Nurse Practitioner Autonomy and Primary Care Independence

Introduction

The current role of nurse practitioners in the United States will need to be upgraded significantly in the near future for two important reasons. First, as components of the Affordable Care Act (ACA) become law and the Act extends coverage to an additional 32 million Americans who will need healthcare, there will be a critical shortage of physicians to serve all those new patients — many of them Baby Boomers moving into and past retirement. Recent estimates project that there will be 45,000 too few physicians by 2020. Second, nurse practitioners (NPs) have been trained to handle many, if not most, of the duties of a primary care physician. The severe shortage of doctors means that people will increasingly receive their primary care from a nurse practitioner simply because the dearth of physicians will place those responsibilities on NPs' shoulders. As a result, NPs will gain recognition as competent, talented healthcare professionals — recognition they have not always received in the past.

Thesis: It is time for nurse practitioners to be given the autonomy they deserve so that they may provide primary care for patients independently. The time has come for the healthcare industry — and for the public — to accept nurse practitioners as primary care providers.

A peer-reviewed article in the Journal of Clinical Nursing draws on an empirical study conducted in New Zealand and Australia that clearly illustrates the core role of a nurse practitioner. The research involved in-depth interviews with 15 nurse practitioners across both countries, along with an examination of published scholarship, nurse practitioner program curricula at universities, and relevant policy documents. Because the nurse practitioner position was relatively new in these two countries, the authors believed that developing "a clearly articulated" and empirically informed "description of the core role of the nurse practitioner" could provide the foundation for updated "educational and practice competency standards" (Carryer et al., 2007, p. 1819).

The Core Role of the NP: Professionalism and Clinical Leadership

The authors identified three core competencies that NPs demonstrate — competencies closely aligned with those of primary care physicians. The first is dynamic practice, characterized by "highly developed clinical practice skills" and "comprehensive skills in patient assessment" (Carryer, p. 1821–1822). NPs in this study conducted "direct physical and psycho-social assessment" of patients; in several cases, they also assessed the communities in which patients lived and the environmental circumstances affecting their health (Carryer, p. 1821).

The second core role is professional efficacy, which entails providing healthcare services in an autonomous environment. "Whilst collaboration is important" to the nurse practitioner, the "very nature of the NP role allows that the nurse is responsible for the complete episode of care" (Carryer, p. 1822). This is also the central argument of this paper: nurse practitioners are trained to act autonomously and should be granted that latitude by the healthcare industry.

The third core role is clinical leadership, which involves delivering "both extensive and extended clinical skills" to patients (Carryer, p. 1823). Clinical leadership also means that NPs are expected to "inform and guide" national and local healthcare policies relevant to good nursing practice.

The central argument of this paper is that it is long overdue for nurse practitioners to become wholly independent of physicians and hospital systems. Nurse practitioners are proven to be competent and rigorously trained, and with the looming physician shortage driven by the ACA, NPs will soon play a significantly larger and more critical role in American healthcare.

Nurse Practitioners and Their Independence

An article in the peer-reviewed Journal of the American Academy of Nurse Practitioners clearly identifies the problem: while the legal authority for NPs to practice independently has long been acknowledged, the ability to "put that authority into practice" has been consistently "undermined" due to the "historical failure of political, professional, and social entities to recognize NPs as providers capable of providing primary care autonomously" (Weiland, 2008, p. 345).

Despite nearly forty years of "proven safe practice," nurse practitioners in America continue to find themselves in a "financially dependent relationship" constrained by non-recognition from existing healthcare authorities (Weiland, p. 345). In the past, NPs were used as "substitutes" for physicians — particularly in rural areas and for low-income populations — yet even then they were not fully independent; they were supervised by physicians and effectively used as "low-cost labor," even though they significantly improved physician productivity (Weiland, p. 347).

Today, nurse practitioners are not "physician substitutes" but rather "independent providers with a unique approach to healthcare" (Weiland, p. 347). And yet many NPs continue to bill under a physician's name. Weiland identifies several reasons for this: NPs often lack adequate information about reimbursement from Medicare and Medicaid, many practice without a provider number, and others lack the knowledge needed to navigate complex insurance and reimbursement regulations (Weiland, p. 350).

The social and financial consequences of these barriers are significant. Non-recognition and underutilization of NPs reduce patient access to care and deny NPs their rightful status as primary providers (Weiland, p. 345). Weiland estimates that the underutilization of nurse practitioners costs U.S. society "approximately $9 billion annually" (p. 345).

Conclusion

It is time for advocates of nurse practitioners, and for nurse practitioners themselves, to roll up their sleeves and demand autonomy and independence in areas where they do not already have it. As argued throughout this paper, NPs are highly trained, competent, and knowledgeable, and it is time to fully support their right to practice independently. The more pressing point is that when the Affordable Care Act becomes fully operational, millions of new patients will require healthcare. Without adequate physicians to provide primary care, the logical and necessary step is to have nurse practitioners step forward and deliver that care. The evidence is clear, the need is urgent, and the time for action is now.