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Issues up close


Family nurse practitioner (FNP) and nurse-midwife Karen Holder, FNP-BC, CNM, MHS, sees patients at a large primary care clinic in Flagstaff, Arizona, as well as at small satellite units in remote communities sprinkled around northern Arizona. Her patient population includes infants and those at the end of life, Medicaid recipients and the uninsured or underinsured, the working poor and the disenfranchised. They come in with typical complaints expected in a primary-care setting: sore throats, sinus infections, prenatal care needs, and hypertension. But because area residents often can’t access healthcare services, Holder increasingly finds herself providing care to patients who are much sicker.

For example, while assessing a woman who came in with an infection, Holder took the time to learn that the patient had recently been discharged from a hospital with a diagnosis of insulin-dependent diabetes. “Her blood sugar was in the 350 range, and she had no clue how to manage her diabetes,” says Holder, an Arizona Nurses Association (AzNA) member and treasurer for the Arizona NP Council, AzNA Chapter 9. “She had no insurance and was scared to death that she’d be sent to the ER.”

After providing her with crucial patient education, Holder developed a plan that incorporated routine outpatient check-ups.

Roughly 1,200 miles away, family nurse practitioner Lila Pennington, DNP, APRN, FNP/GNP-BC, also provides primary health care, seeing patients of all ages and “a little bit of everything” while working at a rural south-central Missouri clinic. She also works at a rural public health department women’s health clinic and coordinates the University of Missouri Sinclair School of Nursing’s FNP area of study. Her ties with many of her patients are long and strong, and they view her as their primary healthcare provider.

“Adult, pediatric, and family nurse practitioners can handle 85% to 90% of what comes into a [primary care] office,” says Pennington, a Missouri Nurses Association (MONA) member. “We carry our own patients, we can refer to physicians, and they can refer patients to us. We are well-prepared health professionals who practice safely within our scope, and we know our limits and when to consult and refer.”

Although NPs and other advanced practice registered nurses (APRNs) have a proven track record of providing cost-effective, quality primary care or specialty services, they continue to face challenges—both large and small—as they try to meet the needs of patients in a healthcare system poised for potentially greater change.

Take the ongoing movement headed by the American Medical Association (AMA) to systematically review the scopes of practice of NPs, nurse anesthetists, and other health professionals in an attempt to limit or reduce their ability to provide care. Fortunately, ANA and its constituent member associations (CMAs) continue to work together with APRN stakeholder groups and others to ensure APRNs can practice fully and provide the care consumers need and deserve through the Coalition for Patients’ Rights (CPR) and other concerted efforts (www.patientsrightscoalition.org).

“This should not get to the point of us versus them (organized medicine),” says Denise Link, PhD, WHNP, an AzNA board member, Arizona Board of Nursing member, and associate dean for Clinical Practice and Community Partnerships at Arizona State University. In the latter role, she oversees five NP-led health centers serving insured and uninsured populations that are ethnically, racially, and socioeconomically diverse. “It’s very obvious that there is plenty of work for everyone. We all have a role, and everyone is needed.”
Consider this: The U.S. Census Bureau projected that the nation’s population will reach about 310 million this year and more than 341 million in 2020. Furthermore, the Association of American Medical Colleges projects a shortfall of as many as 46,000 primary care physicians by 2025.

Benefits, barriers

An estimated 250,527 RNs reported being prepared as an APRN “in one or more advanced specialties or fields,” with 158,348 educated as NPs, according to the recently released report “The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses.” (The other roles are certified nurse-midwife [CNM], certified registered nurse anesthetist, and clinical nurse specialist.)
In its vision of healthcare reform, ANA continually has emphasized the need for a system that focuses on preventive primary care services, and one in which APRNs play a significant role. “NP care is patient-centered care,” Link says. “We provide care based on what we know are the best practices, and we take those best practices and apply them to the individual person who is right in front of us. Our patients also tell us that they feel they are part of the decision-making process and that their preferences are taken into consideration.”

Adds Colorado Nurses Association Executive Director Fran Ricker, MSN, RN, CGRN, “The nursing paradigm is distinct from the medical paradigm. We are prevention- and wellness-focused. APRNs traditionally have worked with underserved populations in both urban and rural areas, and the need for APRNs who can deliver primary and other health services is still great.”

However, NPs and other APRNs face many barriers, from regulatory and legislative to simply bureaucratic, Ricker explains. Some policymakers and members of the public still may not understand what APRNs can do.

And the scopes of practice for APRNs vary across the nation, with some states, such as Arizona, more
favorable than others. (Arizona was ranked No. 1 in a 2006 consumer choice survey that considered state NP regulations.)
“In some parts of the country, nurses are still struggling to get initial authority to practice or prescribe autonomously,” Link says. “In Arizona, we constantly watch new bills and are vigilant of any changes in the political environment so that we won’t lose anything.”

Under Arizona’s nurse practice act, NPs can practice independently, prescribe controlled substances, and order and interpret a wide range of tests and procedures. In Missouri, NPs must have a formal collaborative agreement with a physician who is practicing within a 30-mile radius in a non-health professional shortage area (non-HPSA) and within a 50-mile radius in a HPSA area, among their restrictions.

Working together

In close collaboration with APRN groups, ANA continues to advocate with federal policymakers for an expanded role for APRNs and removal of barriers and discriminatory practices. At these tables and other forums, ANA addresses the vital role that NPs and CNMs must play in the primary care arena.

ANA also continues to work nationally and with its CMAs to provide legal support for threats to scopes of practice, promote APRN practice in a wide range of communications vehicles, and lobby for reimbursement for their services and provider-neutral language used in healthcare legislation and regulations, according to ANA Senior Policy Fellow Lisa Summers, DrPH, CNM.

For example, last December ANA and more than two dozen nursing organizations partnered to sharply reprimand an AMA report that questioned whether NPs are adequately trained and able to provide appropriate care.

In an ongoing effort, ANA has collaborated with a wide-range of nursing groups to develop and implement a new model aimed at standardizing and regulating APRN practice—with an eye toward ensuring independent practice.

In the states, CMAs are working with other key groups to make strides in practice and keep threats at bay. Last year, the Colorado Nurses Association helped APRNs develop a transitional model called the “articulated plan” that allows experienced APRN prescribers to function with more independence. This year, the association successfully fought Medicaid reimbursement cuts to NP services and helped defeat an effort to regulate retail clinics and the APRNs who work in those roles, according to Ricker.

AzNA members recently worked with policymakers on a state bill to ensure that NPs are among the healthcare providers to whom patient cases can be turned over if a physician doesn’t want to provide end-of-life information or counseling. And they are lobbying for psychiatric-mental health NPs to be among the approved providers who can perform court-ordered evaluations and treatments, reports
AzNA Executive Director Joyce Benjamin, MSN, RN.

MONA continues to push for completion of the rule-making process around its win, giving APRNs the authority to prescribe controlled substances, according to MONA Chief Executive Officer Jill Kliethermes, APRN, FNP-BC. In a new state bill being considered, the association wants to ensure that NPs are included as approved healthcare providers, which would allow physical therapists to accept orders for physical therapy from APRNs.

Pennington, who helped shape her own NP educational program more than three decades ago, wants APRNs to be able to practice without a tangle of restrictions. “Required collaboration sometimes slows down care, and the mileage limits [in Missouri] make it more difficult for NPs to get to those rural areas where they can provide care that is needed,” she says.

Looking at the national picture, Holder adds, “It’s pretty clear that NPs and other APRNs are part of the solution to patients’ having greater access to care and quality care.”

Susan Trossman is the senior reporter in ANA’s communications department.

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