Barriers to NP Practice that Impact ^md
Healthcare Redesign
Debra Hain, PhD, ARNP, ANP-BC , GNP-BC
Laureen M. Fleck, PhD, FNP-BC , C DE, FAANP
Abstract
As healthcare reform evolves, nurse practitioners (NP) will play key roles in improving health
outcomes of diverse populations. According to the Institute of Medicine (IOM) 2011 report, The
Future of Nursing: Leading Change Advancing Health, nurses should be change advocates by
caring for populations within complex healthcare systems. The IOM reports asserts, “advanced
practice registered nurses (APRNs) should be able to practice to the fullest extent of their
education and training” (IOM, 2011, s8). However, existing barriers in the healthcare arena limit
APRN practice. This article will discuss some of these barriers and provide suggestions for
possible ways to decrease the barriers.
Citation: Hain, D., Fleck, L., (May 31, 2014) "Barriers to Nurse Practitioner Practice that Impact Healthcare
Redesign" OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 2.
DOI: 10.3912/OJIN.Vol19No02Man02
Key words: Nurse Practitioner, Nurse Practitioner Education, Nurse Practitioner Practice
In 1965, to meet the demands of underserved populations, Loretta Ford and
Henry Silver began the first certificate program that provided nurses with the
skills to deliver primary care to children in community settings. In the 1970’s NP In the 1970’s NP
education moved from a certificate program to programs that offered bachelors e ducation m ove d
or masters degrees. In addition, the population focus was not only pediatric and from a ce rtificate
families, but also began to include adult/gerontology, women’s health, neonatal, program to
and other specialty roles. These early nursing pioneers revolutionized advanced program s that
practice nursing. Present-day NPs assume various roles that include caring for offe re d bache lors
ethnically diverse, underserved populations within an aging society and across or m aste rs
many healthcare settings. The rapid growth of NPs since the initial certificate de gre e s.
programs has been astounding and contemporary NPs have emerged as
leaders in healthcare (Sullivan-Marx, McGivern, Fairman, & Greenberg, 2010).
The NP role in the 21s t century looks much
different than it did in 1965.
De spite m any
positive
e x pansions to
the NP role , the re
continue s to be
m any barrie rs
re quiring
atte ntion of
national and
state le ade rs in
orde r to achie ve
the Triple Aim of
he althcare ...
, Today, NP practice is impacted by four significant policy and regulation initiatives 1) the Consensus Model for
APRN Regulation: Licensure, Accreditation, Certification and Education (APRN Joint Dialogue Group, 2008); 2)
the Doctor of Nursing Practice movement; 3) the IOM report (2011); and 4) the Patient Protection and
Affordable C are Act (PPAC A). Despite many positive expansions to the NP role, there continues to be many
barriers requiring attention of national and state leaders in order to achieve the Triple Aim of healthcare: 1)
better care; 2) better health; and 3) lower healthcare cost (Berwick, Nolan, & Whittington, 2008). The next
part of this paper will discuss some of the barriers to NP practice.
Barriers
State Practice and Licensure
State licensure regulates NP practice and is a barrier to NPs practicing to the
fullest extent of their education and training. Licensure and practice laws for NPs
vary per state, despite a main goal of full practice authority. What does this NP practice is
mean? Full practice authority is “the collection of state practices and licensure re gulate d by
laws that allow for NPs to evaluate patients, diagnose, order, and interpret state
diagnostic tests, initiate and manage treatments-including prescribing lice nsure ...only
medications-under the exclusive licensure authority of the state board of about one -third
nursing” (American Association of Nurse Practitioner (AANP), 2014, p.1). of the nation has
adopte d full
practice authority
lice nsure and
practice laws for
NPs.
The problem is only about one-third of the nation has adopted full practice authority licensure and practice laws
for NPs. The remainder of NPs in the U.S either have: 1) reduced practice and licensure which means the NP
has the ability to engage in at least one element of the NP practice and is regulated through a collaborative
agreement with an outside health discipline in order to provide patient care; or 2) restricted practice and
licensure which means that NP has the ability to engage in at least one element of NP practice and requires
supervision, delegation, or team-management by an outside health discipline in order to provide patient care
(AANP, 2013).
Full practice authority is also referred to autonomous practice or independent
practice. Under full practice authority, NPs are required by their licensing state
IO M re port has to meet educational and practice requirements for licensure, maintain national
re cognize d that certification, consult and refer to other healthcare providers per patient/family
ove rly re strictive needs, and be accountable to the public and state board of nursing for meeting
scope -of-practice the standards of care in practice and professional conduct (AANP, 2014). The
re gulations of IOM report (2011) has recognized that overly restrictive scope-of-practice
NPs in som e regulations of NPs in some states as one of the most serious barriers to
state s as one of accessible care. NPs with the same educational preparation and national
the m ost se rious certification may face a compendium of restrictions when relocating from one
barrie rs to state to another, thus limiting their scope of practice (Safriet, 2011). Variation
acce ssible care . of scope-of-practice across states has an indirect impact on patient care
because the degree of physician supervision may affect practice opportunities
and payer polices for NPs (Yee, Boukus, C ross & Samuel, 2013).
Physician Related Issues
Some physician professional organizations, including the American Medical Association, believe that because
physicians have longer and more rigorous training than NPs, nurse practitioners are incapable of providing
quality, safe care at the same level as physicians (American Medical Association (AMA), 2010; Fairman, Rowe,
Hassmiller, & Shalala, 2011). However, other physicians recognize that the education and training is not the
same as their own, yet continue to value nurse practitioners. In 2009, the American C ollege of Physicians
published a position paper identifying the important role NPs play in meeting the growing demand for primary
care (American C olleges of Physicians, 2009). This may contribute to the confusion among many physicians
regarding the role of nurse practitioners.
In preparation for this article, local nurse practitioners were queried about what
they see as physician related barriers. One common thread was lack of
physician and other healthcare professionals’ knowledge of NPs scope-of- At a tim e whe n
Healthcare Redesign
Debra Hain, PhD, ARNP, ANP-BC , GNP-BC
Laureen M. Fleck, PhD, FNP-BC , C DE, FAANP
Abstract
As healthcare reform evolves, nurse practitioners (NP) will play key roles in improving health
outcomes of diverse populations. According to the Institute of Medicine (IOM) 2011 report, The
Future of Nursing: Leading Change Advancing Health, nurses should be change advocates by
caring for populations within complex healthcare systems. The IOM reports asserts, “advanced
practice registered nurses (APRNs) should be able to practice to the fullest extent of their
education and training” (IOM, 2011, s8). However, existing barriers in the healthcare arena limit
APRN practice. This article will discuss some of these barriers and provide suggestions for
possible ways to decrease the barriers.
Citation: Hain, D., Fleck, L., (May 31, 2014) "Barriers to Nurse Practitioner Practice that Impact Healthcare
Redesign" OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 2.
DOI: 10.3912/OJIN.Vol19No02Man02
Key words: Nurse Practitioner, Nurse Practitioner Education, Nurse Practitioner Practice
In 1965, to meet the demands of underserved populations, Loretta Ford and
Henry Silver began the first certificate program that provided nurses with the
skills to deliver primary care to children in community settings. In the 1970’s NP In the 1970’s NP
education moved from a certificate program to programs that offered bachelors e ducation m ove d
or masters degrees. In addition, the population focus was not only pediatric and from a ce rtificate
families, but also began to include adult/gerontology, women’s health, neonatal, program to
and other specialty roles. These early nursing pioneers revolutionized advanced program s that
practice nursing. Present-day NPs assume various roles that include caring for offe re d bache lors
ethnically diverse, underserved populations within an aging society and across or m aste rs
many healthcare settings. The rapid growth of NPs since the initial certificate de gre e s.
programs has been astounding and contemporary NPs have emerged as
leaders in healthcare (Sullivan-Marx, McGivern, Fairman, & Greenberg, 2010).
The NP role in the 21s t century looks much
different than it did in 1965.
De spite m any
positive
e x pansions to
the NP role , the re
continue s to be
m any barrie rs
re quiring
atte ntion of
national and
state le ade rs in
orde r to achie ve
the Triple Aim of
he althcare ...
, Today, NP practice is impacted by four significant policy and regulation initiatives 1) the Consensus Model for
APRN Regulation: Licensure, Accreditation, Certification and Education (APRN Joint Dialogue Group, 2008); 2)
the Doctor of Nursing Practice movement; 3) the IOM report (2011); and 4) the Patient Protection and
Affordable C are Act (PPAC A). Despite many positive expansions to the NP role, there continues to be many
barriers requiring attention of national and state leaders in order to achieve the Triple Aim of healthcare: 1)
better care; 2) better health; and 3) lower healthcare cost (Berwick, Nolan, & Whittington, 2008). The next
part of this paper will discuss some of the barriers to NP practice.
Barriers
State Practice and Licensure
State licensure regulates NP practice and is a barrier to NPs practicing to the
fullest extent of their education and training. Licensure and practice laws for NPs
vary per state, despite a main goal of full practice authority. What does this NP practice is
mean? Full practice authority is “the collection of state practices and licensure re gulate d by
laws that allow for NPs to evaluate patients, diagnose, order, and interpret state
diagnostic tests, initiate and manage treatments-including prescribing lice nsure ...only
medications-under the exclusive licensure authority of the state board of about one -third
nursing” (American Association of Nurse Practitioner (AANP), 2014, p.1). of the nation has
adopte d full
practice authority
lice nsure and
practice laws for
NPs.
The problem is only about one-third of the nation has adopted full practice authority licensure and practice laws
for NPs. The remainder of NPs in the U.S either have: 1) reduced practice and licensure which means the NP
has the ability to engage in at least one element of the NP practice and is regulated through a collaborative
agreement with an outside health discipline in order to provide patient care; or 2) restricted practice and
licensure which means that NP has the ability to engage in at least one element of NP practice and requires
supervision, delegation, or team-management by an outside health discipline in order to provide patient care
(AANP, 2013).
Full practice authority is also referred to autonomous practice or independent
practice. Under full practice authority, NPs are required by their licensing state
IO M re port has to meet educational and practice requirements for licensure, maintain national
re cognize d that certification, consult and refer to other healthcare providers per patient/family
ove rly re strictive needs, and be accountable to the public and state board of nursing for meeting
scope -of-practice the standards of care in practice and professional conduct (AANP, 2014). The
re gulations of IOM report (2011) has recognized that overly restrictive scope-of-practice
NPs in som e regulations of NPs in some states as one of the most serious barriers to
state s as one of accessible care. NPs with the same educational preparation and national
the m ost se rious certification may face a compendium of restrictions when relocating from one
barrie rs to state to another, thus limiting their scope of practice (Safriet, 2011). Variation
acce ssible care . of scope-of-practice across states has an indirect impact on patient care
because the degree of physician supervision may affect practice opportunities
and payer polices for NPs (Yee, Boukus, C ross & Samuel, 2013).
Physician Related Issues
Some physician professional organizations, including the American Medical Association, believe that because
physicians have longer and more rigorous training than NPs, nurse practitioners are incapable of providing
quality, safe care at the same level as physicians (American Medical Association (AMA), 2010; Fairman, Rowe,
Hassmiller, & Shalala, 2011). However, other physicians recognize that the education and training is not the
same as their own, yet continue to value nurse practitioners. In 2009, the American C ollege of Physicians
published a position paper identifying the important role NPs play in meeting the growing demand for primary
care (American C olleges of Physicians, 2009). This may contribute to the confusion among many physicians
regarding the role of nurse practitioners.
In preparation for this article, local nurse practitioners were queried about what
they see as physician related barriers. One common thread was lack of
physician and other healthcare professionals’ knowledge of NPs scope-of- At a tim e whe n
