NR 510 Historical Development of Advanced Practice Nursing and Evidence-Based Practice Discussion

No matter if your state allows for full practice, reduced practice, or restricted practice, NPs just as RNs are accountable for providing care according to their scope of practice. Mennella and Heering (2017) state “accountability is the primary outcome of all levels of professional nurse autonomy” (p. 1). According to Park, Athey, Pericak, Pulcini, and Greene (2018), 21 states and the District of Columbia allow NPs to practice independently and have full practice authority. In NJ NPs have reduced practice authority and must have physician’s sign off on certain care decisions. I worked in LTC in NJ, we had an NP that came in weekly and did wound rounds. She was able to make care recommendations, but we had to call the primary physician to write the order for the needed treatment.

CNP (Certified Nurse Practitioner)

• Provide primary health care services to pediatrics, families, and geriatrics. These NPs can diagnose and treat illness and injuries. They can prescribe medications and diagnostic tests. Depending on the state that the NP is employed they may have to work with a physician on certain aspects of patient care. (www.nursejournal.org)

CRNA (Certified Registered Nurse Anesthetist)

• Administer anesthesia care to patients. These duties include administering anesthesia during medical and dental procedures, follow-up care, pain management and inserting PICC lines. This is a highly skilled position and requires licensing from the American Association of Nurse Anesthetists. (www.anaa.com)

CNS (Clinical Nurse Specialist)

• Work in many areas of health care including acute care, home health, and community health settings. There knowledge and skills are used to apply theory and research to practice improving patient outcomes. In my hospital the CNS works with stroke and palliative care patients. They manage care of these patients and have the ability to prescribe care based on organizational protocols. (www.graduatenursingedu.org)

CNM (Certified Nurse Midwife)

• These NPs specialize in women’s reproductive health and childbirth. They provide preventative and health maintenance, family planning, and all aspects of childbirth. They provide holistic care to the women in their care. This NP position can be stressful, emotional, and include long hours. (www.registerednursing.org).

APN Role Median Salary
CNP $98,000
CRNA $154,000
CNS $80,000
CNM $91,000

A nurse pracitioner master’s degree program may not be practical for Jessica to complete if she is only given 2 years to complete the degree. Also, if she accepts the administrative position she may find it difficult to complete the intensive practicum required by most programs. However, if she chooses to enroll in a program, she would probably be most suited for a clinical nurse specialist program. In this position she can still have direct patient interaction and can make a positive impact on patient care and outcomes.

Thanks for reading,

Resources:

Certified registered nurse anesthetist fact sheet. (2017, October 10). Retrieved from https://www.aana.com/patients/certified-registered-nurse-anesthetists-fact-sheet.

Certified nurse midwife. (2017). Retrieved from https://www.registerednursing.org/nurse-midwife/.

Clinical nurse specialist (CNS). (2018). Retrieved from https://www.graduatenursingedu.org/clinical-nurse-specialist/.

How to become a CNP certified nurse practitioner. (2017). Retrieved from https://nursejournal.org/nurse-practitioner/how-to-become-a-certified-nurse-practitioner/.

Mennella, H. & Heering, H. (2017). Professional autonomy and advanced nursing practice. Cinahl Information Systems.

Nurse practitioner career guide. (2018). Retrieved from https://nurse.org/resources/nurse-practitioner/.

Park, J., Athey, G., Pericak, A., Pulcini, J., & Greene, J. (2018). To what extent are state scope of practice laws related to nurse practitioners’ day-to-day practice autonomy. Medical Care Research and Review, 75(1), 66-87.

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I will admit that I have not looked a great deal at the liabilities of the various APN roles extensively, but I do have acquaintances in all of the 4 major areas we are discussing. It is my opinion that the CRNA would face the most potential jeopardy simply based on the nature of their position and the ramifications of a mistake to the patient outcomes. That said that, the role of APN is one which requires extreme care and carries the potential to do great harm to patients. This harm can extend to not only what the NP does, but also to what they do not do. In the emergency department where I work, the NP does work independently but does have to present their work to a doctor for verification. The amount of verification is dependent on the reputation the individual has established for themselves based on how they perform their job. I think that there would be implications for both the NP and the doctor who signed off on the treatment faced with litigation. The APN does have a license and must protect themselves through due diligence in all matters of patient care.

NR 510 Historical Development of Advanced Practice Nursing and Evidence-Based Practice Discussion

I appreciate your honesty. I also feel that most NPs are not fully aware of the regulations governing practice in their respective states, nor are NPs fully aware of the liabilities associated with the various APN roles. Even if current and future NPs feel they are knowledgeable about both topics, regulations governing practice and liabilities, they should constantly educate themselves on these matters. In nursing, laws and acceptable practices change all the time. NPs must know the current laws guiding practice at all times. We already know that most physicians view NPs as a threat and that most insurance companies and state/federal policies regarding NPs scope of practice are slow to change; therefore, we must protect ourselves and our profession. The Oregon Nurses Association (2018) has re-posted an article by the Journal for Nurse Practitioners that discusses/gives an overview of APN/NP liability claims. The article contends since the NPs role in healthcare has broadened, it is important that NPs review liability claims to develop “useful risk-management strategies” (Oregon Nurses Association, 2018).

References Oregon Nurses Association. (2018). The journal for nurse practitioners’ article: “NP professional liability: A synopsis of the CNA heal. Retrieved from http://www.oregonrn.org/?389

As their scope of practice and autonomy increases, NPs are being held legally accountable for their actions (Iglehart, 2013). Nurse practitioners must pass classes and certification requirements regarding understanding the legal obligations of prescribing medications (Iglehart, 2013). Regardless of an NPs scope of prescriptive authority, the standard of practice and care is to ensure that any medication prescribed is compatible with other medications a patient is taking and that the correct medication is prescribed. The $525,000 settlement awarded to Sherry Huelskamp (Huelskamp v.Patients First Health Care, LLC) in 2014 against nurse practitioner Barbara King for prescribing the wrong medication emphasizes these standards.

The four APN roles currently defined in practice are Nurse Practitioners (NP), Clinical Nurse Specialists (CNS), Certified Nurse-midwives (CNM), Certified Nurse Anesthetists (CNA). A CNS typically works in a specialized area of nursing practice defined by parameters, such as disease, setting, population (Judge-Ellis & Wilson, 2017). The CNA is restricted to administering pre- and post-anesthesia care to patients for surgery and other procedures. The CNM provides healthcare services to women, such as gynecological services, pregnancy and childbirth care, postpartum services, etc. Jessica will do well in the NP role because of her nursing background and the ability of the NP to serve the same patient populations as the other APN roles. Furthermore, the CNM, CNS, and CNA roles are too restrictive in that nurses who work in these specialized areas of the nursing practice provide distinct services. According to the U.S. Department of Health and Human Services, the most common type of APN is the nurse practitioner (Judge-Ellis & Wilson, 2017). NPs are trained to provide a wide range of primary and acute health care services. NPs diagnose and treat medical conditions, as the scope of practice has expanded to allow NPs to perform many of the same medical services as a physician to include writing prescriptions in approximately 20 states (Judge-Ellis & Wilson, 2017). The median annual salary for NPs is $103,000 (Judge-Ellis & Wilson, 2017). In the other APN roles, Jessica would have to obtain further training if she wanted to expand her scope of practice.

References:

Iglehart, J. K. (2013). Expanding the role of advanced nurse practitioners, risks and rewards. New England Journal of Medicine, 368(1935). Retrieved from DOI: 10.1056/NEJMhpr1301084 Judge-Ellis, T., & Wilson, T. R. (2017). Time and NP practice: Naming, claiming, and explaining the role of nurse practitioners. The Journal for Nurse Practitioners, 139(9), 583-589. Retrieved from DOI: https://doi.org/10.1016/j.nurpra.2017.06.024

Currently, certain rules must be followed to determine if the NP is reimbursed 100 percent. NP billing is done one of two ways: independent or “incident-to”. Independent billing is allowed when the patient is billed directly under the National Provider Identification (NPI) number of the NP providing the service. Incident-to billing occurs if the patient is treated by an NP, but the bill is submitted using the doctor’s NPI number. The first thing that needs to change are measures that require NPs to bill for their services under a physician-colleague’s name and provider number (Pickard, 2014). This makes it look like the NP cannot do his or her job without guidance like an intern; therefore, third party payers do not feel NPs should command top dollar for their services (Pickard, 2014). Furthermore, the difference in reimbursement has to do with multiple regulatory factors: billing guidelines at the state and federal level; credentialing, whether the patient is designated as outpatient or inpatient, and third-party payer policies (NAPNAP, 2018). Billing regulations must be strictly followed because they determine how much the NP can charge for his or her services, govern what services NPs can provide, who they provide services to, where these services can be rendered (NAPNAP, 2018). Each third-party payer (i.e. commercial or government insurer) has different rules on reimbursing NP services on these grounds. For example, reimbursement from private insurance agencies is distinct from the Medicare reimbursement process and may require a credentialing process. In order for reimbursement rates across the roles to be equal, third party payers, such as Medicaid and private insurers, would have to agree on service costs and reimbursement scales (Pickard, 2014). This is unlikely to happen for quite some time since the difference in reimbursement rates has to do with the bundling of services and who pays the bulk of the bill. While the billing process is meant to reflect the NPs productivity, I believe the current billing process is biased toward NPs and favors physicians when both parties provide the same service simply because of the title after the name. For example, if the Physicians Fee Schedule rate for a preventative care visit is $100, Medicare pays the physician $80; the patient then pays the $20 balance to the physician. If an NP performs the same service, Medicare pays the NP $68; the patient pays the NP $17. NPs should be reimbursed the same amount when performing the same service; the only way this will change is for NPs to document the clinical and financial outcomes related to the care they provide (Pickard, 2014). Consistent and thorough documentation from all NPs will support changes in coverage and reimbursement rules (Pickard, 2014).

References:

National Association of Pediatric Nurse Practitioners (NAPNAP). (2018). NP billing, coding, and reimbursement. Retrieved from https://www.napnapcareerguide.com/np-billing-coding-reimbursement/

Pickard, T. (2014). Calculating your worth: Understanding productivity and value. Journal of the Advanced Practitioner in Oncology, 5(2), 128–133. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093517/

I enjoyed reading your post. Your initial sentence is absolutely correct – as nurses education and scope increased, so does the responsibility and liability for performing the correct actions on behalf of a patient.As health care delivery has continued to evolve, many Americans are using NPs for much of their health care needs, making nurse practitioners a critical component of the modern system. This growth in demand and responsibility has also increased and evolved the many risks NPs face in their work environments.As future nurse practitioners, the need to purchase our own professional liability insurance policy is a reality.

A recent review of NP claim report insights show that the majority of claims against NPs developed from a failure involving competencies, such as diagnosis, medication prescribing, or treatment and care management. Allegations related to failure to diagnose and improper prescribing/managing of controlled drugs were found most frequently. This reality displays that nurse practitioners are responsible for reviewing, following up on, and documenting the results of appropriate tests and consultations in a timely manner, as well as properly evaluating each patient prior to prescribing medications. As always, remaining current regarding clinical practice, the need to document al medical treatment, including the care plan, laboratory and diagnostic testing, procedures performed, and medication provided in a timely and objective manner, and engage in an informed consent discussion are some ways to prevent errors and create liability. Increased liability has increased with our soon to be scope of practice. Knowing this in advance can help us prepare appropriately.

Reference:

Stanik-Hutt J, Newhouse RP, White KM, et al., (2013). The Quality and Effectiveness of Care Provided by Nurse Practitioners. J Nurse Practice;9(8):492–500.

It honestly all depends on how you look at the statement to determine if her colleague is right or not. Yes, being an NP is going to be great because I will get to diagnose and write prescriptions. This is how I intend on furthering my education to be able to care for patients. Ultimately, the accountability will not fall on the physician that I am working with. Those decisions are made by me using my license, so I don’t agree. In all reality, I’m sure that if it were to go to court, the physician who does oversee the practice may also get in a form of discipline as well. I don’t believe this is a reason to go back to get my NP though.

After exploring the four APN roles, I actually learned more about the different types of nurse practitioners than I thought I knew. I was most familiar with the CNP and CRNA. Learning that the CNS was clinically very close to that of the CNP. The CNS will provide clinical expertise and leadership in many areas including hospitals, communities, outpatient settings, and long-term settings (Devine, 2017). The responsibilities are essentially very close in nature, providing diagnosis and treatment, health promotion, disease management, prevention, and risk reduction. (Devine, 2017). The CRNA is what I believe to be the best option for Jessica. This role will utilize the experience that she has in surgery, emergency, and pediatrics. She will have autonomy with this role. Being a CRNA comes with tremendous responsibility and a great deal of accountability (Wojciechowski, 2017). The CNM is a NP that specializes in women’s reproductive health and childbirth. Jessica has no experience in OB/GYN, or Labor and Delivery, so this would not be the area of choice that I would choose if I was in Jessica’s situation.

Devine, A. (2017). Clinical Nurse Specialist (CNS) or Certified Nurse Practitioner (CNP)? Industry. Retrieved from https://nurse.orgLinks to an external site. Wojciechowski, M. (2017, January 26). Behind the scenes with a CRNA. [Web log post]. Retrieved from https://dailynurse.comLinks to an external site.

I enjoyed reading your post. I also learned a great deal about the various advanced nursing degrees during the past week. I as well did not know much about the CNS role. Clinical nurse specialists (CNS) tend to be one of the more misunderstood APRN roles. Their responsibilities may also include diagnosis and treatment, health promotion, disease management, prevention, and risk reduction. Clinical nurse specialists are registered nurses with a graduate degree in nursing at the Master’s or Doctorate level and must complete formal education in Pharmacology, Physiology, and Physical Assessment. Very similar to our chosen FNP track. However, CNS scope of practice varies state by state but CNS’s are licensed in 28 present states. The FNP role is licensed to practice in all 50 states and has as of 2017, 22 states and Washington D.C. have granted NPs full practice authority. This is a major difference in acceptability nationwide. I am confident that we will receive the appropriate knowledge as a foundation prior to our clinical’s to meet the needs of the AACN and board of nursing for licensure. I feel like these are safe guards that are in place to protect ourselves and the public to produce solid pracitioner’s.

Reference:

American Association of Colleges of Nursing (AACN). (2014). AACN position statement on the practice docture in nursing. Retrieved from http://www.aacn.nche.edu/DNP/pdf/DNP.pdf (Links to an external site.)Links to an external site.

NR 510 Historical Development of Advanced Practice Nursing and Evidence-Based Practice Discussion