NR 510 Barriers to Practice Discussion

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 agree that guidance from a physician at first would be helpful. The transition from bedside nursing to being the one diagnosing and prescribing is intimidating, and a complete change from what we are used to doing. When I graduated with my BSN and started on the floor, I had twelve weeks of orientation with a floor nurse. The direction she gave helped me significantly. I am not sure I would have been as well equipped if it were not for her. I learned everything about the floor and asked her all my questions. At the same time, this does give nurses the barrier that they cannot practice to their full scope. In the end, it is about gaining trust from the physician you work with. The more skills they see from you, the higher acuity patients you can see. I am ok starting with lower acuity patients to prove myself then working my way up to the sicker patients after gaining more skills and trust. I agree that this is considered a restraint of trade, as the scope of practice is limited.

You bring up a great example in the setting of the emergency room. There are different setting that the nurse practitioner can work that can help reduce the work load in the environment. Although there is some barrier in the nurse practitioners practice in the emergency setting their role is important to reduce to amount of workload which ultimately creates a safer environment for all the patients. Most of the high amount of patients that fill an emergency room are low acuity issues that the nurse practitioner can easily see and discharge the patients to reduce the work load on the physicians who are care for patients who are of higher acuity. I think that once there is an order to admit the patient would be an appropriate time for the physician to take over. Patients that come in for minor issues that may need to be discharged on over the counter pain killers and maybe antibiotics are patients that can easily be taken care of by the advanced practice nurse. Although barriers can at times be frustrating ultimately physicians go to school for a large amount of years with a lot of training and although the advanced practice nurse does need a few barriers and need to be overseen just to ensure patient safety.

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In the emergency room when it is time to admit a patient the seeing provider calls the on call team for whatever is going on with the patient and they decide if they should admit the patient or not. Sometimes something that seems simple can turn into an admission. For example when someone comes in with a broken bone this can be easily seen and treated by the NP. However, there are times when the seemingly simple broken bones turns into a situation where the orthopedic decides they will need surgery. The NP would consult ortho and then they would decide to admit the patient. I do not agree that the ER physician needs to take over when there is an order to admit. The NP can consult the admitting team and they will take over. Sometimes it is a physician that assumes care but often it is a NP or PA. I do believe with admissions if there are more difficult issues then the admitting team will consult the physician.

Thank you for responding to my post I look forward to learning more with you in the coming weeks.

I agree that one must reach out to all available resources when necessary, even if it is just a small question or thought. It is critical for medical professionals to see the full picture when it comes to diagnosing and treating patients, if that full picture includes consulting another provider it is pertitent all providers are not too proud to do so. An established nurse practitioner should be taken seriously and looked upon as a vital resource to ones co workers including physicians. A small study from Canada analyzed the referrals between physicians and nurse practitioners in a primary care setting showing 16% were made by NP’s to physicians and a minute 2% for physicians to nurse practitioners (Fatima, 2009). Nurse practitioners and physicians are trained differently and bring different positive assets to the team evaluating patients and physicians must become more aware of everything they have to offer.

Faria, C. (2009). Nurse practitioner perceptions and experiences of interprofessional collaboration with physicians in primary health care settings (Order No. MR65171). Available from ProQuest Dissertations & Theses Global. (760998386). Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search-proquest-com.chamberlainuniversity.idm.oclc.org/docview/760998386?accountid=147674

I also work in the emergency department and have found that in our organization, the NP must consult with the physician for some cases. In any case that a pediatric under 6 months old is seen in the emergency department or the urgent care, a physician must be consulted. Also in the cases of any patient transfer to a higher acuity facility, a physician must co-sign the EMTALA sheet with the NP. I don’t find that these are bad reasons to have a physician consultation. But after reading the article and some of the other responses by peers, I definitely can see how the use of NPs and their education could be mistreated with the need for physician consultation.

I hope that when I am working as a new NP, I have that ability to feel like I have physicians to look up to for further assistance. I remember how I felt when I was a new graduate with my RN license. I felt like I knew nothing my first day on the job, and that someone had made a big mistake by giving me a license! I honestly learned more on the job, and I most nurses I have talked to feel the same way. I hope the physicians are going to be backing me with knowledge when I am working as a NP.

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

I am aware of patient barriers. My father had an MI a few years back and he was following up with a cardiac NP for his routine follow up appointments. At first he was skeptical of his treatment plans and knowledge in medicine. I had to educate him and inform him that NPs are knowledgeable and are fully educated with medicine as much as doctors. They might even be more compassionate with patients, which can greatly improve their care. I provided him examples and had him rethink some of his past experiences with doctors on how some of them lack compassion. After this he was able to compare the difference and he did mention how the NP actually talks to him like a regular person and explains things in ways where he can understand.

I believe educating the population is extremely important to break these barriers. The population is not informed of the education NPs have to achieve in order to become providers. One way to do this is to inform the population with research in how effective NPs can be in treating common and chronic illnesses. Throughout this NP program, I have come across many scholarly articles that proved NPs are more effective in managing chronic illnesses compared to MDs, such as diabetes mellitus type 2. Therefore, we must do a better job in educating the population in the role of NPs and the extensive education and training they go through to become providers.

Your post sparks some interesting conversations! I agree with you that Physicians have largely dominated the medical field on scientific knowledge and expertise. Even more so, it has always largely been male Physicians. We more definitely have various factors as you mentioned driving the change in who and how providers offer medical care and service to patients. However, even more so than cost as you cite, I feel it will largely be the cultural shift and change in perception needs to change. As authors DeNisco & Barker (2015) note, education of nurses have historically been cited as ‘training’ as opposed to ‘education’. Different connotations have been used to described knowledge and training of medical doctors and nurse practitioners. The healthcare industry has placed the nursing profession into a subservient role rather than a role that utilizes critical thinking as doctors have largely been grouped into. I feel a great amount of societal shifts still need to occur to shift the perception of nursing regardless of an advanced degree from holistic, humanistic and relational and combine it with the hard scientific knowledge base needed to treat the disease process in a healthy way.

As Dr. Storms noted in your response, I have also had many dealings with patients who appear to listen more attentively to male peers that have either a nursing role or respirator role despite my equal qualifications. I do not take personal offense to this, but recognize the cultural dynamics in which people are comfortable within. I take it as an opportunity to teach and education the patients on there disease and ways to treat it!

Reference:

Advanced practice nursing: Essential knowledge for the profession (3rd ed.). Retrieved from https://bookshelf.vitalsource.com (Links to an external site.)
Links to an external site.

I think it is interesting how we are looking into physical appearances and how they can affect the patient’s perception of a healthcare personnel. I have also noticed that when one comes in with a lab coat or maybe the hat OR doctors wear, all of a sudden, the patient may change outlook. I have told a patient information or advice and the patient may appear weary of my advice. However, the medical doctor will say the same advice I would say and the patient would trust what the medical doctor said. For example, I have heard one of my family members state that they do not want a FNP to take care of them when they go to a PCP. I asked why and there was no definite reason but besides that they felt more comfortable with an medical doctor. Medical doctors appear to hold such a high prestige. A study commissioned by the American Academy of Family Physicians shows 72% patients prefer physicians over nurse practitioners for their medical care. However, on the opposite end of the spectrum, the American Association of Nurse Practitioners, conducted their own study of what kind of care patients request. Their own study show that healthcare consumers are in favor and open to expanding responsibility for NPs. The two surveys do not contradict each other but display the unwritten tug-of-war of power. As the baby boomers age and and the surge in newly insured Americans grow, it places a strain in primary care providers. According the AAFP survey, only 7% of respondents said they would prefer a nurse practitioner over a physician while 16% indicated no preference and 5% said they didn’t know. It is interesting to see how perception of a profession can change the outlook of how a patient perceives a medical doctor or a nurse practitioner. (Read & Mayberry, 2015)

Read, A. M., & Mayberry, J. F. (2015). Doctor or nurse? The patients’ choice. Postgraduate Medical Journal, 212.

Love the statistics. The 72% of patient preference for physicians is interesting to me. I believe the 28% should be seen as a positive. I believe the percentage in patient preference to nurse practitioners will increase with time. Kimberly mentioned holistic, humanistic and relational skills. We naturally have these skills and strengthen it with experience through nursing. I believe this will be the game changer to patient preference. NPs and future NPs know we have the knowledge to effectively care for patients and mange their healths. With time, as the population is more informed with the role of NPs, the holistic, humanistic and relational skills we have will make NPs much more desirable.

I agree that times are changing, and I believe that we will see that NPs are going to become prominent in primary care as well as acute care. CMS implemented accountable care organizations (ACOs) to help to improve patient care and reduce costs. Bishop and Jackson (2013) state “the core principles of all ACOs are a strong primary care base, quality improvement that reduces overall costs, and reliable performance measures that give support and ensure that saving are being achieved through actual care improvements” (p. 105). All health care organizations will need NPs to meet the rising demands of primary care especially of those with chronic illness to reduce health risks and improve patient outcomes. Hobson and Curtis (2017) state “chronic disease is a leading cause of death and accounts for the largest proportion of healthcare expenditure among adults in the United States” (p. 644). There needs to be a change in how we treat these patients to prevent acute exacerbations and reduce unplanned hospitalizations.
Thanks for sharing.

Resources:

Bishop, C. and Jackson, J. (2013). Motivational interviewing: how advanced practice nurses can impact the rise of chronic disease. The Journal for Nurse Practitioners, 9(2), 105-109.

Hobson, A. and Curtis, A. (2017). Improving the care of veterans: the role of nurse practitioners in team-based population health management. Journal of the American Association of Nurse Practitioners, 29, 644-650.

The first barrier is state practice and licensure. Each state in the US has its own regulations for the NPs scope of practice. 21 states and the District of Columbia have full practice authority licensure (Park, Athey, Pericak, Pulcini, and Greene, 2018), the other 29 have limited or restricted practice. Those with full practice authority can practice independently, those with limited or restrictive practice must work with a physician or health care system. The next barrier is physician related issues. This barrier comes from physician’s believing that the training and education of NPs is not sufficient to put them on the same level as a physician. The third barrier is payer policies. Nursing in general has never been a billable profession. Nurses are considered an expense that are combined with other costs billed by health care systems. State legislature regulates the scope of NP practice and if their services are not recognized it forces the NP to bill as an employee of a physician or a health care system. The fourth barrier is the inability for primary care NPs to follow their patients to acute care settings, causing a gap in the continuity of patient care. If the NP is unable to admit the patient to the acute care setting another provider will do the admitting and gaps may be formed when the admitting practitioner does not know the patient’s complete history. The last barrier to practice of the article is job satisfaction and intent to vacate their current position. NPs that are positions that lack autonomy and career advancement chose to leave their position to seek finding these attributes in other positions.

It is not surprising that there are numerous barriers to NP practice. Even as a student in a FNP program there are times that I do not fully understand exactly what the scope of practice is for NPs in each specialty. As a new nurse I worked with two NPs, one in primary care and one in wound care. The NP in primary care wanted to be made aware of all changes in her patient’s condition and we had her cell phone for orders. There were times we would call her for orders and she would have to call us back since what we were asking for was out of her scope of practice. For example, if we had a patient that had declined, and the family was asking for a hospice evaluation she could not order that, however, she could write the orders to manage the hospice care. Our wound care nurse would do rounds weekly and make care recommendations, orders we could not write unless we got orders from the primary physician. I have never been involved in the legislative level of nursing, but I have written to my state legislatures on several occasions when bills were coming up that I did not agree with. These barriers do concern me, but they motivate me. There is a need for better management of those with chronic illness and I feel that NPs are well positioned to fill this gap in primary care. Nurses are required to see the whole patient picture and treat the patient holistically. When a patient is admitted to the hospital each medical specialty focuses on why they were consulted, rarely the whole patient picture. Employing NPs to manage patient care will improve collaboration of the interdisciplinary team, resulting in better patient care and outcomes. Eriksson, Lindblad, Moller, and Gillsjo (2018) in their research of holistic NP care found “the new role of APN led to increased accessibility of health care and reduced waiting times…the APNs professional approach includes provisions of individualized and holistic health care conveyed with a respectful and flexible approach” (p. 5).

Restraint of trade limit one’s ability to compete in the free market. These barriers represent a restraint of trade. I have read that nurse practitioners have the education and training that compares to junior physicians. These physicians are qualified to provide the same care as NPs with full practice authority. Allowing NPs full practice authority could cause competition between primary care physicians and advanced nurse practitioners. I was once told by a physician that the only way to get paid was to admit and discharge a patient, everything in between meant nothing. Another physician told me that if I should get a doctorate of nursing degree I should not call myself doctor because I will still be a nurse. If NPs are allowed full admitting and prescribing rights, primary physicians will have competition and have more accountability for outcomes. I feel like physicians want to employ NPs as additions to their practice but they do not want them as competition.

Nurses can influence these barriers by being active in their health care system and being a part of nursing organizations. Legislation needs to be changed, legislatures need to understand that NPs have the education and training to be active independent health care providers.

Resources:

Eriksson, I., Lindblad, M., Moller, U., & Gillsjo, C. Holistic health care: patients’ experiences of health care provided by an advance practice nurse. International Journal of Nursing Practice, 1-7. doi:10.1111/ijn.12603

Hain, D. and Fleck, L. (2014). Barriers to NP practice that impact healthcare redesign. Online Journal of Issues in Nursing, 19(2).

NR 510 Barriers to Practice Discussion