Appendix b Survey “blameless” Course Survey

1. I am a: Nursing Junior Nursing Senior

2. The course stimulated my interest in the subject of social justice.

Strongly agree agree neutral disagree strongly disagree n/a

3. The use of television clips reinforced concepts of mental health and mental illness.

Strongly agree agree neutral disagree strongly disagree n/a

4. The class reinforced the connection between socioeconomic status and physical health.

Strongly agree agree neutral disagree strongly disagree n/a

5. The class reinforced the connection between socioeconomic status and mental health

Strongly agree agree neutral disagree strongly disagree n/a

6. My understanding of the challenges the poor face in society has increased with this course.

Strongly agree agree neutral disagree strongly disagree n/a

7. The knowledge from this class helps me understand concepts presented in other nursing classes.

Strongly agree agree neutral disagree strongly disagree n/a

8. The course increased my understanding of the connection between mental health and physical health.

Strongly agree agree neutral disagree strongly disagree n/a

9. The course helped me understand the impact of trauma on overall health.

Strongly agree agree neutral disagree strongly disagree n/a

10. I am able to apply psychiatric content portrayed in this TV series to real-world clinical situations.

Strongly agree agree neutral disagree strongly disagree n/a

11. I am able to put medical knowledge into context using this TV series, and apply it to real-world situations.

Strongly agree agree neutral disagree strongly disagree n/a

12. Would you consider taking another course using popular media to learn nursing concepts?

Yes No Maybe

Introduction

Nurse Practitioners and barriers to Practice in Primary Care

Reeja Mathew, BSN, RN-BC, CV-BC

Margaret Marie Cox, DNP, ANP-C, RN

Abstract

The nurse practitioner (NP) workforce has increased steadily over the past two decades. This growth occurred in every region of the United States and was driven by the rapid expansion of education programs that attracted nurses of the millennial generation. Approximately 270,000 NPs are licensed to practice in the United States in various settings (Gigli et al., 2019). The number of primary care NPs is projected to increase by 93% between 2013 and 2025 (Poghosyan, 2018). With the increasing primary care physician shortage and the 150 million adults with one or more chronic conditions, the U.S. healthcare system must rely on advanced nurse practitioners as alternative primary care providers. (Luo et al., 2021). The expanding workforce of NPs in the United States could play a vital role in meeting the increasing demand for primary care. Removing state-level scope of practice (SOP) restrictions, regulations that govern the degree of prescriptive and/or practice authority granted to NPs, has been debated as a strategy to increase access to care since the time of healthcare reform (Patel et al., 2018). This paper aims to identify the barriers to NP practice in primary care and examine transformational leadership (TFL) principles as an effective framework for promoting NP practice.

Keywords: nurse practitioner (NP), advanced practice registered nurse (APRN), scope of practice, primary care

Nurse practitioners (NPs) in primary care face many challenges and barriers that impede their practice. This paper focuses on barriers to practice, such as practice authority, prescriptive authority, and reimbursement issues to work independently as primary care providers and their implications for practice. The theory framework of transformational leadership (TFL) is recognized as a practical leadership style to overcome these barriers. According to Fitzpatrick and McCarthy (2014), transformational leadership is the process of developing a mutual relationship with followers that elevate and nurture them to become leaders. Nurse practitioners can apply the four elements of transformational leadership—idealized influence, inspirational motivation, intellectual stimulation, and individual consideration—to guide their practice (Collins et al., 2019). In TFL, people require a sense of mission and purpose to work effectively, as in primary care when NPs have to work with physicians.

Reeja Mathew, BSN, RN-BC, CV-BC

Mt. Sinai South Nassau, Oceanside, New York & Adelphi University, Garden City, New York

Margaret Marie Cox, DNP, ANP-C, RN Adelphi University, Garden City, New York even with the exponential growth of nurse practitioners at the national level, scope of practice restrictions limit the full-service potential of NPs’ education and qualifications.

Practice Authority

Nurse practitioners are advanced practice registered nurses (APRNs) who receive graduate education at the master’s, post-master’s, or doctoral level and obtain national board certification. Established educational standards for NP education ensure the attainment of the APRN core, role core, and population core competencies (American Association of Nurse Practitioners [AANP], 2019). The APRN’s clinical role is defined by the scope of practice (SOP) set by the state statutes. It varies from state to state. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (LACE) is the landmark policy that establishes principles outlining the SOP for all APRNs (Gonzalez & Gigli, 2021).

Even with the exponential growth of NPs at the national level, SOP restrictions limit the full-service potential of NPs’ education and qualifications. Policy and organizational barriers still affect the NP workforce and its ability to deliver high-quality, cost-effective, patient-centered care. (Poghosyan et al., 2021). In the United States, the NP SOP policy is categorized as “full,” “reduced,” or “restricted” at the state level (Patel et al., 2018). The American Association of Nurse Practitioners (AANP) defines full practice authority (FPA) as “evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing” (Ayami & Furlong, 2019). Currently, 22 states (44%) and the District of Columbia grant FPA, which allows NPs to manage all aspects of patient care, including practicing and prescribing, without physician supervision. The remaining states granted “reduced practice” (17 states, or 34%) and “restricted practice” (12 states, or 24%), respectively (Peterson, 2017). Restricted practice requires physician supervision to provide select practice or prescriptive activities. In reduced practice, NPs need physician supervision in all aspects of rendering care. (Patel et al., 2018).

Prescriptive Authority

Prescriptive authority refers to a nurse practitioner’s authority to prescribe pharmacologic medications and nonpharmacological therapies (AANP, 2019). In contrast to RNs who carry out practitioners’ orders, APRNs have the capacity to prescribe medications. NPs acquired the prescriptive ability through didactic training in pharmacology and pharmacotherapeutics in their educational curriculum endorsed by the Commission on Collegiate Nursing Education (CCNE) (Diegel Vacek & Vuckovic, 2019). NPs’ prescriptive authority differs considerably depending on the state laws (Germack, 2020). The District of Columbia and 22 states with FPA allow NPs to prescribe medications independently without physician supervision.

States with reduced authority require a relationship with a physician that outlines the NP’s prescribing abilities. NPs have reduced authority in 16 states and work alongside physicians in joint practice agreements (Zhang & Patel, 2021; Park et al., 2018). NPs in states with restricted practice are required to have physician supervision or delegation when prescribing medications and controlled substances. Some states specify whether a nurse practitioner must complete a transition to practice period before being able to prescribe independently.

Reimbursement

The current healthcare industry is focusing on “value-based purchasing” and shifting away from a system that rewards volume to one that focuses on efficiency and value. The U.S. Department of Health and Human Services declared plans to transition 50% of Medicaid and 100% of Medicare fee-for-service reimbursements to alternative payment models (i.e., bundled payment, accountable care organizations (ACOs), or patient-centered medical homes) by 2025 (Razavi et al., 2021). These transformations challenge clinicians to deliver services more efficiently by holding them accountable for the cost and quality of care, whereas nurse practitioners are well fitted for these goals.

The Balanced Budget Act of 1997 granted NPs the authority to bill Medicare for services that they perform directly. However, NPs are reimbursed at 85% of the physician rate in the Medicare reimbursement policy (Bischof & Greenberg, 2021). The COVID-19 pandemic unlocked the necessity for NPs to extend their care in more settings, leading to the temporary removal of practice restrictions and access to care in many states. This pandemic proved the NP’s ability to provide health care in various settings, including rural, underserved, and vulnerable populations such as older adults and those with low socioeconomic status (Bischof & Greenberg, 2021). Hence there is a crucial need to make primary care reimbursement for all primary care providers equitable. Uniformity of reimbursement would increase the number of practicing primary care NPs to meet the growing healthcare needs of primary care.

The NP’s role as Primary Care Provider

According to AANP, more than 75% of actively practicing NPs in primary care are essential to the U.S. primary care workforce. Some states recognize an NP as a primary care provider, whereas others do not. NPs are prepared through advanced graduate education and clinical training to deliver comprehensive health services to people of all ages. They have an active role in diagnosing, prescribing, treating, counseling, and teaching. NPs diagnose, order, perform and interpret lab results, and manage acute and chronic conditions with an emphasis on health promotion and disease prevention. As our nation encounters the future challenges of an aging population, rising healthcare costs, and the increasing burden of chronic disease, there is an imperative need for NPs as primary care providers to practice to the maximum capacity of their scope of practice (Patel et al., 2018). They can provide high-quality, patient-centered, and costeffective care. There are challenges and tensions between advanced nurse practitioners and physicians to create a collaborative relationship and recognize the individual characteristics required for their specific roles. Some physicians are embarrassed by the change in roles in primary care. They lack confidence in the adequacy of the training and education provided for the advanced nursing role and, therefore, in the nurse’s

Figure 1

Nurse Practitioner Reimbursement From Medicare and Medicaid Services Over Time

1965 1977 1990 1997 2020

 Medical Inception

 NPs may only bill under a physician's “incident to.”

 Rural Health Clinic Service Act

 NPs can receive direct reimbursement in rural health clinics at 85%.

 Omnibus Reconciliation Act

 Reimbursement is extended to rural areas and nursing homes at 85%.

 Balanced Budget Act

 Location restrictions removed 85% reimbursement remains.

 COVID-19 skills and abilities to take on the responsibilities of a primary provider role (Perloff et al., 2017).

 Many states temporarily removed practice restrictions. Reimbursement still at 85%.

Note : The chart shows nurse practitioner reimbursement from Medicare and Medicaid services over time. From “Post COVID-19 Reimbursement Parity for Nurse Practitioners,” by A. Bischof and S. Greenberg, 2021, OJIN: The Online Journal of Issues in Nursing, 26(2) (https://doi.org/10.3912/ojin.vol26no02man03).

Implications for Practice

The present and future of the primary care healthcare system in the United States rest on the adequacy and reliability of a pool of primary care professionals. With the increasing shortage of primary care physicians, the healthcare system should consider advanced practitioners as alternative providers. However, the supply of NPs is limited due to their restricted scopes of practice, which prevents them from practicing to the fullest capacity of their education. Restrictive practices also increase healthcare costs related to physician supervision, limited healthcare services, and access to care, especially in underserved and uninsured populations (Peterson, 2017). The full SOP of NPs most benefit people in rural areas and those with demanding medical care needs. The FPA of NPs promotes professional independence that facilitates more efficient allocation of the health labor force in all settings.

NPs across the United States are attaining FPA, including approval to prescribe legend and controlled drugs. Unconfined prescriptive authority is necessary for NPs to practice to the full extent of their education and training. NPs have the prescriptive authority to prescribe controlled substances in all 50 states. However, NPs cannot prescribe Schedule II substances in some states and must apply separately for these privileges after state-specified requirements such as time in practice or additional training requirements are satisfied (National Council of State Boards of Nursing, 2021). The opioid use disorder and the current COVID-19 pandemic have proven the need for full prescriptive authority for NPs, especially those working in rural, remote, and underserved areas where physicians are not readily available (Germack, 2020). The Affordable Care Act (ACA) has resulted in increased workload and patient demands for primary care, necessitating the FPA for maximum utilization of advanced practice providers (Zhang & Patel, 2021). Expanding the prescriptive authority of APRNs is one mechanism to alleviate the increased healthcare needs of the public.

The independent practice ability of NPs within organizations promotes their role as primary care providers. The key to success is negotiating the position between team members and reaching a consensus on how the different health professionals work together. There is uncertainty about the NP’s practice across all geographical regions of the United States without appropriate financial reimbursement, similar to primary care physicians (Poghosyan, 2018). The application of the transformational leadership style to nursing practice help to alleviate the practice resistance in primary care.

Conclusion

There is an inevitable necessity for full practice and prescriptive authority for NPs serving different population foci in primary health care settings in order to achieve maximum patient benefits in health care delivery. NPs working in primary care also deserve equal reimbursement and funding to that of physicians for delivering health services. Studies have shown that NPs can provide quality, cost-effective, and holistic care with better patient outcomes than physicians (Aymami & Furlong, 2019). The APRN workforce is essential to meet the future healthcare needs of the nation with its aging population and patients with chronic diseases. Furthermore, NPs have a high potential to meet the healthcare needs of rural, underserved, uninsured, and vulnerable populations.

Healthcare organizations and policy- and decision-makers need to redefine the boundaries of advanced practitioners and support practice transformation to integrate and maximize NPs to the full extent of their capacities. Transformational leadership can be applied to promote nurse practitioner practice in primary care. Transformation to APRNs’ fullest scopes of practice in primary care settings is a promising strategy for enhancing the quality and efficiency of primary care and managing the immense unmet healthcare needs of individuals, families, and communities.

Healthcare organizations and policy- and decision-makers need to redefine the boundaries of advanced practitioners and support practice transformation to integrate and maximize nurse practitioners to the full extent of their capacities.

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