Nursing Shortages in the United States

Introduction
One of the main objectives of the Office of Disease Prevention and Health Promotion’s Healthy People 2020 campaign is to increase access to care for patients (ODPHP, 2018). However, with more and more primary care physicians leaving primary care for specialized medicine, there is a gap in care coverage. That gap could be filled if advanced practice registered nurses (APRNs) were permitted to practice to the full extent of their education and training—but they are not. The Institute of Medicine (IOM, 2010) recommends that they should and gives explicit steps on how that recommendation can come about.
Selected Recommendation
Recommendation #1: “Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following actions” (IOM, 2010, p. 1).
Background
The field of nursing was originally promoted to help fill the gap created by the demand for services and the lack of providers in the latter half of the 20th century when more and more people began using health care. Throughout the ‘50s and ‘60s, physicians collaborated with and trained nurses so that the latter would be able to give primary care to patients (O’Brien, 2003). However, there was no adequate channel for credentialing these nurses, and their education and training was never quite put to use in the way it was intended. The IOM (2010) has stressed that now is the time to make that happen.
Current Characteristics
Some states are beginning to listen to what the IOM (2010) has urged. The Robert Wood Johnson Foundation (2015) reports that “in March, Nebraska granted nurse practitioners (NPs) the ability to provide the full complement of services they are educated and trained to deliver. In May, Maryland enacted its own ‘full-practice authority’ law. And similar legislation is pending in many other states.” However, many other states are still behind the curve and old laws preventing nurses achieving the full scope of their practice remain on the books.
Impact of the Recommendation
From the Perspective of Consumers
Consumers would benefit because they would have increased access to care.
From the Perspective of Nurses
Nurses would benefit because they would finally be free from all scope-of-practice barriers.
From the Perspective of Other Health Professionals
Other health professionals such as primary care physicians would benefit because there would be less pressure and stress placed on them to provide all the access points to care.
From the Perspective of Additional Stakeholders
Legislators and the communities they represent would benefit because the former would enjoy the appreciation and support of their constituents, who would benefit because their communities would now have greater freedom to gain access to care.
Current Solutions
The current solution, recommended by the IOM is to eliminate scope-of-practice barriers by expanding and amending the Medicare program to cover services provided by APRNs in the same manner that they cover the services provided by physicians.
Other solutions include (IOM, 2010):
· Extend the increase in Medicaid reimbursement rates for primary care physicians included in the ACA to advanced practice registered nurses providing similar primary care services.
· Limit federal funding for nursing education programs to only those programs in states that have adopted the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18).
· Require insurers participating in the Federal Employees Health Benefits Program to include coverage of those services of advanced practice registered nurses that are within their scope of practice under applicable state law.
· Review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anticompetitive effects without contributing to the health and safety of the public. States with unduly restrictive regulations should be urged to amend them to allow advanced practice registered nurses to provide care to patients in all circumstances in which they are qualified to do so
Final Conclusions
The IOM’s (2010) recommended solutions would help to bring about more equity in the health care industry by granting APRNs the freedom to practice to the fullest extent of their education and training. The Office of Disease Prevention and Health is calling for greater access to care for patients all over the U.S.—and nothing could make that call heard more than the implementation of the IOM’s (2010) recommendations regarding eliminating the barriers to APRN’s scope-of-practice.
References
IOM. (2010). The future of nursing. Retrieved from http://nacns.org/wp-content/uploads/2016/11/5-IOM-Report.pdf
O’Brien, J. (2003). How nurse practitioners obtained provider status: Lessons for pharmacists. American Journal of Health-System Pharmacy, 60(22), 2301-2307.
ODPHP. (2018). Access to health services. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services
Robert Wood Johnson Foundation. (2015). More states removing barriers to nurses’ scope of practice. Retrieved from https://www.rwjf.org/en/library/articles-and-news/2015/07/more-states-removing-barriers.html
2: Policy Analysis
Part 1: Defining the Policy Issue
As the Institute of Medicine (IOM, 2010) has recommended, advanced practice registered nurses (APRNs) must be able to practice to the fullest extent of their education and training. The IOM (2010) asserts that states must “remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training” (p. 1). This policy issue is an important one because it addresses a serious issue in today’s health care environment—the lack of access to care for many patient.
One of the main objectives of the Office of Disease Prevention and Health Promotion’s Healthy People 2020 campaign is to increase access to care for patients (ODPHP, 2018). However, with more and more primary care physicians leaving primary care for specialized medicine, there is a gap in care coverage. That gap could be filled if APRNs were permitted to practice to the full extent of their education and training—but they are not. The Institute of Medicine (IOM, 2010) recommends that they should and gives explicit steps on how that recommendation can come about.
How the Issue Affects the Policy Arena
The field of nursing was originally promoted to help fill the gap created by the demand for services and the lack of providers in the latter half of the 20th century when more and more people began using health care. Throughout the ‘50s and ‘60s, physicians collaborated with and trained nurses so that the latter would be able to give primary care to patients (O’Brien, 2003). However, there was no adequate channel for credentialing these nurses, and their education and training was never quite put to use in the way it was intended. The IOM (2010) has stressed that now is the time to make that happen. This policy affects the policy arena because it calls for a change in the laws and legal framework regarding the practice of medicine, reimbursements, coverage, etc.
Current Politics of the Issue
Some states are beginning to listen to what the IOM (2010) has urged. The Robert Wood Johnson Foundation (2015) reports that “in March, Nebraska granted nurse practitioners (NPs) the ability to provide the full complement of services they are educated and trained to deliver. In May, Maryland enacted its own ‘full-practice authority’ law. And similar legislation is pending in many other states.” However, many other states are still behind the curve and old laws preventing nurses achieving the full scope of their practice remain on the books, and federal law has not budged regarding allowing APRNs to be reimbursed under Medicare.
Level in the Policy Making Process of This Issue
At this time, this issue is being addressed at the state government level. Federal level policy would also have to be addressed in order to meet the recommendations of the IOM (2010) regarding expanding and amending the Medicare program.
Part 2: Applying a Policy Analysis Framework to Explore the Issues
Social Context
American physicians began working closely with clinically-experienced nurses as the need arose in the 20th century. The growing demand for specialized services had caused a number of physicians to leave primary care service behind and focus more exclusively on providing specialized care. This exodus had produced a gap in primary care in many regions of the country. As a result, many patients were not receiving the kind of care they required and desired. Throughout the 1950s and 1960s, doctors collaborated with and trained nurses to offer primary care to these patients (O’Brien, 2003). By 1965, the U.S. provided Medicare and Medicaid to health care patients whose low income meant they were unable to pay for health care. By subsidizing health care costs, the government increased demand for primary care. As physicians had already been moving into specialized care services, nurses played a major role in filling the gap (Medicare Payment Advisory Commission, 2002) and the government was instrumental in making demand possible.
Ethical Context
From a utilitarian perspective, allowing APRNs to practice to the full extent of their education and training is the only ethical step to take: it would benefit the greatest number of people and thus serve the national community as the greatest good. This ethical consideration is rooted in the fact that the APRN is qualified to give this type of care.
Drs. Loretta Ford and Henry Silver developed the first NP program for nursing students. Ford was a nurse and Silver was a physician. Working together they were able to understand what each field could bring to the table in producing a new program that would enable nurses to deliver primary care. This program was geared towards training nurses at a higher level so that they could fill the hole left behind by physicians.
Legal Context
State laws have placed barriers around the extent to which APRNs may practice independently of physicians. This puts pressure on the industry as a whole by restricting in legalistic terms that are outmoded and outdated the ability for patients to obtain access to care.
Historical Context
As O’Brien (2003) states, the curriculum devised by Ford and Silver “focused on health promotion, disease prevention, and the health of children and families.” Nurses were specifically trained to operate at a higher level—precisely that level at which their physician mentors had been training them in the 1950s and early 1960s. The University of Colorado understood the need for health care professionals to do something to address the situation and nurse educators took the initiative to provide nurse students with the education they needed to give patients the care they desired.
By 1979, there were 15,000 nurse practitioners in the U.S. The number of NPs continued to increase, from 15,000 in 1979 to 24,000 in 1983. Steering committees formed, more associations were established, and millions of dollars from the federal government were allocated to help fund nurse practitioner education. By 1989, 90% of all nurse practitioner programs were post-graduate programs (American Association of Nurse Practitioners, 2017).
The lack of a proper channel for credentialing was one of several challenges that the early APRNs faced. The studies that were preformed in the 1970s and 1980s allowed skeptics to see that nurses were fully capable of delivering the kind of primary care that physicians had provided in the first part of the century. Indeed, as has already been shown, a number of studies have indicated that NPs were even more capable of providing quality primary care than physicians. By the 1990s, the primary care physician shortage was no longer as bad as it had been in earlier decades, and some groups within the health care industry wanted to move NPs out of the primary care role (O’Brien, 2003). Mundinger (1994) noted in a study, however, that nurse practitioners should be more appreciated for the job they were doing, stating, “When measures of diagnostic certainty, management competence, or comprehensiveness, quality, and cost are used, virtually every study indicates that the primary care provided by nurse practitioners is equivalent or superior to that provided by physicians” (p. 214). Like so many other researchers, Mundinger (1994) fully validated the hard work and expertise that nurse practitioners were bringing to health care.
Thus, the history of the ARPN is one in which a vital need was evident in the world of health care: more patients were coming to physicians seeking care, yet physicians were leaving the field of primary care services in order to provide specialized care. Patients now able to afford primary care visits thanks to government funding were left without recourse. Nurses, as they have always done throughout history, stepped up and took upon themselves the challenge of meeting the need of patients looking for care. With the guidance of Drs. Ford and Silver, a nurse and physician team working together to address this issue by providing nurses with formal education and training in primary care, the ARPN movement was born. Today, however, it is threatened by legalistic oversight.
Financial/Economic Context
The lack of access to care actually costs communities a great deal for a number of reasons. Would-be patients who are in serious need of medical care but lack access often end up on the streets, homeless, or self-medicating with the use of illicit drugs. These behaviors can land them in jails, which are supported by taxpayer funds. To house a single prisoner costs taxpayers approximately $60,000 per year (Szabo, 2014). There is also an economic toll as so many young men and women who might otherwise be entering the workforce as capable workers are instead denied the care they require and end up leaving the workforce because their infirmities are not treated.
Theoretical Underpinnings of the Policy
As the IOM asserts, nurses should be viewed as equal partners with physicians, as they have trained under them and are qualified to serve patients.
Stakeholders of Interest
Consumers. Consumers would benefit because they would have increased access to care.
Nurses. Nurses would benefit because they would finally be free from all scope-of-practice barriers.
Physicians. Other health professionals such as primary care physicians would benefit because there would be less pressure and stress placed on them to provide all the access points to care.
Legislators and their constituents. Legislators and the communities they represent would benefit because the former would enjoy the appreciation and support of their constituents, who would benefit because their communities would now have greater freedom to gain access to care.
Nursing Policy/Position Statement on this Issue
The IOM (2010) has asserted that the policy of limiting APRN’s scope-of-practice is unconscionable and that all barriers must be removed: “Advanced practice registered nurses should be able to practice to the full extent of their education and training” (p. 1).
Part 3: Policy Options and Solutions
Policy Option/Solution 1—No Change
Theoretical underpinnings. The status quo is acceptable to most.
Health advocacy aspects and leadership requirements. No change would require no effort on the part of advocacy experts and leaders: they could simply ignore the need for greater access to care.
What this option provides in terms of the need for inter-professional
collaboration. No change would mean APRNs in many states still rely on physician oversight in order to practice.
Pros and cons (cost benefits, effectiveness, and efficiency). No pros—all cons: costs would continue to rise for communities suffering from poor access to care (Szabo, 2014). Health care would continue to be less effective and efficient than it could be as the Office of Disease Prevention and Health Promotion (ODPHP, 2018) has pointed out because of the limitations of access to care.
Policy Option/Solution 2—Partial Change
Theoretical underpinnings. What’s good for some is not good for others.
Health advocacy aspects and leadership requirements. Some leaders and advocates are pushing for change in some states—which means a gradual change is occurring in terms of states granting APRNs more room to practice—but federal subsidies may still be withheld which means APRNs risk not being compensated like they should be.
What this option provides in terms of the need for inter-professional collaboration. Without federal regulations changing, APRNs will still likely rely on physician-led practice facilities.
Pros and cons (cost benefits, effectiveness, and efficiency). It has the potential, theoretically, to open access to care, increase effectiveness and efficiency and bring down cost of care through competition.
Policy Option/Solution 3—Maximum Change
Theoretical underpinnings. Equitability among health care professionals is deserved.
Health advocacy aspects and leadership requirements. Advocates and leaders would have to lobby the federal government to update regulations regarding Medicare and Medicaid rules for covering APRN services.
What this option provides in terms of the need for inter-professional collaboration. APRNs could operate fully and independently of primary care physicians.
Pros and cons (cost benefits, effectiveness, and efficiency). Costs care would come down from increased competition; greater access to care would be available, and a more efficient health care industry would thrive.
Part 4: Building Consensus
The recommended policy option for solving the issue is Solution 3—Maximum Change. Step 1 will be to lobby the federal government hard in order to change policy on Medicare and Medicaid, in accordance with the recommended steps of the IOM (2010). Step 2 would be to follow up with local and state governments to press for the end of barriers to APRN’s scope-of-practice. Step 3 would be to work with health care organizations to publish literature in support of the IOM’s call to liberate APRNs.

References
American Association of Nurse Practitioners. (2017). Historical timeline. AANP.
Retreived from https://www.aanp.org/all-about-nps/historical-timeline
IOM. (2010). The future of nursing. Retrieved from
http://nacns.org/wp-content/uploads/2016/11/5-IOM-Report.pdf
Mundinger, M. (1994). Advanced-practice nursing—good medicine for physicians?
New England Journal of Medicine, 330, 211-214.
O’Brien, J. (2003). How nurse practitioners obtained provider status: Lessons for
pharmacists. American Journal of Health-System Pharmacy, 60(22), 2301-2307.
ODPHP. (2018). Access to health services. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services
Robert Wood Johnson Foundation. (2015). More states removing barriers to nurses’
scope of practice. Retrieved from https://www.rwjf.org/en/library/articles-and-news/2015/07/more-states-removing-barriers.html
Szabo, L. (2014). Cost of not caring: Nowhere to go. Retrieved from
https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/