to appeal to their states about the way they are allowed to practice. To do this they will need to research and provide data stating the care they give, and the care given by physicians. They will need evidence about practices to be able to change the minds and get regulations changed. This will not be an overnight process, so they will also need to be willing to commit to making a change over years.

Reference

Hain, D., & Fleck, L. (2014, May). Barriers to Nurse Practitioner Practice that Impact Healthcare Redesign. OJIN: The Online Journal of Issues in Nursing, Vol. 19, No. 2, Manuscript 2, doi: 10.3912/OJIN.Vol19No02Man02

I also work in the emergency department and we have both nurse practitioners and physician assistants working.  I do see that many of the more critical patients are picked up by the doctors and not the PA or NP.  This is not always the case as we have one NP who is without question a rock star.  She has the ability to handle any situation and is involved in trauma cases when certain doctors are there.  I was very impressed by her as I watched the confident manner in which she conducted her business.  I think that there are definite times where opportunities are limited for the NP but I also feel that these obstacles can be overcome by displaying competence and gaining the reputation of being able to handle any and all cases.  I see that the doctors have differing levels of confidence in the PAs and NPs based on how they view their abilities.  I suppose this is just human nature and helps to protect the organization.

To answer your question, I feel this regulation causes yet another barrier for NPs. However, the rules guiding the ACNP scope of practice is to avoid malpractice or negligence suits that stem from the NP providing care outside his or her training, knowledge, and skill level (Hoffman & Guttendorf, 2017). To become an Acute Care Nurse Practitioner (ACNP), a nurse must choose a patient population (pediatric or adult/gerontology patients) to focus on. Upon receiving a master’s degree from an accredited school, the ACNP becomes licensed as a PNP-AC (pediatric nurse practitioner) or AG-ACNP (adult gerontology). NPs without ACNP credentialing are still qualified to work with these patient populations because all NPs (especially FNPs and CNSs) are trained to diagnose, treat, and manage acute conditions and chronic illnesses for all patient populations (Hoffman & Guttendorf, 2017). However, FNPs and CNS’s typically provide treatment to patients with acute conditions that are not life-threatening). The dynamics of care and treatment change when a patient’s health is deteriorating.

Furthermore, not all NPs have detailed or exhaustive training to diagnose and treat medical conditions for patient populations in certain settings (Nurse Journal, 2018). More so than the CNM or CNA, the FNP and CNS are better qualified to treat patients of all ages with chronic diseases (Nurse Journal, 2018). The distinction is slight but clear since the goal of NP training is to make it patient population specific. It would not be wise for a CNM or CNA to take a contract providing health services to a 45-year-old patient who is bedridden, overweight and suffering from hypertension and type II diabetes. The new clause is to help NPs understand what type of work and work environment is best suited for their training and specialized skills. The key words are specialized skills. While I feel the new clause is restrictive, it is a good measure to integrate. NPs should look at the new clause in a positive way, sort of like the difference in training and skill level of a family practitioner, brain surgeon, cardiologist, gynecologist, etc. Some nurses may feel this extra provision forces them to get training in things they already know how to do; however, they should look at it as professional pre-caution. Listing you know how to do something on your resume is one thing; having the certification to prove you know how to do it is better. The goal is to provide a high level of patient centered care and address uniformity and simplification measures. Under the new APRN Consensus Model, NPs can become qualified experts in a specific role instead of general experts in multiple roles (Hoffman & Guttendorf, 2017). While all these rules are confusing, they are necessary.

References

Hoffman, L. A., & Guttendorf, J. (2017). Preparation and evolving role of the acute care nurse practitioner. CHEST Journal, 152(6), 1339-1345. Retrieved from DOI: https://doi.org/10.1016/j.chest.2017.08.007

Nurse Journal. (2018). FNP vs ACNP core differences. Retrieved from https://nursejournal.org/family-practice/fnp-vs-acnp-core-differences/

When I graduate with an advanced practice nursing degree, I hope to practice in Illinois. In the state of Illinois, Nurse practitioners are required to operate within a reduced-practice jurisdiction. A physician must supervise the patient (AANP, 2018). A practicing advanced practice nurse who has completed 250 hours of continuing education and/or training and 4,000 hours of clinical practice after being certified by the department can practice autonomously, without the guidance of a physician (Illinois Nurse Practice Act) without a written collaborative agreement.  The state of Illinois prohibits APNs from prescribing Schedule II opioids and benzos without consulting a physician who will oversee the prescription (Illinois Nurse Practice Act). There are times when an APRN must partner with a physician, even if they have full practice authority (Illinois Nurse Practice Act). Nurse practitioners can practice, administer, evaluate, and prescribe regulated medications in 23 states, according to the American Association of Nurse Practitioners. The Illinois practice has been modified in 16 states. Nurse practitioners must have a mutual agreement with licensed physicians in order to administer such narcotic medications and medical maintenance. In addition, the majority of traditional practices occur in 12 southern states. Traditionally, states instruct a professional healthcare provider to supervise medical care for a lifetime. Throughout my exploration of obstacles at both the federal and state levels, the most frequently encountered obstacle was the lack of understanding of the critical position held by nurse practitioners (Wheeler et al, 2022). Patients are diagnosed and managed by nurse practitioners in collaboration with physicians. Consequently, physicians perceive nurse practitioners as intimidating. Doctors are much more expensive than nurse practitioners for healthcare. It reduces the cost of healthcare and makes it more accessible to many people if they are held to an equivalent level of accountability.

 Additionally, ANPs need to be acknowledged and understood for what they do and whether they have the appropriate training (Reebals et al, 2022). The Illinois House of Representatives is represented by Raja Krishnamoorthi, a Democrat. The 8th Congressional District in Illinois is represented by him. Tammy Duckworth and Dick Durbin are the state senators. Both belong to the Democratic Party. J.B. Pritzker, the state’s newly elected Democrat Governor, was elected in January 2019. Exploring APRN Interest groups, I was surprised to discover how many there are. The majority of nursing specialties and career paths have their own interest groups. Two of the most important interest groups (Professional Nursing Organizations) are the American Association of Nurse Practitioners and the Illinois Society for Advanced Practice Nursing. Two kinds of policies are described in the Health Care Policy textbook: direct actions to enhance and save health, and positions and administrations of public health. It is the responsibility of state and local officials to promote public health and safety and to regulate private corporations and individuals. The concepts of taxing or exempting from taxing enable Congress to experience healthier manners implicitly (Hult et al., 2021). Getting involved with different groups and communities is one method to influence policy reform. Participating in a group that aids nurse practitioners in working with their state and national governments obtains you one stage closer to changing regulation. For instance, if you have an intellectual approach to enhancing healthcare by helping nurse practitioners in accomplishing their jobs adequately, being associated with an industry that deals directly with the government would authorize you to have your voice heard. Conveying the recommendation to your representative primary would enable you to develop a legitimate strategy, which your representative will then grant to the government. Participation, in my belief, is one of the most effective techniques to produce change.

In the video, Taxes is one of the states where NPs have restricted practice. It is difficult for healthcare workers and the general population to understand the role and responsibilities of NPs. Full or reduce practice will allow for improvement in accessing care to primary care providers in health professional shortage areas and it can also allow an increase in practicing ownership among NPs (DePriest et al, 2020). Talking about the different education and amount of experience in clinical practice. I think nurses going into advanced nurse practitioner school have some experience with patient care before they start advancing their education so they have knowledge of patient treatment and responsibilities. Having to go to school for 3 years for advanced practice nursing versus eight years for medical school can not determine the ability to practice independently.  

DePriest, D’Aoust, R., Samuel, L., Commodore-Mensah, Y., Hanson, G., & Slade, E. P. (2020). Nurse practitioners’ workforce outcomes under the implementation of full practice authority. Nursing Outlook, 68(4), 459–467. https://doi.org/10.1016/j.outlook.2020.05.008

 This is an informative post. Indeed, one of the major practice barriers for APNs in all 4 roles in the state of New Jersey is denying them authority to practice to the full extent of their education. This barrier is also manifested on a national level where many states prevent APNs from practicing with full authority and require either supervision or a collaboration agreement (Hudspeth & Klein, 2019). The US healthcare system is currently changing and the patient population keeps becoming more diverse, which warrants fundamental changes in the healthcare delivery system to keep up with these changes. Today, there is a shortage of healthcare providers in the United States due to the expansion of insurance coverage under the ACA. As such, it is important to grant APNs authority to practice to the full scope of their education and training to help in developing needed healthcare workforce to help in attaining the primary health care need of the US. 

 Various methods can be used by APNs to influence policy change. The first method is to build a relationship with legislators. APNs should consider developing an effective relationship with lawmakers with interests in healthcare bills to help in advancing healthcare policy change at the legislative level (Wichaikhum et al., 2020). APNs can also influence policy change by participating on national boards. APNs can seek appointments or invitations to participate on federal or state boards that influence policy. This provides a better opportunity to influence policy formulation and the future of nursing. The other method is to collaborate with lobbyists. It is recommended that nurses need to consider becoming lobbyists to champion policy changes. However, they can also consider partnering with lobbyists and giving them evidence-based data to convince lawmakers to advance policy changes to help in enhancing the healthcare system. 

References

Hudspeth, R. S., & Klein, T. A. (2019). Understanding nurse practitioner scope of practice: regulatory, practice, and employment perspectives now and for the future. Journal of the American Association of Nurse Practitioners, 31(8), 468-473. DOI:10.1097/JXX.0000000000000268

Wichaikhum, O., Abhicharttibutra, K., Nantsupawat, A., Kowitlawakul, Y., & Kunaviktikul, W. (2020). Developing a strategic model of participation in policy development for nurses. International nursing review, 67(1), 11-18. https://doi.org/10.1111/inr.12571

 There are four roles that define the advanced practice nurse, this includes midwife, nurse anesthetist, nurse practitioner, and clinical nurse specialist. In the state of Ohio, there are certain regulatory restrictions on the advanced practice nurse. For example, a nurse practitioner must practice under a standard care arrangement with a physician. This agreement among us includes prescription parameters as well as the nurse practitioner’s performance being reviewed by the physician. Even though the position does not need to practice on site with the nurse practitioner, her performance will be reviewed on an annual basis. Also, an advanced practice nurse does not have permission to admit a patient to a hospital which tells me there is a lack of understanding of the advanced practice registered nurse as well as a lack of recognition. Another barrier I believe is the state mandation , collaborating with a physician may be costly.  But even with these restrictions Ohio is not as strict as other states nationally we are actually considered to be reduced practice regulation state versus the full and the restricted.

      It is said that the exact function of the nurse practitioner is not well understood by physicians (Torrens,2020) and their counterparts. This to me can’t interfere with the ability to practice independently because of the competition received from our constituents.

        Key members of the state’s legislative branch and executive branch are our current governor Mike DeWine, four-year term, Lieutenant governor Jon Husted elected to a four-year term, current attorney general Dave Yost and our Secretary of State Frank LaRose.

       There are a few groups that exist that will influence the advanced practice nurse policy. AANP is one of them, they take on the role in advancing the nurse practitioner on a federal and state level.  OAAPN is an organization that try’s to eliminate practice barriers for all providers that provide quality of care to Ohioans.

       There are different methods turn off lose change in policy what is by changing public opinion and educate them on the role of the APN. When dealing with public health the government must intervene and make appropriate improvements to policies and create new ones(Teitelbaum,2020).

Practice barriers for the APN in the roles of nurse midwife, nurse anesthetist, nurse practitioner, and clinical nurse specialist continue on federal and state levels.  On the federal level, Medicare has disparate reimbursements of 85% for APNs compared to the physician fee schedule.  Offices are incentivized to bill NPs care under physicians’ National Provider Identifier not allowing true reporting of the quality care by NPs.  Although there is uniform education preparation around the country, each state has different definitions of scope of practice with varying practice regulation (Poghosyan, 2018).  These barriers include whether an APN can have full practice, reduced practice, or restricted