In the view of many policy-makers, Advanced Practice Registered Nurses (APRNs) have a vital role to play in meeting the increased demand for health care services resulting from health care reform, an aging population, and looming health workforce shortages. But significant hurdles must first be cleared, including legal restrictions on APRNs' practice and a variety of institutional and cultural barriers. The 20th issue of the Robert Wood Johnson Foundation's Charting Nursing's Future (CNF) series of policy briefs examines the problem in detail, highlighting examples in which such barriers have been overcome.
It has been nearly five decades since the University of Colorado launched a pilot program to give baccalaureate-trained practicing public health nurses the additional skills they would need to provide well-baby and well-child care, according to the brief, Improving Patient Access to High Quality Care: How to Fully Utilize the Skills, Knowledge, and Experience of Advanced Practice Registered Nurses. The program effectively created a new type of health care provider: the pediatric nurse practitioner.
“It created quite a stir for the nurse to move the stethoscope from the arm for the blood pressure to the chest to listen to the heart,” says Loretta Ford, EdD, RN, PNP, who pioneered the program. But the nurses were well received by patients, and the movement grew, both in numbers and in the scope of practice for these well-educated nurses. APRNs now provide primary care and various kinds of specialty care to people of all ages as nurse practitioners, nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.
Barriers to Practice
But today, just when the country needs these nurses the most, significant obstacles block their ability to help patients. Perhaps the most significant problem is that many states restrict APRNs' practice by law or regulation. Most states require APRNs to have a joint protocol with a collaborating physician in order to diagnose, treat, and prescribe. As the CNF brief notes, the Institute of Medicine's 2010 landmark report, The Future of Nursing: Leading Change, Advancing Health, found no evidence that such requirements result in better outcomes for patients. By contrast, these restrictions can delay care if physicians are not readily available, and can make it difficult for APRNs to provide care in rural areas where doctors are often scarce.
In addition, Medicare imposes restrictions on whether APRNs can admit patients, serve as primary care providers, or sign orders for long-term care services. Similarly, Medicaid won't reimburse APRNs for certain services, and health insurance companies are not required to recognize APRNs as primary care providers or reimburse them directly.
Institutional and cultural barriers are a problem as well. At some hospitals, for example, medical staff bylaws restrict who can admit patients or perform certain procedures, even if a qualified APRN is available. And in many health care institutions, implementation of team-based, interprofessional collaboration is defeated by dated models of authoritarian leadership.
Models for Success
The CNF brief highlights a number of examples where such barriers have been overcome:
The US Department of Veterans Affairs (the VA) employs more than 5,000 APRNs at its facilities across the nation, and they deliver primary, specialty, acute, ambulatory, tele-health, and home health care services. But the scope of their practice depends on where specifically they serve. In an effort to standardize care, the VA has developed a new policy that it intends to implement this year that will allow APRNs who meet certain criteria to practice to the full extent of their education and training without direct supervision from a physician. The VA has concluded that the constitutional doctrine of federal supremacy supports the policy, which will effectively supersede state laws in some instances. “We see this as a way to align our system to fully utilize the talent we have,” says Cathy E. Rick, RN, FACHE, FAAN, chief officer in the VA’s Office of Nursing Services. “The timing is right, thanks to the good work the Robert Wood Johnson Foundation did in conjunction with the IOM [Future of Nursing] report.”
The University of Pennsylvania Health System has pioneered the Transitional Care Model, an approach that relies on ARPN specialists to design and implement comprehensive plans for follow-up care for discharged hospital patients. The plans include regular telephone outreach and home visits to convalescing patients. The model has been tested repeatedly with high-risk, high-cost, high-volume patients of all ages, with impressive results. The initial clinical trial focused on perinatal and neonatal nursing care for very low-birthweight infants. The result: Infants were released from the hospital an average of 11 days earlier, with equivalent health outcomes, and a net savings of more than $18,000 per patient. Subsequent trials have tested the approach on women with high-risk pregnancies, as well as chronically ill older adults. Those tests turned up positive results, too, with improved health outcomes, patient satisfaction, and cost savings. In addition to the University of Pennsylvania, some two dozen health systems and communities have employed some form of the model.
The Duke University Health System's Department of Cardiovascular Medicine has adopted an interprofessional team-based approach to increase access to care and improve patient satisfaction. The approach contrasts with the department's previous model, in which clinics were run by MDs who handed off specific tasks to nurse practitioners (NPs) and physician assistants (PAs). Under the new model, doctors, nurses and PAs are all able to work to the top of their competency and licensure. “A model like this requires a cultural shift” says Allison Dimsdale, DNP, RN, NP, who spearheaded the redesign. The NPs have a broader set of responsibilities than before, and physicians have to learn to recognize and rely on NPs and RNs as teammates. “We couldn’t do this without considerable trust and confidence among key players,” Dimsdale says.
These and other models offer the promise of a truly patient-centered and more cost-efficient health care system. In the words of Lloyd H. Dean, CEO of Dignity Health and a member of the strategic advisory committee of the Future of Nursing: Campaign for Action, an initiative of the Robert Wood Johnson Foundation and AARP, "Although research suggests that APRNs are well equipped to deliver safe and effective care, legal, regulatory, institutional, and cultural barriers prevent many from practicing to the full extent of their training and education. We need to change that to make the best use of health care’s human capital.”
Read Charting Nursing's Future Issue 20: Improving Patient Access to High Quality Care: How to Fully Utilize the Skills, Knowledge, and Experience of Advanced Practice Registered Nurses.