Task: Legislative issues affecting advanced practice nursing

Political advocacy and practice barriers: A survey of Florida APRNs. Clinicians’ Attitudes to Clinical Practice Guidelines: A Systematic Review February 3, 2011 Authors Cynthia M. Farquhar, M.B.Ch.B., M.D., Emma W. Kofa, and Jean R. Slutsky, M.S.P.H. Citation C. M. Farquhar, E. W. Kofa, and J. R. Slutsky, “Clinicians’ Attitudes to Clinical Practice Guidelines: A Systematic Review,” Medical Journal of Australia, Nov. 4, 2002 177(9):502–06. The Issue Clinicians are commonly thought to hold negative perceptions of clinical practice guidelines—regarding them as overly prescriptive, for example, or driven by cost-cutting concerns. This Commonwealth Fund– supported study is a systematic review of clinicians’ attitudes toward clinical guidelines, based on surveys published in English from 1990 to 2000. What the Study Found The researchers found that most clinicians viewed clinical guidelines as helpful sources of advice (weighted mean, 75%), good educational tools (71%), and intended to improve quality (70%). However, some clinicians considered guidelines to be impractical to use with individual patients (30%). Some felt that they reduced physicians’ autonomy and oversimplified medicine (34%), were likely to increase litigation (41%), and were intended to cut costs (53%). Conclusions Based on their review, the authors conclude that “contrary to popular belief, negative clinician attitudes are not the major barrier to implementation of [clinical practice guidelines].” Thus, clinician intransigence is not likely to be the main reason that clinical practice guidelines have failed to reduce variations in practice. Barriers to NP Practice that Impact Healthcare Redesign ^md Debra Hain, PhD, ARNP, ANP-BC, GNP-BC Laureen M. Fleck, PhD, FNP-BC, CDE, FAANP Abstract 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. Citation: Hain, D., Fleck, L., (May 31, 2014) “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 Key words: Nurse Practitioner, Nurse Practitioner Education, Nurse Practitioner Practice 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). The NP role in the 21st century looks much different than it did in 1965. 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… In the 1970’s NP education moved from a certificate program to programs that offered bachelors or masters degrees. 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. Barriers State Practice and Licensure 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).

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. 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). Task: Legislative issues affecting advanced practice nursing

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. 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 At a time when healthcare reform rapidly evolving, it is critical that NPs and physicians collaborate to achieve best is rapidly evolving, practices. Although, physicians and NPs possess a similar goal of improving it is critical that patient outcomes, barriers to successful collaboration exist. Lack of knowledge of NPs and physicians NPs scope-of-practice has been identified as a barrier to successful collaboration collaborate to (Clarin, 2007; Phillips, Harper, Wakefield, Green, & Fryer, 2002). The traditional achieve best medical hierarchal model of practice contributes to ineffective teamwork. This practices. 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. Task: Legislative issues affecting advanced practice nursing

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 scopeof-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. Payer Policies 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 Restrictive scopelicensure. Restrictive scope-of-practice may lead to stricter payer policies limiting of-practice may NPs ability to practice independently. They are essentially forced to be in practice lead to stricter as employees of physician practice, hospitals or other entities (Yee et al., 2013). payer policies Commercial health plan payment policies may vary and often don’t recognize NPs limiting NPs ability as primary care providers. Task: Legislative issues affecting advanced practice nursing

In addition, these payers may be resistant to to practice credentialing or directly paying NPs for services they provide. In some practices, independently. 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. 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. State insurance mandates are important to NP practice because they affect nurse practitioners’ ability to independently practice and bill for services. 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). Other Barriers 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). Task: Legislative issues affecting advanced practice nursing

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. Addressing Barriers Policy Initiatives 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 hav e the greatest impact on NPs ability to practice the fullest extent of their education and training (Devi, 2011). Task: Legislative issues affecting advanced practice nursing

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 regula…