Np Barriers Proposal Nurse Practitioner

Np Barriers Proposal

Nurse Practitioner

personal professional practice barriers proposal

Legally, NPs possess the authority to practice independently. Non-recognition of the NPs authority, however, routinely hinders their ability to put that authority into practice. During the proposed *** study, "Nurse Practitioner Personal Professional Practice Barriers," the researcher will examine a number of existing barriers that may challenge and prevent the NP from establishing an independent practice.

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Background/Paradigm Statement:

NURSE PRACTITIONER

PERSONAL PROFESSIONAL PRACTICE BARRIERS PROPOSAL

Factors of physician dominance, reimbursement, and state rules and regulations have created practice environments that are detrimental to full recognition of NPs as autonomous providers, hence, to their full utilization"

Sandra a. Weiland (2008, Introduction section, ¶ 3).

Background

Nurse Practitioners (NP) are not capable of autonomously providing primary care. This statement, although false, nevertheless, appears to be historically supported by political, professional, and social entities as they have routinely failed to recognize NPs as providers, capable of providing primary care autonomously. In the journal publication, "Reflections on independence in nurse practitioner practice," Sandra a. Weiland, MSC, FNP (2008), Tri-County Family Health Clinic, Wapanucka, Oklahoma, examines numerous factors relating to nurse practitioners practicing as independent primary care providers. Legally, NPs possess the authority to practice independently. Non-recognition of the NPs authority, however, routinely hinders their ability to put that authority into practice. During the proposed study, "Nurse Practitioner Personal Professional Practice Barriers," the researcher will examine a number of existing barriers that may challenge and prevent the NP from establishing an independent practice.

Statement of the problem

As the nurse practitioner role has evolved, despite 40 years of providing documented safe practice, complex federal and state reimbursement policies continue to economically and professionally thwart the prospect for the NP to become an independent practitioner. In turn, "NPs remain in a financially dependent relationship" (Weiland, ¶ 1). On the positive side of this issue, President Clinton passed legislation passed in the Budget Act to increase and expand the role of the nurse practitioner. Recent Legislation in Massachusetts made the nurse practitioner, en masse, primary care providers. NPs possess the autonomy and prescriptive authority of physicians, as they complete about 90% of the work of physicians, yet they only receive approximately 85% of the physician fee.

Research supports the stance that the NP provides care as good as, in some instances better than, the physician to the consumer. Nevertheless, NPs en masse are not establishing their own professional practices.

Research Questions

To address a number of challenges relating NPs establishing their personal, professional practices, the proposed study will address the primary research question: How may the nurse practitioner best address and overcome barriers that may challenge and/or thwart efforts to establish an independent practice? The following five sub-questions will serve to support the answer for the study's leading question:

1. What roles/needs may Nurse Practitioners fill in healthcare?

2. How may the care nurse practitioners provide compare to that of physicians?

3. What barriers may prevent Nurse Practitioners from establishing a personal professional practice?

4. What recent legislation regarding nurse practitioners did Massachusetts pass?

5. What theoretical concept/s may contribute to addressing challenges inherent in the nurse practitioner role?

Study Relevance

In an April 26, 2009 news account, "Shortage of Doctors an Obstacle to Obama Goals," Robert Pear relates contemporary concerns regarding the quest to help ensure the supply of physicians can adequately meet the needs of America's aging population and the reported millions currently uninsured individuals who would gain coverage under legislation the president proposes. Although some sources relate negative perceptions toward the concept of NPs filling positions that physicians traditionally inherit, others heartily support this notion. From the researcher's initial review of literature relating to this current controversial subject, the researcher asserts the proposed study will prove to be significant as it enhances the understanding regarding both sides of an issue that impacts not only local NPs and physicians, but also the individuals, patients and the communities these men and women serve.

Theory

Dr. Patricia E. Benner adapted the Dreyfus model to clinical nursing practice. Ann Marriner-Tomey and Martha Raile Alligood (2006) explain in the book, Nursing Theorists and their Work, that after the Dreyfus brothers studied the performance of chess masters and pilots in emergency situations, they developed the skill acquisition mode. The overview of the work, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, by Benner (1984), Professor Emerita, Dept. Of Social and Behavioral Sciences, University of California, San Francisco, relates Brenner's adaptation of the Dreyfus five levels of skill acquisition. Benner contends that while acquiring and developing a particular skill, the student passes through five levels of proficiency. These levels include" novice, advanced beginner, competent, proficient, and expert" (Sonoma State University, 2001, Benner's Stages…section). In the book, Expanding Nursing Knowledge: Understanding and Researching your Own Practice, Gary Rolfe (1998), explains that Benner advocates " the nurse's own professional judgment, consisting of a combination of personal and experiential knowledge in addition to the knowledge obtained from scientific research, is just such an epistemology of practice…" (p. 40). Benner significantly influenced the notion of expertise.

During the next section of the proposed study, the Literature Review, the presents relevant information to enhance the understanding of existing barriers that may challenge and prevent the NP from establishing an independent practice. This information, in time, will relate answers to how the NPs may counter those challenges to establish a personal professional practice.

CHAPTER II

LITERATURE REVIEW

The key aspects of a research proposal include conducting an extensive literature survey, Dr. Henry N. Kemoni (2008), Senior Lecturer at the School of Information Sciences, Moi University, Kenya, explains. In the report, "Theoretical framework and literature review in graduate records management research," Kemoni stresses that as the researcher must become familiar with the study phenomenon, the literature helps the researcher gain a valid understanding of the selected research problem. During the literature review for the forthcoming study, the researcher plans to address the following themes to support the proposed study:

Roles/Needs Nurse Practitioners Fill

Nurse Practitioners and Physician Care Compared

Barriers to Establishing Professional Practice

Recent Massachusetts Legislation

Theoretical Concepts to Address Challenges

Roles/Needs Nurse Practitioners Fill

The number of nurse practitioners in the U.S. during 2006 was estimated to be at least 145,000. The publication, "Frequently asked questions about nurse practitioners," (2006) contends that NPs, registered nurses prepared, through advanced education and clinical training, provide a broad range of preventive and acute health care services to individuals of all ages.

NPs take health histories and provide complete physical examinations; diagnose and treat many common acute and chronic problems; interpret laboratory results and X-rays; prescribe and manage medications and other therapies; provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance; and refer patients to other health professionals as needed. NPs are authorized to practice across the nation and have prescriptive privileges, of varying degrees, in 49 states. (Frequently asked…, 2006, p.1).

The article, "Frequently asked questions about nurse practitioners," (2006) further contends that nurse practitioners have provided a healthy partnership with their patients for more than 40 years. The nurse practitioner role had its inception in the mid-1960s in response to a nationwide shortage of physicians. The first NP Program was developed as a master's degree curriculum at the University of Colorado's School of Nursing in 1965, founded by Loretta C. Ford, a nursing faculty member and Dr. Henry K. Silver, a pediatrician. Programs were developed across the country to provide additional education for experienced nurses to enable them to provide primary health care services to large underserved populations. The first programs were in pediatrics and they soon spread to many other health care specialties (Frequently asked…, 2006, p.1).

Dr. Jenny Carryer, Clinical Chair of Nursing, Massey University, New Zealand, Dr. Glenn Gardner, Professor Clinical Nursing, Queensland University, Dr. Sandra Dunn, Professor Clinical Nursing Practice, Flinders University/Medical Centre, Melbourne and Dr. Anne Gardner (2007), Associate Professor Nursing, Deakin University and Cabrini Health, Melbourne, predict that due to the increasing need to manage chronic illness, to deliver effective primary health services, and to effectively manage workforce challenges, NPs will constitute a vital component of the future health workforce. In the journal publication, "The capability of nurse practitioners may be diminished by controlling protocols," Gardner, Dunn and Gardner note that the NP role historically originated in the United States during the 1960s to help improve primary health care to under-serviced communities. The NP provides a "flexible, accessible and much needed service, which easily spans the boundaries of health maintenance and illness management" (Carryer, Gardner, Dunn & Gardner, 2007, Workforce flexibility section, ¶ 2). Not utilizing NPs to their fullest potential, due to constraining protocols, these authors contend, wastes human resource that could contribute to the well-being of patients who need their care.

Nurse Practitioners and Physician Care Compared

Under the supervision of physicians, according to Weiland (2008), NPs serving as physician extenders improved physician productivity and income. Emphasizing the medical role of the NP as a physician substitute, however, Weiland argues, proves unfortunate as the philosophical approach of the NP differs from that of the MD. The NP emphasizes health promotion, while, particularly in North America, the MD primarily focuses on disease treatment. The role of the NP and the MD are simultaneously similar yet differ from each other. Consequently, no reason supports the contention that one group must be dependent and the other dependent. "Measuring NP performance against the physician (or any other group) as the gold standard is inappropriate because the philosophical approach of the NP is singular," Weiland (the NP as…section, ¶ 2) stresses. NPs offer a unique approach to health care and are independent providers of health care services. They are not physician substitutes. Weiland points out:

Underutilization of NPs has been estimated to cost society approximately $9 billion annually. Indeed, the social burden of healthcare spending nears $1.9 trillion. Medicare alone spent up to $256.8 billion in 2003. Additionally, a physician shortage of 200,000 is projected by 2020, and 46.6 million people are currently without health insurance. The impact is that society is paying for nonrecognition of this resource, not just financially but by a serious lack of access to care. The role of NPs can be carried out only with full professional recognition as independent providers. (Weiland, 2008, Introduction section, ¶ 3)

Dr. Alice Running, Associate Professor, Orvis School of Nursing, University of Nevada, Lisa Hoffman and Victoria Mercer (2008), both of Department of Psychology, University of Nevada, note that due to dramatic changes in health care in the U.S. during the last decade, significant healthcare reorganization occurred. In turn, relationships with other healthcare providers have started to shift, with new roles for NPs beginning to evolve. Shifts in these relationships, possibly relate to increasing independent practice, as well as access to medications requiring licensure, and direct Medicaid and Medicare reimbursement. Consequently as numerous NPs also apply for and obtain hospital privileges comparable to those of physicians, the ensuing changes potentially affect the dynamic relationship between NPs and physicians. Research demonstrates that as NPs work in collaboration with physicians, the health care system improves in a number of ways, including improved patient access and reduced physician workloads, contributing to increased reports of physician job satisfaction. Productivity within practices has been enhanced, and patient satisfaction has increased" (Running, Hoffman & Mercer, 2008, Introduction section, ¶ 2). Although NPs, perceived as versatile and flexible, also regularly fill the gaps in specialty settings, they typically receive 40% less than physicians.

Barriers to Establishing Professional Practice

As the researcher alluded to during the proposed study's introduction, a number of factors prove detrimental NPs securing full recognition of as autonomous providers of medical care. Some of the components which thwart NPs establishing private practice environments where their services may be fully utilized not only include physician dominance and reimbursement challenges, but also federal and state rules and regulations Weiland (2008) notes a number of social and economic outcomes of nonrecognition and underutilization of NPs to include:

1. Denial of primary provider status,

2. decreased patient access to care, and

3. increased healthcare costs (Weiland, 2008, Introduction section, ¶ 3).

In the journal publication, "Shifting Patterns of Practice: Nurse Practitioners in a Managed Care Environment," Dr. Rosemary Johnson (2005), University of Southern Maine, Portland, Maine, explains how managed care affects the NPs' daily practice and ways NPs respond to a changing managed care workplace. According to findings from this study, tension between a business and a professional ethic concerns NPs as managed care values emphasize "cost containment, efficiencies, and bottom line issues" (Johnson, Discussion section, ¶ 1). Values the NP providers support, on the other hand, emphasize patient-centered holistic care. At the heart of the NP role, Johnson concludes, NP students need to be better prepared for the business side of professional practice, as well as in the ethical dilemmas that occur when one attempts to balance a business and a professional ethic.

Linda Miller Atkinson (2007), a partner in Atkinson, Petruska, Kozma & Hart, notes in the journal publication, "Who's really in charge? Physician assistants and nurse practitioners are common in health care facilities. But how much responsibility do they have? If a patient is injured, you need to find out who - the midlevel provider, the supervising doctor, the facility, or all of them - is responsible," that due to legal constraints, physicians always supervise clinically practicing physician assistants and nurse practitioners. This practice reportedly links to avoiding potentially dangerous and sometimes deadly results, such as the following:

Hospital emergency departments often delegate walk-ins to midlevel providers who are not supervised directly or consistently.

Private family clinics use "sign-in logs" to separate patients who need or want to see a doctor from those who can see midlevel providers, leaving this clinical decision to the patient -- the person least capable of making it.

Surgeons use midlevel practitioners as assistants and then delegate follow-up responsibilities including ordering medications and determining when to discontinue them -- to them. In some cases, surgeons effectively abandon their patients.

In large measure, health care in prisons is provided almost entirely by PAs who are hesitant -- because of budgetary pressures -- to order testing or transport to a hospital, and whose supervision consists of having a physician review the charts weekly at most.

Specialists depend on midlevel providers for monitoring and follow-up even in complicated medical cases, expecting them to alert the specialists to drug reactions, drug toxicities, and other complications that often exceed the midlevel provider's expertise. (Atkinson, 2007, the problem section, ¶ 1-6).

Atkinson (2007) points out that each state has enacted enabling statutes to define and regulate permissible activities of midlevel providers, such as NPs, may provide. Traditionally, to regulate NPs, states define their scope of practice, require they be supervised by a licensed physician, require a particular level of written direction, and control the level of education required for licensure.

Weiland (2008) purports that organized medicine has been a stalwart in discrediting NPs as competent providers.that in order to maintain the medical profession's dominance as well as the exclusivity of their role as primary care providers, o Dr. Ford recalls a time when the American Medical Association depicted "NPs as ducks (symbolizing "quacks")..." (p. 31 (.Despite four decades of collegial collaboration and numerous compelling studies that demonstrate NPs are competent, that is, quality of care is no different from that of physicians, physicians continue to express concerns that NPs lack the training necessary to provide comparable care (Weiland, 2008, Evolution of…section, ¶ 1).

Recent Massachusetts Legislation

The article, "Legislative news," (2008) explains that Massachusetts recently began to address its primary care provider shortage by passing legislation (Chapter 305), proposed by Senate President Therese Murray, to confront issues of access, quality and transparency in health care. "The recognition of nurse practitioners as primary care providers is vital to this legislation and will immediately and dramatically increase the number of providers available to residents" (Legislative news, ¶ 1). The need for legislation such as this proves critical as a number of Massachusetts physicians do not currently accept. Some individuals seeking medical care in the state, according to the Massachusetts Medical Society, have to wait an average of 8-12 weeks to schedule a primary care appointment.

Currently, the law requires all Massachusetts health insurers to recognize NPs as primary care providers, a potential solution to the current primary care challenges Massachusetts currently seeks to resolve. Nancy O'Rourke, president of the Massachusetts Coalition of Nurse Practitioners, stresses that nurse practitioners can effectively diagnose, treat and prescribe medications in each state in the U.S. According to the Massachusetts Medical Society, recently most patients who present to a primary care practice and see a nurse practitioner deliberately chose to do so. As NPs provide care and manage chronic disease, they constitute an ideal remedy to solvingthe shortage of primary care providers not only in Massachusetts, but throughout the U.S.

Theoretical Concepts to Address Challenges

According to the Dreyfus model which Benner adapted to nursing, noted earlier in the study proposal, as an individual acquires and develops a skill, he/she passes through the following five levels of proficiency (abbreviated for the proposal):

Stage 1: Novice: Beginners have had no experience of the situations in which they are expected to perform. Novices are taught rules to help them

Stage 2: Advanced Beginner: Advanced beginners are those who can demonstrate marginally acceptable performance, those who have coped with enough real situations to note, or to have pointed out to them by a mentor, the recurring meaningful situational components

Stage 3: Competent: Competence, typified by the nurse who has been on the job in the same or similar situations two or three years, develops when the nurse begins to see his or her actions in terms of long-range goals or plans of which he or she is consciously aware

Stage 4: Proficient: The proficient performer perceives situations as wholes rather than in terms of chopped up parts or aspects, and performance is guided by maxims. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals

Stage 5: The Expert: The expert performer no longer relies on an analytic

principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action. The expert nurse, with an enormous background of experience, now has an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions. The expert operates from a deep understanding of the total situation…. (Benner, as cited in Sonoma State University, 2001, Benner's Stages…Section)

The literature in the proposed study will expound on theoretical concepts to address challenges to NPs establishing personal professional practices, as well as other themes noted in the proposal's literature review. The literature reviewed will ultimately address the study's primary research question: How may the nurse practitioner best address and overcome barriers that may challenge and/or thwart efforts to establish an independent practice? During the next chapter, the Methodology, the researcher explains how the study proposes to conduct the forthcoming study.