NURSE PRACTITIONER WEEK SPECIAL ISSUE 2021
PRESENTED BY:
®
®
Table of Contents
In This Issue 3
Editor’s Notebook
Features 4
Making the Jump to Solo Practice: How Solo NPs Built Jobs They Love By Julia Quinn-Szcesuil
8
Changes COVID-19 Brought to the Nurse Practitioner’s World By Michele Wojciechowski
10
A Caring Community: Nurse Practitioners Find Their Calling Working in Community Health Settings By Linda Childers
14
Advocating for Full Practice Autonomy for Nurse Practitioners By James Z. Daniels
18
Is Nurse Practitioner Education in Need of Reform? By Nachole Johnson, MSN, FNP-BC
2
Nurse Practitioner Week Special Issue 2021
®
Editor’s Notebook NPs are the Solution
CORPORATE HEADQUARTERS/ EDITORIAL OFFICE
From combating COVID-19 to fighting for full practice autonomy nationwide, nurse practitioners have had an exceptionally busy year—and this is likely to continue with the looming shortage of physicians. In honor of National Nurse Practitioner Week, this issue spotlights the important issues NPs currently face. Do you wish you had more one-on-one time with patients? If the answer is yes, then maybe it’s time to consider starting your own practice. Julia Quinn-Szcesuil shares the success stories of NPs so you can learn all about the rewards—and the potential challenges you may face depending on whether you live in a state allowing full practice autonomy or requiring physician oversight—so you can be fully prepared before making the leap. The COVID-19 pandemic changed health care as we know it, and many are at risk of burning out as a result. Michele Wojciechowski chats with NPs about what has changed for them specifically and how the pandemic has led to some positive changes for patients and practitioners alike. The recent health care crisis has put a spotlight on community health. Linda Childers investigates how NPs working at community health centers are helping to fill the gap with medically underserved communities and reduce barriers to care.
11 West 42nd Street, 15th Floor New York, NY 10036 212-431-4370 n Fax: 212-941-7842
SPRINGER PUBLISHING COMPANY
CEO & Publisher Mary Gatsch Vice President & CFO Jeffrey Meltzer NURSE PRACTITIONER WEEK
SPECIAL ISSUE
Editor-in-Chief Megan Larkin
Creative Director Kevin Kall
Production Manager Diana Osborne
Digital Media Manager Andrew Bennie National Sales Manager Andrew Bennie 212-845-9933 abennie@springerpub.com
Granting NPs full practice autonomy in states such as North Carolina could go a long way in helping the U.S. combat staffing shortages. James Daniels sits down with two NPs in the state to discuss the legislative possibility of getting rid of this roadblock to care. The coronavirus has made it painfully clear that we need more primary care providers. And yet, there’s a hesitation in some states to allow NPs to practice independently. Nachole Johnson investigates whether NP education may need reform to adequately address this. We’ve been hearing about a staffing shortage in health care for a long time, and the solution has been right in front of us.
—Megan Larkin
For editorial inquiries and submissions: editor@minoritynurse.com For subscription inquiries and address changes: © Copyright 2021 Springer Publishing Company, LLC. All rights reserved. Reproduction, distribution, or translation without express written permission is strictly prohibited.
admin@minoritynurse.com
Making the Jump to Solo Practice: How Solo NPs Built Jobs They Love BY JULIA QUINN-SZCESUIL
A
s the United States makes slow but steady progress in granting nurse practitioners the authority to practice autonomously (according to the American Association of Nurse Practitioners, nearly half the states and U.S. territories allow this), nurse practitioners around the country are finding professional and personal career satisfaction in practicing on their own. With a considerable professional nursing foundation and the business acumen to build a practice from scratch, these nurses are filling a health care need that continues to grow.
Overscheduled Nurses Say Enough Tani Schare, RN, MSN, FNPC, CCRN, is the founder and owner of Mariposa Family Medicine in Albuquerque, New Mexico, and says her drive to strike out on her own stemmed from an increasingly hurried way of nursing. “You don’t feel like there’s enough time,” she says. “You are always rushed. When you work for someone else, you are not able to set good limits.” That changed, she says, when she started her own practice. “Now I get to set the
The flexibility to schedule fewer patients and spend a longer time with them offers relief for many NPs and their patients. opening and closing hours and determine the amount of patients we see in a day or how may acute visits,” Schare says.
The workload is greater when you own your own business, but they are motivated by the rewards. “When I worked as a nurse in a hospital and a doctor would give orders, I would sometimes think, ‘I would do this instead,’” says Kathy Fresquez-Chavez, DNP, FNP-C, MSN, the owner of Bella Vida Health Care Clinic and Medi-Spa in Los Lunas, New Mexico. “And I found that what I was doing was the correct way to go.” The flexibility to schedule fewer patients and spend a longer time with them offers relief for many NPs and their patients. “I’ve heard of nurse practitioners who are expected to see 20 to 30 patients a say,” says Schare. “Health care doesn’t have to be like this.” Fresquez-Chavez says the patient/NP bond is exceptional. “I become a part of their family,” she says. “I see their kids as babies and as they get older.”
Preparation Is Key Solo nurse practitioners say preparation is essential, and even when you think you are fully prepared, be ready for the unexpected. “It’s a huge learning curve,” warns Schare. Fresquez-Chavez says she gained important knowledge by working in many areas of nursing. “If I could do it, I did,” she says. By doing so, each task built a foundation she would come to rely on. Irene Bean, DNP, FNP-BC, PMHNP-BC, FAANP, a family psychiatric nurse practitioner and CEO of Serenity Health Care, PC & Weight Loss Clinic in Madison, Tennessee agrees. Early in her career, she approached every
responsibility as a learning experience, taking on both nursing and administrative
Solo nurse practitioners say preparation is essential, and even when you think you are fully prepared, be ready for the unexpected. tasks to learn. “I never turned anything down,” she says. Both NPs gained a thorough skill set and became trusted colleagues of many physicians and other NPs.
Know the Business Side of Nursing Solo practitioners need to familiarize themselves with even the smallest details about running a practice so their business is successful, says Fresquez-Chavez. For instance, will you want hospital privileges? What kind of insurance will the practice accept and how will you set those contracts? How will you effectively manage your staff? How will you market your new practice?
“As a solo practitioner, if you’re afraid to communicate with your peers, you’re not going to get too far in this business,” says Bean, who also founded the Tennessee Nurse Practitioner Association chapter. “There’s not a lot of training for this in nursing school at all,” says Schare. She took an online
www.minoritynurse.com
course that was geared toward nurse practitioners who wanted to open their own business. Building connections and collaborations with others in the medical and business communities is important to keep things running smoothly. Fresquez-Chavez collaborated with many medical teams and could call on them if she had questions early on. “Those things stay with you,” she says. “I had their respect, and they supported and helped me.” And get involved with your local or state nurse practitioners’ professional organization. “As a solo practitioner, if you’re afraid to communicate with your peers, you’re not going to get too far in this business,” says Bean, who also founded the Tennessee Nurse Practitioner Association chapter.
Be Familiar with State Regulations Understanding your state’s regulations is key as well. In New Mexico, where FresquezChavez and Schare practice, nurses have authority to practice with full autonomy and require no physician oversight. Bean’s solo practice, however, is in a state that restricts full autonomy. “Practicing in a restrictive state has many challenges, especially for an NP-owned practice,” says Bean, a nurse for more than 20 years and a solo practice owner for 13. “In Tennessee and other states requiring collaboration, the physicians are paid to review charts of patients they have not seen,” explains Bean. “In the 13 years of ownership, I have not called my collaborative provider for assistance with a patient because I will
www.dailynurse.com
www.springerpub.com
5
refer to the appropriate specialist if it is a complicated case.” And while Bean is able to own her practice, the barri-
“In Tennessee and other states requiring collaboration, the physicians are paid to review charts of patients they have not seen,” explains Bean.
ers are unnecessary, she says, noting that the restrictions
6
were temporarily lifted during COVID. “Patients should have the right to choose who provides their care and should be able to select an NP as their primary care provider,” she says. “NPs are not trying to replace physicians. We are here to offer an affordable and quality care option for the patient.”
Career Satisfaction, Better Outcomes As you begin your solo practice, recognize that you’ll definitely be scared, but, says Fresquez-Chavez, that shouldn’t stop you. “I
Nurse Practitioner Week Special Issue 2021
encourage every nurse to stand up and go for it,” she says. “This gives you a lot of freedom, but it’s also just a
As you begin your solo practice, recognize that you’ll definitely be scared, but, says Fresquez-Chavez, that shouldn’t stop you.
be able to do everything you possibly can.” Solo NPs say the patient relationships are meaningful, and they know solo practices help the crunch on family care providers. Schare says that she takes pride in her growing practice, and she never stops trying to make it better. “I am providing a service people haven’t had before,” she says. “When you own it, you protect it.” Julia Quinn-Szcesuil is a free-
good feeling to make a decision to help a patient and to
lance writer based in Bolton, Massachusetts.
frontier.edu
Creating a Culture of Diversity Advance your career and have a greater impact in diverse, rural, and underserved communities with Frontier Nursing University’s distance education model. Become a Nurse-Midwife or Nurse Practitioner. Specialties Offered: Nurse-Midwife | Family Nurse Practitioner | Women’s Health Care NP | Psychiatric-Mental Health NP
Distance Education Programs: Master of Science in Nursing | Doctor of Nursing Practice | Post-Graduate Certificates
“FNU is one of the best things to ever happen to me. I read about the amazing sense of community... and I knew it was the place for me. It is unlike any other online education program I have ever encountered.” Maria Labadie-DeGennaro DNP, MSN, APRN, FNP-C, CHPN FNU alumnus
Learn more about our Diversity Impact Program at frontier.edu/diversity.
Changes COVID-19 Brought to the Nurse Practitioner’s World BY MICHELE WOJCIECHOWSKI
The pandemic has affected all nurses in all fields. Some NPs weigh in on how COVID-19 has changed their work.
D
uring the pandemic, Alvin Mena Cantero, DNP, FNP-C, MSN, APRN, CEO and health care provider at Alvin Clinica Familiar, Inc. in Houston, Texas, says that he’s seeing more patients each day—anywhere from 65 to 75 patients across a variety of demographics. Up to 85 percent are Latinx, “largely because Spanish speakers prefer providers who speak the same language and can therefore help them to fully understand messages.” “Many nurse practitioners are overwhelmed with trying to help everyone and their families, and many providers have experienced flashback and burnout episodes,” Cantero explains. “Dealing with this pandemic has been like constantly working in an ER setting for most health care providers… I have advised my fellow health care providers/nurses to avoid working too many extra shifts in the hospital because it can aggravate burnout syndrome, which in the worst case may cause them to make a mistake that may cost a patient’s life.” Cantero has been using telehealth regularly. “It has been a great way to prevent overcrowding in my practice, especially because most of the other clinics near my practice shut down during the beginning of the pandemic,” he says. “By using telehealth, I have also been able to educate more of my patients about vaccinations and the importance of early detection and prevention of COVID-19.” One problem, says Cantero, is that in Texas many NPs have left the state. “Despite the hard work and increased scope of practice in order to fill the gap within primary care in underserved communities, the state of Texas, like many others, has
thus far failed to recognize nurse practitioners’ independence in full scope of practice and still mandates them to be overseen by supervising physicians,” he says. “I believe this only lowered the quality of care provided to our communities during this pandemic…Many nurses have
“Despite the hard work and increased scope of practice in order to fill the gap within primary care in underserved communities, the state of Texas, like many others, has thus far failed to recognize nurse practitioners’ independence in full scope of practice and still mandates them to be overseen by supervising physicians,” he says. moved to other states for this reason, which has aggravated the nursing shortage.” Meanwhile, Melissa Valdes, APRN, a family nurse practitioner who has been working in the Community Health of South Florida, Inc.’s (CHI) Mobile Medical Van (MMV), which is described as a state-of-the-art health care facility that provides health care in underserved communities such as public housing communities, migrant communities, homeless encampments, day cares, and more. The staff provides health care services, including COVID vaccines as well as COVID testing. Before COVID-19 hit, Valdes says that they were not using telehealth in the MMV. But then it became a necessity. “Some patients don’t feel comfortable coming into our mobile medical van or visiting the CHI health
centers because of COVID fears, so we are using telehealth quite a bit more these days,” she says. “We are also being more creative and strategic about how we motivate patients to get vaccinated and spread the word about the good of vaccines to their friends and families. This entails speaking about the vaccine in simple, clear terms, avoiding too much medical terminology, and includes sharing our own experiences with COVID and the vaccine. For example, I often share the story of my 85-yearold grandmother’s experience with COVID who got the disease after being vaccinated, but who was able to recover quickly, largely, we believe, as a result of having been vaccinated.”
we tend to share our own experiences with COVID and vaccinations as we get out the message to our patients
Before COVID-19 hit, Valdes says that they were not using telehealth in the MMV. But then it became a necessity.
Cantero hopes that once the pandemic gets under control, health care personnel will get psychological evaluations.
Both Valdes and Cantero say that they have become even closer with their patients during the pandemic. “I also formed closer relationships with patients’ relatives, since in many cases, if a patient contracted COVID-19, their entire family did as well,” says Cantero. “I think a more trusting relationship was built, and I capitalized on this opportunity to educate my community regarding COVID-19 prevention and the importance of vaccination. I also focus on education patients about disease prevention and health care promotion sincere there is a high census of patients suffering from hypertension, diabetes mellitus, and obesity.” “You do get closer with patients during COVID since
Cantero hopes that once the pandemic gets under control, health care personnel will get psychological evaluations. “It’s important for health care providers and nurses to keep supporting each other and be humble and kind both toward each other and our patients. It’s very important to be there for your patients, but also for yourself, your wellbeing, and your family.”
www.minoritynurse.com
Both Valdes and Cantero say that they have become even closer with their patients during the pandemic. that the vaccines are effective and safe,” says Valdes. “Many patients identify with these experiences, and sharing stories helps build trust, which is critical to the relationship between health care professionals and patients.”
Michele Wojciechowski is a national award-winning freelance writer based in Baltimore, Maryland. She loves writing about the nursing field but comes close to fainting when she actually sees blood. She’s also author of the humor book, Next Time I Move, They’ll Carry Me Out in a Box.
www.dailynurse.com
www.springerpub.com
9
A Caring Community: Nurse Practitioners Find Their Calling Working in Community Health Settings BY LINDA CHILDERS
A
t the Sacramento Native American Health Center (SNAHC) in Sacramento, California, Julie Omishakin, MSN, FNP-C, greets her first patient of the day, a man recently diagnosed
With the Association of American Medical Colleges (AAMC) predicting a physician shortage of up to nearly 122,000 physicians by 2032, the American Association of Nurse Practitioners (AANP) believe that NPs are key to bridging the gap in health care. Julie Omishakin, MSN, FNP-C
with hypertension. After ensuring he’s monitoring his blood pressure regularly and taking his prescribed medication, she reminds him that he’s also due for some cancer screening tests. Omishakin is one of many nurse practitioners (NPs) across the country that provide primary care in a community health setting. These community health centers, also known as community clinics or Federally Qualified Health Centers (FQHCs), serve as a safety net to uninsured and underinsured patients. They provide medically underserved communities with affordable, comprehensive medical care and reduce barriers to care including language and travel distance. With the Association of American Medical Colleges (AAMC) predicting a physician shortage of up to nearly 122,000 physicians by 2032, the American Association of Nurse Practitioners (AANP)
believe that NPs are key to bridging the gap in health care. According to the AANP, there are currently more than 325,000 NPs practicing across the country, and 30,000 NPs entering the workforce each year. More than 85% of NPs are trained in primary care and one in four NPs practice in rural areas that lack access to health care. For Omishakin, working at a FQHC means taking a holistic approach to patient care and treating the whole patient, not just a singular medical event. Twenty-six percent of the patients seen at the center are Native American, from both local and out-of-state Tribes. The center serves as a safety net in the Sacramento area,
Clinics such as SNAHC improve health outcomes and reduce health disparities in marginalized communities by making health care accessible for all patients.
where changes to Medi-Cal (California’s Medicaid program) benefits have left many with limited access to health care. A new study found that physicians run into more obstacles when trying to bill Medicaid than they do with other insurers. In addition, Medicaid reimbursement for doctors is lower than Medicare and private insurance coverage. As a result, many physicians are reluctant to accept Medicaid patients, making it difficult for these patients to find doctors who will treat them.
Clinics such as SNAHC improve health outcomes and reduce health disparities in marginalized communities by making health care accessible for all patients. In addition to primary care, SNAHC offers patients medical, dental, vision, and behavioral health services. “Our care goes beyond the traditional 10-minute office visit,” Omishakin says. “We spend 15-30 minutes with each patient and automatically screen them for depression, as well as ensuring they’re up-todate on annual screenings.” A nurse practitioner for the past eight years, Omishakin says she finds working in community health to be extremely rewarding. “We’re providing care to people who are working hard to make ends meet and offering them health care options they might not have otherwise,” she says.
Providing Care for All Ages In Riverside, California, Cynthia Jovanov, DNP, FNP, NP-BC, president elect for the California Association for Nurse Practitioners (CANP), works at a community clinic, with Dr. Luther Mangoba, providing primary care to patients who are largely on Medi-Cal. “We see patients ranging from pediatrics to geriatrics,” says Jovanov, who also works as an adjunct professor at California Baptist University and as a general surgery NP at Eisenhower Medical Center. “Recently we’ve seen a spike in college-aged students who either don’t have insurance or are uninsured after they’ve turning 26 and are no longer covered by their family’s health insurance.”
www.minoritynurse.com
For Jovanov, who grew up in Riverside, caring for those in her community has allowed her to come full circle in her career. “We care for so many different people who hail from various walks of life,” she says. “I think the key is meeting patients where they are at that moment in their
“It’s impossible to meet the growing demand for primary care with just physicians, especially since so many don’t accept Medi-Cal/ Medicaid,” Jovanov says. Cynthia Jovanov, DNP, FNP, NP-BC
lives and understanding their vulnerability.” Jovanov says one of the most critical issues NPs face today is being granted full practice authority (FPA). After a decade of working towards FPA, California Governor Gavin Newsom signed AB 890 legislation in 2020, expanding the existing scope of practice laws for NPs. It became law in January 2021, allowing NPs to practice independently after finishing a transitional oversight period. Currently, there are 24 states plus Washington D.C., that have full practice authority for nurse practitioners. The remaining states have either reduced or restricted practice. This map shows an overview of NP licensure for all 50 states: https://www.aanp.org/advocacy/ state/state-practice-environment “It’s impossible to meet the growing demand for primary care with just physicians, especially since so many don’t
www.dailynurse.com
www.springerpub.com
11
Antoinette Barrett, NP, CPNP, with some patients
accept Medi-Cal/Medicaid,” Jovanov says. According to the University of California, 65 million Americans reside in federally designated health professional shortage areas (HPSAs) for primary care. These areas tend to be in remote rural towns and low-income areas, the same areas where a growing number of NPs provide care.
A Mobile Community Clinic Antoinette Barrett, NP, CPNP, is clinical supervisor of Cedars Sinai Medical Center’s Community Outreach Assistance for Children’s Health (COACH) for Kids program in Los Angeles, California. As part of a mobile medical and case management program, Barrett and her colleagues provide primary and
12
preventative health services to low-income and medically underserved children and their families in Los Angeles County. Barrett, who previously worked in pediatrics in a hospital setting, says community work is an entirely different type of nursing than working at a patient’s bedside. The COACH program connects with local schools and also takes their services to shelters and public housing units, providing critical health services to families who live below the poverty line. “Our mobile medical units regularly travel to areas of Los Angeles where families don’t have access to medical care,” she says. “We treat children with asthma, respiratory infections, diabetes—we’re a
Nurse Practitioner Week Special Issue 2021
nurse-run primary care clinic on wheels.” Barrett says many of the children seen in the COACH
Barrett, who previously worked in pediatrics in a hospital setting, says community work is an entirely different type of nursing than working at a patient’s bedside.
program have only received fragmented medical care in the past. “They may have been seen at an urgent care clinic or emergency room when they became ill, but we find a lot of children who are behind in
their immunizations or who have developmental delays that weren’t previously diagnosed,” she says. At COACH, nurse practitioners work to connect families with a regular medical provider and also address any other barriers to care such as food insecurity and transportation issues. “After learning that many of our families didn’t have a pharmacy in their neighborhoods, we began dispensing medications from our mobile clinics to make the process easier,” Barrett says. Linda Childers is a freelance writer based in California.
HEALTH CARE DOESN’T STAND STILL, AND NEITHER DO YOU. TAKE YOUR NEXT STEP IN CHANGING THE FACE OF NURSING. 2,000+ students: 53% minority, 16% male 160 faculty members
CONTRIBUTE TO THE CHANGING FACE OF NURSING. EXPLORE YOUR OPTIONS:
nationally top-ranked bachelor’s (RN-to-BSN), master’s, DNP, PhD, and certificate programs top 10 in the nation for ranked DNP specialties and online MSN and certificate programs 11th in receipt of research funding from NIH (for public schools of nursing) ranked No. 18 in the nation for best online graduate nursing programs for veterans JOIN US to contribute your background and perspectives to the critical work we do to cultivate healthier communities locally, nationally, and around the world.
nursing.umaryland.edu/explore
Health
Professions
Higher Education Excellence in Diversity Award winner in 2018, 2019, 2020, and 2021
www.minoritynurse.com
2021
®
Top Colleges for Diversity
www.dailynurse.com
www.springerpub.com
13
Advocating for Full Practice Autonomy for Nurse Practitioners BY JAMES Z. DANIELS
T
here are 24 states in the United States that have freed nurse practitioners from the requirement that they work in collaboration with a supervising physician as they go about the business of providing care to any and all patients. North Carolina, unfortunately, is not one of them. Nurse practitioners believe that these regulations have lost their usefulness
Many in the physician community, while agreeing that it is critical that health care be available far and wide, have their own reasons for opposing granting full professional autonomy to nurse practitioners. and are organized to change it. Their position is that these provisions actually constrain the delivery of effective, efficient, and accessible health care and have huge implications for impacting public health. They are organized and are taking the medical organizations head on through leveraging the persuasive and politically astute nurses elected to the legislature—and there are five of them, as well as the support of the North Carolina Nurses Association and the National Association of Nurse Practitioners. Many in the physician community, while agreeing that it is critical that health care be available far and wide, have their own reasons for opposing granting full professional autonomy to nurse practitioners. They too have marshalled
their ability to remind elected officials of the financial support they received from the medical community that can easily be transferred elsewhere. It appears that since 2014 this issue has been debated, argued over, and challenged with a dab of acrimony at times in the North Carolina legislature where it now rests. Herein is an account of how this process has achieved a significant level of public awareness that influences the outcome from the perspective of two NPs. It intersects the heightened discussions on health quality, health availability, health access, and health costs to cite some of the dominant themes. North Carolina law is explicit. NPs and certified
The states that have liberalized the role of the NP and have seized on the challenge of making health care services more widely available believe there is a quantifiable benefit. Others are bogged down in seeing it as a challenge to physicians’ right to exclusivity in the practice of their training and their craft.
nurse midwives are to be supervised by a physician. These health providers are classified as advance practice nurses because of their credentials, training, and experience. State regulations require that these nurses have a standing agreement with a physician and meet with
them every six months. A written statement defines the joint practice of a physician and an NP in a collaborative and complementary working relationship. It frequently includes the responsibilities of both the collaborating physician and the NP and often defines the prescriptive authority of an NP. These are the issues that encircle autonomy and are a nationwide phenomenon. How these provisions are actually made operational is also an issue and adds a dimension to the question of the regulation’s necessity. The states that have liberalized the role of the NP and have seized on the challenge of making health care services more widely available believe there is a quantifiable benefit. Others are bogged down in seeing it as a challenge to physicians’ right to exclusivity in the practice of their training and their craft. Advanced practice nurses are registered nurses that include nurse practitioners who have received additional training and education to play a more advanced role in the health care system. They may have a master’s degree, post-master’s certificate, or practice-focused Doctor of Nursing Practice degree or even the PhD. With their advanced training, they have the expert knowledge, clinical expertise, and complex decision-making ability necessary for expanded practice and accountability. Advanced practice nurses are capable of handling more complex casework than a registered nurse (RN), and do this with greater autonomy and discretion, and in some areas, are able to practice independently, without the supervision of a physician.
www.minoritynurse.com
As a result, advanced practice nurses are increasingly relied upon to meet the demand in primary care especially in rural and underserved areas. In New York State, Governor Andrew Cuomo in June of this year, signed into law provisions that no longer require the NP to work under the supervision of a collaborating physician. It requires that practice of care be delivered in accordance with written practice protocols. NPs may enter into a written practice agreement with a collaborating physician if they so choose. It marked the end of a legislative battle that has lasted for a decade. Schquthia Peacock, FNP, completed her MSN at the University of North Carolina and her internship to satisfy the designation as a FNP in 1999. That year, the private practice clinic where she served filed for bankruptcy. Three of the employees, 2 NPs and a physician decided that they would purchase the business and asked Schquthia to join them. In 2000, it opened under new management as Preston Medical Associates with a new business model in the upscale town of Cary, North Carolina, with a staff of seven diverse employees, comprised of three NPs and a physician. This practice does not face, acutely, the issue of physician oversight and collaboration because access to one is easily attainable to satisfy all the provisions of the (NPR) Nurse Practitioner Regulations. The limited business experience of Schquthia Peacock and her associates necessitated the hiring of a business consultant to ensure that the insurance reimbursement process was operating
www.dailynurse.com
www.springerpub.com
15
Schquthia Peacock, FNP
at the highest level of efficiency guided by established performance metrics. Two issues have stood out for the now seasoned team of providers. They must ensure timely reimbursement from all insur-
“The facts are,” says Peacock, “we are committed to expanding legislation to support the scope of practice and enlarging the health care work force to allow access to care in geographic regions where patients have limited access to quality care.” ance providers and the timely reporting of their health outcomes experience to comply with the Affordable Care Act because these factors together affect cash flow.
16
The practice does not advertise its services. They are made known via word of mouth and the rating they receive on the insurance provider sites. They maintain their visibility by having significant presence at community events and sponsor a free annual health clinic that is well attended with patients travelling considerable distances to the site, which is set up tent-style in the clinic’s parking lot. Because of their diversity, they believe they are competitive against other providers in the area. They ensure that their engagement with their patients is culturally appropriate. The North Carolina Nurses Association supports the legislation to remove the barriers and the constraints on nurse practitioners, and there are several elected representatives who have emphasized that the change does not have much to do with them practicing medicine like doctors. Rather,
Nurse Practitioner Week Special Issue 2021
they have made it plain that for them the issue is driven by their desire to eliminate barriers to health care access because of archaic laws and regulations. The barriers are preventing nurse practitioners from practicing to the full scope of services for which we were educated and
trained. “The facts are,” says Peacock, “we are committed to expanding legislation to sup port the scope of practice and enlarging the health care work force to allow access to care in geographic regions where patients have limited access to quality care.”
Lashonda Wallace, PhD, MSN, FNP, with a patient
Some reports suggest that physicians are less eager to practice in these rural and underserved communities and this is where the NP community can help fill the gap. Forty percent of North Carolina is considered rural. As North Carolina grapples with the expansion of Medicaid, and this is certain to continue, the need for nurse practitioners will remain front and center to serve a rapidly expanding population demanding more health services. On the Southeastern cost of North Carolina is the city of Wilmington, where there is a nurse practitioner led clinic run entirely by four racially diverse FNPs. The city has a memorable history that evokes both praise and disdain. Towards the end of the 19th century, Wilmington was a majority-black, racially integrated prosperous city, and the largest city in North Carolina. In the Wilmington massacre of 1898, Democrat white supremacists launched a coup that overthrew the legitimately elected local government.
They destroyed the property and businesses of black citizens built up since the Civil War, including the only black newspaper in the city, and killed an estimated 60 to more than 300 people. Today the city is one third minority and has become a visitor mecca in the summer because of its beaches. The test of the rationale to perpetuate physician supervision of nurse practitioners, comes up short when its impact on Lashonda Wallace, PhD, MSN, FNP, is examined. Wallace is highly qualified to function within the prescribed protocols given her credentials. She, however, is bound by the same regulations as a newly minted MSN graduate, in spite of her credentials. Wallace’s clinic is unique in several ways. It is part of a medical service entity—a hospital, yet independent. It serves a very diverse population; it is funded entirely by the Federal government and is constrained by North Carolina’s NP regulations on how care is administered. It delivers care within an OPM (Outpatient Management) system.
“How has the physician oversight requirement impacted your work of getting treatment to patients?” I ask Dr. Wallace. “Primarily during those times when I needed approval or instruction for a particular case related to care coordination. Additionally, I had some limitations when treating a patient with Hepatitis-C diagnosis in the primary care setting, the HIV patient had restrictions on securing insurance coverage because some carriers demand sign-off only from MDs. Delays of this type impacted life-saving treatment readily available in the family care setting but not accepted by the insurance carrier.” Wallace describes a very real episode where a patient in a long-term treatment regimen develops an acute condition and needs admission to the hospital. As an NP, she cannot execute this referral because the clinic does not have hospital privileges, and she is not authorized to make this referral even though she is capable of conducting an examination and diagnoses. “Delays of most
www.minoritynurse.com
any type affects continuity of care outcomes,” she says. The clinic’s NPs get out in the rural communities covering several counties by visiting community centers, conducting health care fairs, and supporting organizations that are focused on improving community health. This gets her and her associates connected to rural and underserved points of influence where they build credibility and community engagement. This year, as in prior years, the bill now before the legislative committee of the General Assembly of North Carolina awaits a hearing, a necessary step required by law. Perhaps as this process gets underway, the resulting outcome will be one of opposing sides agreeing that lifting the constraining provisions on nurse practitioners is the right thing to do. This would be a good outcome. James Z. Daniels is a consultant and writer who lives in Durham, North Carolina and frequently contributes to Minority Nurse.
www.dailynurse.com
www.springerpub.com
17
Is Nurse Practitioner Education in Need of Reform? BY NACHOLE JOHNSON, MSN, FNP-BC
I
f the pandemic has shown us anything, it’s that we need more primary care providers to care for sick individuals. During the pandemic, nurse practitioners (NPs) across the nation stepped up and provided care during the crisis when there was a shortage of physicians. Although this isn’t new–NPs have been providing exceptional care for years preceding the pandemic. In a study conducted by the Veterans Administration, when compared to their MD counterparts, patients who had NPs as primary care providers (PCPs) experienced similar outcomes and incurred less utilization at a comparable cost relative to those managed by MDs. When evaluating the outcome of this study, NPs seem to be the answer to a cost-effective approach to addressing the shortage of primary care physicians, but this isn’t the case. Why the hesitation?
Education: The Real Issue at Hand At the time of the writing of this article, there are currently 24 states and three U.S. territories that grant full practice authority (FPA) to NPs. NPs have worked tirelessly for years to get legislation passed for FPA across the nation. Although studies show that care provided by an NP is comparable to physicians, there is a growing issue within the NP community that many are ashamed to admit. Educational standards are lacking in some programs and leaving new graduate NPs feeling unprepared for clinical practice. The lack of a clear consensus of educational standards for NPs is hurting the profession.
The minimum requirement of 500 clinical hours needed to graduate, as well as the lack of properly placing students with preceptors in the clinical setting, has taken a toll on the quality of recent NP graduates. Requirements for admission to an NP program are also a cause for concern since they
Educational standards are lacking in some programs and leaving new graduate NPs feeling unprepared for clinical practice.
vary between schools. Some programs require previous RN experience prior to admission while others don’t–the same goes with an entrance interview. There is no uniformity in the admission process of an NP program. When asked about NP educational standards, John Canion, FNP-BC, ENP-C, an emergency nurse practitioner in Texas, says they’re “suboptimal.” “There’s no barrier to entry [to NP school], even if it’s minimal, there needs to be a barrier to entry.” The issue within the NP community regarding educational standards is starting to seep out with more people taking notice—mainly physicians. Some physician groups make it a point to expose gaps in NP education by humiliating NPs and other midlevel providers online. While one of the website names in question includes “midlevel,” a majority of the posts are not about physician assistants, but NPs. Another physician group, Physicians for Patient Protection, calls their
work advocacy to “ensure physician-led care for all patients and to advocate for truth and advocacy regarding healthcare practitioners.”
Changes in Nurse Practitioner Education There are always two sides to every story and the debate on NP education is no different. Those who have graduated prior to the last decade have seen changes in the education newer NPs receive. When
“The [APRN] Consensus Model was designed to resolve the scope of practice issues, but it didn’t resolve the issue— it made it worse,” argues Canion. “People are interpreting it 1,000 different ways.” trying to pinpoint the timeframe when changes occurred some believe it was with the introduction of the APRN Consensus Model. Introduced in 2008, but not fully implemented until 2015, the APRN Consensus Model is a “uniform model of regulation for the future of advanced practice nursing that is designed to align the interrelationships among licensure, accreditation, certification, and education (LACE).” “The [APRN] Consensus Model was designed to resolve the scope of practice issues, but it didn’t resolve the issue—it made it worse,” argues Canion. “People are interpreting it 1,000 different ways.” According to Jana Zwilling, PhD, APRN, FNP-C, a clinical assistant professor of nursing
www.minoritynurse.com
at the University of North Dakota, there have been two major changes affecting NP education in the past 10-15 years: the increasing need for primary care providers and the shift to clinical doctorates for NPs. “University systems and other educational institutions have built programs to expand the capacity to educate nurse practitioners in the United States in hopes of providing more NPs to fill the gaps in health care access,” says Zwilling.
The Future In the last few years, the profession has seen the rapid growth of NPs as Zwilling mentions. Between 2010 and 2017, the profession expanded by 109% and continues to grow. The Bureau of Labor Statistics projects that between 2020 and 2030 another 114,900 NPs will be added to the profession with a growth rate of 52% in a single
Due to the unregulated proliferation of NP graduates, wages for NPs have gone down, there are oversaturation issues in some regions, and the public perception of our reputation stands to erode. decade. What does the rapid growth of NPs mean for the future if educational standards are not reformed? If changes don’t occur within the NP educational system a myriad of issues will take place—some are already being witnessed. Due to the unregulated proliferation of NP
www.dailynurse.com
www.springerpub.com
19
graduates, wages for NPs have gone down, there are oversaturation issues in some regions, and the public perception of our reputation stands to erode. Canion believes the worst possible outcome would be for states that have FPA to redact privileges. “We’re hurting our profession; what’s eventually going to happen if we don’t fix it [education], is that we’re going to lose full practice authority.” What the future holds for the profession is unknown, but Zwilling explains that educators are aware of issues and
20
that it takes time to implement new policies. “The 6th edition of the Criteria for Evaluation of Nurse Practitioner Programs by The National Task Force on Quality
What the future holds for the profession is unknown, but Zwilling explains that educators are aware of issues and that it takes time to implement new policies.
Nurse Practitioner Week Special Issue 2021
Nurse Practitioner Education is due to be published by the end of the year,” says Zwilling. “It will likely address concerns having arisen recently such as clinical sites not accepting students from programs without an on-campus component, having an appropriate number of faculty to support students, and the ability to provide adequate resources for the number of students enrolled.” While NP educators and practicing NPs expectantly wait for educational reform, physician groups will continue to address shortcomings
that erode trust in the public perception of the profession. When discussing the future of the NP profession, Canion says, “We have to be hypercritical of our own education in order to ensure we’re producing the best NPs possible.” Nachole Johnson, MSN, FNP-BC, is the CEO of ReNursing Edu and author of multiple titles that focus on NP education and business. Her vast experience allows her to offer knowledge to help others in nursing; whether wanting to pursue graduate NP studies or wanting to start their own business.
OUR SCHOOL GIVES YOU KNOWLEDGE.
YOUR LEADERSHIP WILL CHANGE LIVES. The Betty Irene Moore School of Nursing at UC Davis prepares successful nurse leaders. We offer two doctoral programs for nurses — a Doctor of Philosophy and a Doctor of Nursing Practice. As one of the only graduate nursing schools committed to activating change where it’s needed the most, we go beyond clinical education with programs that elevate your ability, confidence and vision to become a new type of health care leader. We need students like you — who seek a greater impact in health and believe in better. Learn how you can grow and go beyond today at nursing.ucdavis.edu/ advanceyourcareer.
www.minoritynurse.com
www.dailynurse.com
www.springerpub.com
21
