Expanding the Scope of Advanced Practice Registered Nurse Practice

Primary Care: Advanced Nurse Practitioners
In recent years, there has been a notable shortage of primary care physicians due to a number of systemic factors within the healthcare system, including the rising cost of medical school, which is driving many young physicians to choose specializations rather than the field of primary care. Yet primary care is on the front lines of protecting the health of patients. Primary care can prevent the festering of chronic diseases and is less expensive and less intrusive to the healthcare system and the patient as a whole than is secondary or tertiary care. This paper will examine the existing literature on the role of nurses in primary care and evaluate the role nurses can play in improving this area of medicine.
Synopsis of Studies
According to a 2012 study in Health Affairs journal, physicians groups have strongly opposed the expansion of the role of the advanced nurse practitioner (APRN) into primary care, arguing that physicians have unique capabilities that cannot be replicated and this will threaten patient safety. However, the objectivity of this claim has been questioned, given that a systematic review of 26 studies “found that health status, treatment practices, and prescribing behavior were consistent between nurse practitioners and physicians” (“Nurse Practitioners and Primary Care,” 2012, par. 13). In fact, arguably, the use of physicians for routine primary care overtaxes the healthcare system’s scarce resources of physicians, which can be better employed in other areas.
Unfortunately, many states still limit the scope of APRNs. But given that it takes a much shorter period of time to educate an APRN than a physician, the journal Health Affairs argues that since there is no substantive difference in quality of care or patient satisfaction and considerable cost savings and benefits, expanding the scope of primary care on a nationwide basis is vital to address the shortage. A study by Bauer (2010) likewise confirmed that, in the wake of the passage of the Affordable Care Act (ACA) which, if it continues to stand as a matter of law, will increase the demand for primary care physicians as more and more individuals have health insurance and see providers on a regular basis, APRNs offer a cost-effective alternative to primary care physicians. Although there still is a shortage of nurse practitioners, the rate of APRNs is still projected to grow in the future at a faster rate than primary care physicians. As noted by Auerbach (2012), the number of nurse practitioners is projected to grow by 13% by the year 2025.
Qualitative research has also been found to validate the inclusion of APRNs. A study by Poghosyan (et al. 2017) of primary care NPs recruited from the Massachusetts Coalition of Nurse Practitioners found that the distinction between the role of NP and physician was clearly defined and that they were able to function effectively within their scope of practice without encroaching upon the physicians’ exclusive roles under the law. When APRNs are supported, their roles with other healthcare providers were described as being characterized by “favorable relationships, characterized by ongoing communication, trust, respect, and willingness for collaborative practice (Poghosyan et al., 2017, par.15). But in Massachusetts, APRNs are given wider scope of practice than in many other states. As noted by Xue (et al. 2016) in a systemic review of state laws, scope of practice laws are one of the most critical barriers in expanding APRN’s ability to practice to the full range of their ability, regardless of individual institutional support.
This is significant, given the need for interdisciplinary communication in healthcare and is testimony to the importance of dialogue rather than hostility between providers. Although the results from qualitative research are not always widely generalizable, the Poghosyan (et al. 2017) study highlights how positive relationships between APRNs and patients can be fostered within primary care without threatening physicians. Massachusetts has also had universal healthcare for all of its citizens for longer than most of the nation and thus functions as a useful test case example of cost savings in using APRNs.
This qualitative study likewise confirmed an earlier quantitative study by Poghosyan (et al. 2015), which compared practice environments in Massachusetts and New York state using the Nurse Practitioner Primary Care Organizational Climate Questionnaire in which NPs reported having good relationships with physicians and that the main problems they encountered were related to administrative issues and a lack of institutional support, versus role conflicts with physicians. In fact, even a study in the New England Journal of Medicine has supported the use of APRNs, with Donelan (et al. 2013) citing a 2010, Institute of Medicine study entitled The Future of Nursing: Leading Change, Advancing Health advocating that APRNs “practice to the full extent of their education and training” (par. 8).
The NEJM study still noted a great deal of pushback from primary care physicians in regards to the IOM recommendation, as its quantitative survey of 467 nurse practitioners and 505 physicians revealed 70% of physicians and 90% of nurse practitioners agreed that nurses should be able to practice at the full, legal scope of their abilities but physicians disagreed that nurses were capable of fulfilling many critical functions, including leading medical homes or receiving comparable pay to what physicians receive for the same services (Donelan et al. 2013). Not only does this indicate conflict between the different provider roles in practice, it also indicates there may be conflict about the definition of what constitutes the full scope of advanced nursing practice within the field of primary care.
It should be noted, however, that the NEJM study was a general survey of primary care physicians, versus earlier studies which had focused on specific areas of the nation in which APRNs had been practicing independently for longer periods of time; it also asked in addition to expanding the scope of practice under the law if whether APRNs should be compensated more for their services, versus whether they should provide such services at all. In fact, one of the arguments for APRNs is that since they are compensated at a lower rate of reimbursement by Medicaid and Medicare, they can offer more cost-effective primary care to vulnerable, low-income and elderly populations (which are making up a higher percentage of the healthcare system’s population in the United States) than can primary care physicians.
In a study by Ying and Intrator, (2016), low-income individuals, racial minorities, and other disadvantaged groups in healthcare such as veterans are at far greater risk for a wide array of chronic illnesses, including diabetes, obesity, Alzheimer’s disease, depression and cardiovascular conditions. Nurse practitioners can engage in valuable outreach to such groups, particularly in areas where there is little healthcare access, such as rural areas. This highlights the extent to which the primary care physician shortage has had adverse effects, not simply in the healthcare system in general, but on specific population groups. The authors note that health inequalities associated with historically discriminated-against groups “have been associated with enormous economic costs, resulting in $229 billion in direct medical care expenditures and $1.24 trillion in lost productivity from 2003 to 2006” (Ying & Intrator, 2016, par.3). Rectifying this imbalance between NPs and physicians thus has a social justice dimension, not simply a cost dimension.
Synthesis
Overall, the balance of evidence suggests that empowering nurse practitioners to practice to the full scope of their care will result in cost savings and comparable levels of care to physicians. For specific populations that have inadequate access to primary care, expanding scope of practice laws can be particularly vital. However, legal constraints and in some instances resistance by physicians continue to hamper APRNs, despite the existing shortage of primary are physicians.
Discussion: Study Design
Both qualitative and quantitative studies have been used to justify expanding the scope of practice of APRNs. Quantitative studies, however, have the advantage of providing concrete evidence-based data to suggest a change in policy. One possible study would be to compare high-risk individuals with chronic diseases in states with expansive scope-of-practice laws versus those with relatively narrow laws and to compare health results using large data sets. Controls for sociodemographic factors would be necessary but this would determine if, over time, empowering APRNs had a detrimental effect upon the healthcare outcomes of the populations expanded access to primary care (through the ACA and APRN outreach to underserved areas) can provide.


Conclusion
Current data suggests that APRNs can rectify deficits in providing primary care to certain populations. Expanding scope-of-practice laws and combating resistance by physicians with evidence from systematic reviews and other data which meets the gold standard of hard evidence is critical in allowing APRNs to practice at the full range of their abilities.


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