Continuing the quest for the least restrictive practice environment
Scope of practice … three small words that invoke passionate responses within the practice setting.
In the trenches, physicians and advanced practice registered nurses (APRNs) typically have a highly-collegial, highly-collaborative relationship as they work together to provide the best care possible for patients. At an organizational level, however, differing viewpoints on skill sets have begun to lead to something akin to a turf war.
In a legislative report to its members this past February, the Missouri State Medical Association referred to advance practice nurses waiting to testify about a bill that would give them independent practice authority as a “gaggle” and said “they flooded the room like 12-year-olds at a Justin Bieber concert.” Later in the letter, testifying physicians were referred to as “the good guys,” leaving the reader to surmise just who the bad guys were.
Lisa Summers, CNM, DrPH, senior policy fellow in the Department of Nursing Practice and Policy for the American Nurses Association (ANA), said what really matters is ensuring patients receive high quality care from all providers. Not surprisingly, the ANA is very supportive of creating the least restrictive practice environment possible to ensure patients have access to care, APRNs are able to maximize their skill sets, and costs are lowered in a delivery system that is overburdened and understaffed.
“First and foremost is the work that’s going on around implementation of the Affordable Care Act. We’re going to add 34 million people to the rolls so who is going to take care of them?” Summers questioned. “In order to increase access to care and to maintain quality and reduce costs, we need to build more effective healthcare teams and that involves removing scope of practice barriers.”
Even if the Supreme Court strikes down part or all of ACA, the law has shifted perceptions about how care is viewed. There is a strong push toward ACOs and the patient-centered care model, which both rely heavily on preventive services and coordinated care to improve outcomes and reduce costs.
“There is a growing movement away from the old ‘captain of the ship’ model to the ‘pit crew’ model,” noted Summers of the team approach.
She added the desire of APRNs to have an autonomous practice doesn’t mean they hope to work in a silo. “There’s no one healthcare professional who can do everything for every patient. Collaboration between healthcare providers is a key skill of any healthcare professional. It ought to be built into our system in a whole host of ways, but it’s not something you can legislate.”
Summers noted the Institute of Medicine Future of Nursing Report referenced scope of practice barriers for APRNs as the very first recommendation that deserved attention. She noted evidence-based research hasn’t borne out harm to patients receiving basic services from an APRN. In fact, she said, “The state of Washington has long had laws and regulations that facilitate the practice of advance practice nurses. Not only has the sky not fallen in, but Washington was held out as an example when CMS wrote their proposed rules for state insurance exchanges.”
She added that it isn’t just APRNs who face practice barriers. Summers said RNs and a number of other health professionals are often underutilized, as well. Nurses, she said, have a great ability to coordinate care to manage chronic conditions and help reduce readmissions. The challenge, she said, is to really quantify the value of nursing, which is difficult because it hasn’t been identified as a reimbursable service.
Whether or not ACA expands the insurance rolls, the nation’s delivery system anticipates increasing utilization in the wake of an aging population. To meet the demand, providers of all skill levels will be required.
“The bottom line is there is a lot of primary and preventive care that patients need that doesn’t require a medical degree to provide,” said Summers. “For us at the ANA, the real question is how do we build truly patient-centered, interdisciplinary teams where all the healthcare professionals involved can work to the full extent of their education and training?”