Background
Nurse practitioners (NP) practice is affected by four central policy and regulation activities. These initiatives involve the education process, the IOM report, the consensus model for APN regulation and the doctor of nursing practice movement (Sabo et al., 2017). Despite the several additions to the position of the NP in healthcare today, nurses continue to face various barriers which have to be assessed by the concerned leaders for the achievement of the triple aim of healthcare which includes increased level of care, health and better healthcare costs for patients within the healthcare sector (Lown et al., 2016). The main of this paper will be to engage in the assessment of barriers to NP, along with the presentation of some solutions that can be used to mitigate these barriers.
Barriers to Healthcare
State Practice and Licenses
The state licensure acts as a primary regulator of NP practice and affects the ability of NPs to provide services to the most extensive level of their education. While the main objective of licensure is to enhance NPs by facilitating the extensive authority to practice and licenses are different from every state with different requirements being stated. The extensive authority to practice refers to the various existence of state procedures, which enables NPs to engage in the evaluation and diagnosis of their patients. This also included ordering and interpreting diagnostic tests, as well as initiating and managing treatment (such as the prescription of treatment) under while being authorized by the state board of nursing (MacLellan et al., 2015).
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The main issue, in this case, is that only approximately a small portion of the country has engaged in the adoption of the extensive practice authority licensure for NPs. The other sections of nurse practitioners in the county are exposed to a decreased practice and licensure, which indicates that NPs may take part in almost one component of their practice. In this case, the regulation of the NP occurs under collaborations between different healthcare providers for providing high quality patient care (Cimiotti et al., 2019). Secondly, there is restricted practice for most NPs which shows that they have the capability to engage in a component of NP practices but under supervision or team management by an alternate authority for the provision of patient care.
Extensive authority can be defined as independent practice. Under this form of authority, there is a requirement for NPs by their respective states to adhere to the education and training needs for licenses, the maintenance of national certificates, and consultation with other healthcare providers as according to the patient or family needs that exist (Cross et al., 2015). NPs are also held to accountability by the public and state board of nursing to ensure that they meet the standard of care that exists in regards to professional conduct. The IOM report has established that extensive restriction of the scope of NPs in particular locations acts as a considerable barrier to accessing care (Altman et al, 2016). NPs with similar educational background and certifications may encounter several restrictions in their choice of relocation from one state to the other. This presents a limitation to their practice in the new state, which affects their capability to present the standard of care that they want. Variances in the range of practice for NPs in different states may indirectly affect the patient care since the magnitude of physician supervision may have an effect on the proactive capabilities for NPs.
Complications associated with Physicians
Various physician professional organizations hold the view that physicians possess more extensive training than NPs. Hence, this perspective leads to the belief that NPs cannot present a similar level of quality care that physicians can present. On the other hand, others make the recognition that while the educational background is not similar to that of physicians, nurse practitioners still hold the same value as physicians in the provision of health care services (Poghosyan et al., 2017). The identification of the significant roles that NPs have in addressing the increasing need for primary care is important. This has resulted in confusion in the community of physicians concerning how the role of nurse practitioners should be regarded.
Most physicians are unaware of the level to which NPs can practice. This is crucial at a time of rapid evolution in healthcare due to the increased need for collaboration between physicians and NPs. Furthermore, both physicians and NPs have a similar objective for enhancing patient outcomes. This makes the confusion about the roles of NPs a significant barrier in the practice of NPs and their collaboration with other healthcare providers in the sector. The conventional medical hierarchical framework practice results in a lower degree of teamwork. This is because the conventional model promotes the domination of physicians over the healthcare team (Cimiotti et al., 2019). Due to the increasing shortages of those that provide primary care, healthcare professionals have been struggling with care for an increasing ageing population. This means that the traditional model is no longer be enough. It is essential to structure collaboration and team frameworks of care which take advantage of all the skills and capabilities of professionals within healthcare teams. The accomplishment of these frameworks is challenging due to the view that various nurse physicians have of nurse practitioners as not possessing the needed competency for the provision of quality care. This makes the belief a significant obstacle in the practice of nurses.
As already stated, in several states, NPs have had to struggle with restrictive practice. Some of the reasons cited against the Advanced Practice Registered Nurse bill in Florida include the existence of significant distinctions in educational background between NPs and physicians and issues concerning the capability of nurses to prescribe a controlled substance safely (Poghosyan, 2018). Other reasons include the shortage of physicians in the state which rules that initiatives should instead support the growth in the number of physicians. Lastly, the belief held by physicians is that there is a challenge associated with controlling healthcare costs and extension of the NPs roles may result in reimbursing NPs to a level similar to that of physicians (Poghosyan, 2018). This may increase the crisis of the expenses within the state. Arguments concerning these issues have resulted in the emphasis of the scope of practice issue with some legislator advocating for the expansion of the role of NPs and others opposing this expansion by supporting physician organizations,
Despite the shortage in healthcare providers, it is unlikely that primary care physicians will provide support for the development of the position and the existence of nurse practitioners. While a majority of physicians are in agreement that NPs should engage in their positions to the overarching limit of their training, they are not in agreement that NPs should be under the receipt of equitable payment for the provision of the same services they provide (Luster-Tucker, 2016). Contrastingly, most NPs view that they should receive equal pay for the services that they provide. Moreover, most physicians have the perspective that they provide services of higher quality care to patients. This is mainly due to the view of the education and training of physicians as not being as comprehensive as theirs.
Payer Policies
Many NPs state that per policies have a considerable effect on their capability of practicing to the extensive level of their licenses and educational backgrounds. The payer policy is usually connected to the state regulation. If the scope of practice is restricted, there may also be increased restriction on payer policies which limit the abilities of NPs to engage in independent practice (Bown, 2018). They are typically forced to practice as staff in physician practices, and other medical institutions. Commercial health plan payment policies vary from one state to the other and usually do not view NPs as being central providers of care.
Moreover, payers may showcase resistance to the direct payment of NPs for the care that is provided. In most cases, the billing for care that is received is usually offered under the name of the physicians. The centre for Medicare and Medicaid Services (CMS) establish that billing incidents needs the physician to establish the first plans of care and the NPs to perform follow-up care with the existing physicians. Hence, this type of practice may result in the limitation of practice locations to only those linked to a physician. Even in a state in which NPs have extensive authority to practice, various payers bar NPs from the practice of their services independent of a physician through the absence of direct payment or reimbursement at lower rates (Xue et al., 2016).
State insurance mandates are significant to NP practice as they impact the capability of NPs to practice on their own. This mandates are different from one bill to another and from one state to the other and considerably enhance the costs associated with health insurance. The issue is that several states do not have established mandates for the appropriate payment for NPs to primary care providers. NPs are identified as receiving a lower level of payment in comparison to their physician colleagues. This decreased level of payment, increase the difficulty associated with the financial sustenance of a primary care practice.
Solutions to Barriers
Based on the identified barriers, policy initiatives act as the best way to mitigate the effects that limit healthcare redesign. The existing dialogue as to whether nurse practitioners have the ability of providing the same level of quality care decreases the capability to have impactful debates regarding strategies to meet the elevated need for PCPs. Reformation at the state level has its concentration of factors such as the scope of practice within a specific state and the associated payer policy. Nursing organizations in the country such as the American Nurses Association (ANA) have become proponents for enabling NPs to practice to the highest extension of their educational background (Brassard et al., 2011). Moreover, there are several NP organizations which have continued to struggle to promote legislative activities. Physician supervision appears to have the most substantial effect on the ability of NPs to practice.
The elimination of differences in the extensions of practice is critical to the removal of barriers to independent practice. It also acts as a necessary element to the provision of superior primary care in the healthcare sector. A single-advanced practice license for NPs should be established which will allow for independent practice with regulations concerning supervision by physicians and collaborations between care providers. Collaborative agreements refer to formal agreements which are presented to state boards of nursing. The standardization of APRN regulations may enhance the level of consistency across the nation and the quality of NP educational processes to increase how uniform the involved graduates are (Chism, 2017). Moreover, NPs have showcased a capability to provide quality, and cost-effective care and, therefore, deserve equal payment for the care that they provide. Along with the quality of care, NPs should have the same level of accountability for their contributions to increased quality of primary care through the inclusion of performance measures of NPs who take part in independent practice.
Implications for Practice
There has to be an innovative approach to the delivery of quality and efficient primary care in a sector with an expected shortage in employees. This means creating an integrative workforce where NPs structure relations with physicians. PCPs could reference NPs with a specialty in various areas. As according to IOM (2011) report, NPs are supposed to possess an active role as members of leaders of an inter-professional team. In a sector that is continually changing, NPs should utilize a results-driven process to care, by evidencing that innovative NP frameworks of care can result in the improvement of outcomes.
Emphasizing complication in quality may present a well-structured direct for sections that need to be improved. The institution of the Doctor of Nursing Practice (DNP) degree has created opportunities that enables nursing to inquire and improve quality (Zaccagnini et al., 2019). The areas involved in the creation of these opportunities include the use of informatics and the management of disease processes. There is an anticipation that these degree will make considerable contributions to the redesigning of the healthcare sector. Healthcare design must involve payer policy reform. The restructuring has to include the increased support of inter-professional teams and multi-collaborative teams. This is because collaborations between physicians and NPs is an essential aspect of transforming healthcare.
Inter-professional education is also another area that should be placed under consideration for the advanced reformation of the healthcare sector. Inter-professional education refers to interventions in which the members of more than one healthcare profession learn to interact together, with the sole aim of enhancing inter-professional collaboration. Inter-professional education will not only change the perspectives that physicians and NPs have of each other but also improve the welfare of the patients and clients involved. Systematic reviews have shown that IPE interventions, in comparison to no education, have positive results such as enhanced satisfaction of patients, health outcomes of individuals with particular disease management, and a decrease in medical complications. A need exists for extensive research will explore the advantages of IPE on health outcomes along with the impact on collaborations between practitioners and physicians. Hence, NPs can assist others in recognizing the significance of care as opposed to cure. This will support a shift from the focus on the treatment of diseases to the promotion of health.
Conclusion
The extension of healthcare insurance, as stated in the Affordable Care Act (ACA), will have a considerable effect on the healthcare sector, which includes the healthcare providers, policymakers and payers. This is due to the increased demand for healthcare services which is evident. Healthcare professionals are now facing the challenge to satisfy the demand of an increasingly ageing and considerably diverse population which is made worse by the increased shortage of healthcare providers and staff. Through education and training, NPs have the capacity and capability of serving in the roles of PCPs with the potential of making a considerable contribution to the improvement of clinical results. The role of NPs is described through their scope-of-practice as well as their employment agreements, which typically disregards the educational backgrounds that they have been exposed to. This, along with the skewed perspective of physicians regarding the roles and capability of NPs to provide a high quality of healthcare, has affected the ability of NPs to contribute to the triple aim of healthcare. As discussed in this paper, the only way these barriers can be removed is through a shift in policies and uniformity in scope-of-practice across different roles as well as the institution of inter-professional education. In this way, the healthcare sector can be redesigned and allow nurse practitioners to have a more significant contribution toward enhancing health outcomes.
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