Category Archives: Scope of practice
RWJF Scholars in the News: Medical debt disparities, nurses providing primary care, technologies that maximize time with patients, and more.
Around the country, print, broadcast, and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows, alumni, and grantees. Some recent examples:
In a study of women diagnosed with breast cancer, RWJF Physician Faculty Scholars alumna Reshma Jagsi, MD, PhD, found that Black and Latina patients were more than twice as likely as White patients to have medical debt and to skip treatments due to concerns about costs. Jagsi tells Reuters that “our findings suggest that racial and ethnic minority patients appear to be more vulnerable, as are those who are too young to qualify for Medicare, those who lack prescription drug coverage, those who reduce their work hours after diagnosis, and those with lower household income at the time of diagnosis.”
Expanding nurse practitioners’ role in primary care could help meet new demands on California’s health care system, as millions of previously uninsured residents gain coverage under the Affordable Care Act, according to Susan Reinhard, RN, PhD, senior vice president of the AARP Public Policy Institute. “We should make sure that the nurse practitioners can use every ounce of their talent for what is needed,” she tells the AARP Bulletin. “Consumers should have a choice of different clinicians who will suit their preferences and their needs.” Reinhard is chief strategist for the Center to Champion Nursing in America, a partnership of AARP, AARP Foundation, and RWJF and co-director of the Future of Nursing: Campaign for Action.
At a recent information technology summit, Ann O’Brien, MSN, RN, an RWJF Executive Nurse Fellow, discussed her work with Kaiser Permanente to leverage new health care technology to maximize nurses’ valuable time providing patient care. O’Brien explains that “you have to look at what can enable small amounts of change,” because saving seconds with each repeated use of rapid sign-on technology, for example, can mean gaining extra minutes in a day for a nurse to provide direct care, FierceHealthIT reports.
Kentucky Gov. Steve Beshear signed legislation last week that lifts a key limitation on advanced practice registered nurses (APRNs) and increases consumer access to health care.
The new law “allows more flexibility for nurse practitioners to provide accessible health care to Kentuckians,” Beshear said. “Nurse practitioners are a critical part of helping more Kentuckians get the medical care they need quickly and efficiently, and I am proud of the bipartisan effort to serve Kentucky’s health needs.”
In the past, APRNs were only allowed to prescribe medication with a physician’s written consent. The new law removes that requirement for APRNs who have four or more years of experience prescribing medication under a collaborative agreement with a physician or as an independent practitioner in another state, according to the Future of Nursing: Campaign for Action.
Efforts to expand the role of nurse practitioners (NPs) to help address the country’s shortage of primary care providers have been bolstered by legislation in several states. But laws expanding scope of practice may not do all they could to relieve the nation’s primary care crisis, according to a new study by researchers at the Columbia University School of Nursing, which suggests that the culture in health care settings can impede full utilization of NPs.
The study, published in the Journal of Professional Nursing, was conducted in Massachusetts, where state health reform increased demand for primary care and legislation recognized NPs as primary care providers. Researchers found that gains made by government can be neutralized by formal and informal practices at health care organizations. For example, the study cited instances where NPs were not allowed to conduct physical assessments or see new patients.
“Organizational policies can often trump governmental policies, keeping the contribution of the nurse practitioner unrecognized and preventing them from making the fullest contribution possible to effective patient care,” lead researcher Lusine Poghosyan, PhD, RN, an assistant professor of nursing at Columbia and a Robert Wood Johnson Foundation Nurse Faculty Scholar, said in a news release.
This is part of the December 2013 issue of Sharing Nursing’s Knowledge.
Americans Favor Increased Access to Nurse Practitioners
A new telephone survey commissioned by the American Association of Nurse Practitioners (AANP) shows strong support for increased access to care provided by nurse practitioners (NPs).
Among the survey's findings:
- A large majority favors removal of requirements that NPs work only under the supervision of physicians. Sixty-two percent of respondents support allowing NPs to prescribe medications and order diagnostic tests without such supervision. Just 17 states and the District of Columbia currently grant NPs full-practice authority, according to AANP.
- An overwhelming majority of Americans back legislation making it easier to choose NPs as their health care providers. Seventy percent of respondents favor legislation to eliminate barriers preventing patients from choosing NPs.
- There is widespread familiarity with NPs. Eighty percent of respondents have either seen an NP or know someone who has. More than half (53 percent) say a family member has seen one.
"These results clearly confirm what we have known anecdotally for years: American health care consumers trust NPs and want greater access to the safe, effective services they provide," AANP Co-President Ken Miller said in a news release.
The telephone survey was conducted by The Mellman Group, a Washington, D.C.-based polling firm. Its margin of error is +/-3.1 percent at the 95-percent level of confidence.
This is part of the December 2013 issue of Sharing Nursing's Knowledge.
“Nurse practitioners, health aides, pharmacists, dietitians, psychologists and others already care for patients in numerous ways, and their roles should expand in the future. The rise of nonphysician providers will enable more team care. Skilled health aides will monitor patients at home and alert a doctor if certain medical parameters decline. Nurses will provide wound care to diabetic patients, adjust medications like blood thinners and provide the initial management of chemotherapy side effects for cancer patients. ... Policy changes will be necessary to reach the full potential of team care. That means expanding the scope of practice laws for nurse practitioners and pharmacists to allow them to provide comprehensive primary care ... Most important, we need to change medical school curriculum to provide training in team care to take full advantage of the capabilities of nonphysicians in caring for patients.”
-- Scott Gottlieb, MD, American Enterprise Institute, and Ezekiel J. Emanuel, MD, PhD, University of Pennsylvania, No, There Won’t Be a Doctor Shortage, New York Times, December 4, 2013.
“Let me put it this way, we have over 1,200 pre-nursing students. I can only take about 108 a year. In the fall, we had over 600 applicants for 44 positions. Realistically, we are turning away people with 3.6 and 3.7 GPAs. And I think that story is playing out on CSU campuses everywhere.”
-- Dwight Sweeney, PhD, California State University, San Bernardino, Nursing Students Being Turned Away Amid Faculty Shortage in Cal State System, Los Angeles Daily News, December 1, 2013
Linda H. Aiken, PhD, FAAN, FRCN, RN, is the Claire M. Fagin Leadership Professor in Nursing, a professor of sociology, and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. Aiken is a research manager supporting the Future of Nursing: Campaign for Action and a National Advisory Committee member for the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative. This is cross-posted on the Leonard Davis Institute Voices blog.
All too often, the debate about expanding the role of nurse practitioners (NPs) and physician’s assistants (PAs) takes place in a vacuum, as though these practitioners do not already deliver significant amounts of primary care. But they do, and existing evidence indicates that quality of care and patient satisfaction are good as a result.
Even before the passage of the Affordable Care Act, the nation had a shortage of primary care providers. The shortage is likely to intensify when the demand for primary care increases as millions become insured. The numbers of and roles assumed by NPs and PAs have been growing steadily, and allowing these providers to take on an even greater role could address the increased demand for primary care.
Susan B. Hassmiller, PhD, RN, FAAN, is senior adviser for nursing at the Robert Wood Johnson Foundation, and director of the Future of Nursing: Campaign for Action.
On Thursday, New York Times blogger Pauline Chen, MD, took a fresh look at the disagreements over the services that advanced practice registered nurses should be authorized to provide, reporting on a primary care meeting at which a doctor dared to raise “the unmentionable” topic with his colleagues. The room, she reports, erupted into discord and chaos.
The same divide was documented in a survey reported by the New England Journal of Medicine in May. It is a terrible shame. What we need, now more than ever, is open and reasoned conversation within and between health care fields about the best way to provide high quality care and improve our population’s health.
These are challenging times for our health care system. Millions of Americans are about to gain insurance through the Affordable Care Act. Our population is getting older and living with more chronic illnesses. And we have an urgent need to promote prevention, improve quality, and contain costs.
There is no question that we need more physicians and more primary care physicians in particular. There is no question that physicians should treat the sickest patients and those with the most complex health problems. But there also is no question that we need nurse practitioners to be able to practice to the full extent of their education and training.
The Iowa Supreme Court ruled last week that advanced registered nurse practitioners (ARNPs) can supervise fluoroscopy, a high-tech X-ray and imaging procedure. The high court ruling was in response to a challenge by three nursing organizations to an earlier decision from a district court.
“We believe the district court erred in second-guessing the department of public health and nursing board on the adequacy of ARNP training to supervise fluoroscopy,” the Iowa Supreme Court wrote. “The record affirmatively shows ARNPs have been safely supervising fluoroscopy and are adequately trained to do so… Allowing ARNP supervision of fluoroscopy improves access to healthcare for rural Iowans and helps lower costs.”
Experts say the ruling has implications for patients, especially those living in rural areas with limited access to doctors, who will be able to get test results more quickly. That can alleviate fears if the fluoroscopy shows that a patient does not have a serious health problem or, conversely, it can facilitate quicker treatment if a patient needs it.
Julie A. Fairman, PhD, RN, FAAN, is Nightingale Professor of Nursing at the University of Pennsylvania School of Nursing, and director of the Barbara Bates Center for the Study of the History of Nursing. She is a predoctoral fellow at the Penn Nursing Center for Health Outcomes and Policy Research and recipient of an RWJF Investigator Award in Health Policy Research. Safiyyah Okoye, BSN, RN, and Jill Vanek, BSN, MSN, are students at the University of Pennsylvania School of Nursing.
The 2011 Institute of Medicine (IOM) report “Future of Nursing: Leading Change, Advancing Health” pointed out that because nursing scope of practice regulations vary across states, and because there is little rationale for these variations, the federal government, through the Federal Trade Commission (FTC) and the Antitrust Division of the Department of Justice, “is well situated to promote effective reforms [related to regulation of APRN scope of practice] by collecting and disseminating best practices from across the country and incentivizing their adoption.”
The IOM recommended that the FTC and the Department of Justice review existing and proposed state regulations related to advanced practice registered nurses (APRNs) to identify those that limit competition without contributing to the health and safety of the public, and urge such states to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.
Created in 1914 to promote consumer protection by eliminating and preventing anticompetitive, unsafe, or deceptive business practices, the FTC is the logical agency to address scope of practice laws. The FTC’s responsibility is to promote competition, inform consumer choice, and protect consumer safety. All are directly related to APRN scope of practice regulations, including those mandating physician supervision and oversight of APRNs when there is not “a compelling consumer protection rationale” for doing so. That includes evidence justifying restrictions on APRNs’ ability to provide health care services that could override the public interests with regard to choice, cost or competition.
Judith Hansen, MS, BSN, RN, is the executive director of the Wisconsin Center of Nursing and co-lead of the Wisconsin Action Coalition.
Since the release of the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, leaders in Wisconsin have made concerted efforts to plan well and engage nurses and key stakeholders. Our goal is to empower them with a firm foundation so they will be ready to implement the report’s recommendations.
Our first task was to create awareness and knowledge of the IOM Report, so initial efforts began even before we were designated as a state Action Coalition. In September 2010, the University of Wisconsin-Madison (UW) School of Nursing launched the report by bringing ‘home’ Donna Shalala, PhD, FAAN, former chancellor at UW.
Shalala, also a former head of the U.S. Department of Health and Human Services, chaired the Committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, at the IOM, and provided a powerful keynote address to engage the nurses of Wisconsin. To continue this process, the Wisconsin Center for Nursing (WCN), utilizing its partnership and grant funding through the Wisconsin Department of Workforce Development, sponsored a summit in May, 2011.
As the state’s nursing workforce center, WCN has existing partnerships with a vast array of partners including the Wisconsin Nurses’ Association, the Wisconsin Nurses’ Coalition, the Administrators of Nursing Education in Wisconsin, the Wisconsin Organization of Nurse Executives, the Wisconsin Department of Health Services, the Wisconsin Healthcare Workforce Data Collaborative, and baccalaureate and technical school education programs.