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Over the past decade, increasing complexity of patient population, new education requirements for healthcare professionals and Affordable Care Act (ACA) have rearranged the health care system paying particular focus on the nurse practitioners’ (NPs) role. The scope of practice of NPs has been extended to reduce the gap in primary care. Initially, NPs’ population of focus was family and pediatrics, but later the scope was expanded to include neonatal, gerontology and other specialty roles. Currently, NPs assume numerous functions including caring for the underserved and ethnically diverse population in various healthcare settings. The Institute of Medicine (IOM) recommends NPs to practice to the full extent of their knowledge and training (Donelan, DesRoches, Dittus, & Buerhaus, 2013). Despite the improvement of NPs’ education and expansion of their roles, their practice is limited by some barriers. Although ACA produces additional strain on primary care workforce, the lack of awareness of NPs’ scope of practice restricts the services they can provide (Donelan et al., 2013; Hain & Fleck, 2014). The insufficiency of knowledge of NPs’ capability and what can be done in primary care settings among providers, organizations, and patients restricts NPs from practicing independently, serving as providers of primary care and prescribing medications.
Lack of Knowledge of NPs Scope of Practice
As a part of healthcare reforms, the role of NPs has been expanded to primary health care settings. This extension of the NPs’ function is expected to increase health care access and reduce the gap between supply and demand for care. Hain and Fleck (2014) posit that NPs are highly competent in providing primary care. They are highly trained, thus being able to deliver a variety of services. Although primary care delivered by NPs leads to positive outcomes, the clarity of the NPs’ role creates barriers to the deployment of these health professionals in primary care settings. There is the lack of knowledge among providers about the role and the scope of NPs’ practice. Most of the healthcare providers believe that NPs are not competent to treat patients with complex conditions. Additionally, NPs are forced to negotiate around practice restrictions that limit their ability to deliver optimal patient care. The scarcity of knowledge about NPs and their contribution to primary health care among health care professionals and resistance from physicians and general public are the most common barriers that limit the ability of NPs to practice to their full potential. The failure of the existing health care system to acknowledge the skills and the abilities of the NPs restricts their practice in primary care. Sangster-Gormley, Martin-Misener and Burge (2013) assert that NPs have the skills and the training required to meet patients’ needs from a holistic view. They are knowledgeable and competent providers who can offer comprehensive primary care. Providing NPs with an opportunity to practice to their full potential can assist in developing the workforce necessary to meet the growing demand for primary care services and contribute to the unique skills of delivering holistic care.
NPs lack opportunity to attain fully autonomous practice including prescriptive authority. Other healthcare professionals do not allow NPs to be independent in making clinical decisions. They are denied the prescriptive authority and, in some health care settings, cannot attend patients without supervision. The degree of independence of NPs in prescribing varies from one state to another as well as the type of drugs that NPs may prescribe. In some states, NPs are not allowed to prescribe a full range drugs without the involvement of a physician. Other states limit the selection of those possible drugs (Donelan et al., 2013). These restrictions have detrimental consequences to the NPs’ professional stature and access to health care services.
NPs face numerous challenges in primary care settings due to the lack of awareness of their scope of practice among healthcare professionals. Opposition by physicians creates barriers in expanding NPs’ role in health care facilities. In their study, Hain and Fleck (2014) found that physicians oppose the expansion of NPs functions to primary care settings. They believe that NPs’ education is not adequate to equip them skills required to deliver quality care. Due to differences in educational preparation, physicians lack confidence in NPs’ ability to practice in settings, which are characterized by diverse patient population with complex health conditions. NPs continue to struggle to move from restrictive to full practice due to the opposition from some providers and medical organizations. Donelan et al. (2013) found that physicians’ shortage does not support the expansion of NPs’ scope of practice. The increased number of health care workers in the primary care setting will lead to improved health of patients. However, most of the physicians oppose the notion that expanding the NPs’ workforce can improve the safety, equity, access and effectiveness of care. Although the majority of physicians believe that NPs should practice to their fullest extent of knowledge, most of them admit that NPs do not possess sufficient competence to lead care in medical homes and they should not receive equal compensation for similar services. At the same time, IOM report proposes that NPs should take a leading role in medical homes, admit patients to hospitals and receive the same compensation as physicians for similar services. Moreover, the study found that physicians consider that they deliver better health care than NPs, though on practice, the latter deliver high quality care and thus are equally important like physicians in improving health outcomes. Hain and Fleck (2014) assert that NPs’ functions are more superior to physicians’ ones in primary health care settings. Unlike physicians, NPs have adequate time with the patients, and thus they can assist them in planning their care by counseling on the best practices to manage their health.
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Several physicians’ organizations oppose the future of nursing recommendation regarding the expansion of NPs roles. These associations insist that NPs can only practice under supervision. They have raised concerns that unsupervised NPs will cause misdiagnosis and prescription errors that may lead to life-threatening problems. Physicians’ organizations argue that NPs lack the competence to manage complex patients suffering from multisystem health conditions. Furthermore, they are perceived that NPs will order unnecessary tests and referrals, which may increase the cost of healthcare. Empirical studies have found none of these concerns valid. No study has reported medication errors to occur more frequently among NP than physicians (Donelan et al., 2013; Hain & Fleck, 2014). There is no evidence that NPs makes errors in their prescription practices or clinical decision-making. Case management by NPs has indicated that hospital visits have been significantly reduced. Consequently, such situation leads to reduction of healthcare costs.
The aim of NPs and other healthcare professionals is to improve health outcomes, but there are barriers to work collaboratively. The absence of awareness of the NPs’ scope of practice among health care providers is a common barrier in working collaboratively. According to Hain and Fleck (2014), it hinders the development of a collaborative care model that recognizes and values NPs’ competence. The acceptance of NPs in primary care settings is influenced by health care professionals’ trust on NPs capabilities, knowledge and understanding of their functions in the setting. The majority of health care providers lack experience working with NPs, and thus they are not aware of their scope of practice. Physicians and NPs do treat patients as a team due to deficient knowledge of how their roles may complement each other. The lack of insight into NP’s scope of practice leads to stagnation in effective collaboration between NPs and physicians, which may result in patient care delay.
There is a concern that NPs do not possess sufficient knowledge for treating patients optimally. NPs and physicians need collaborative agreements to accomplish adequate health care for patients. Some NPs work in states that require them to collaborate with physicians. However, NPs and physicians hold different opinions on whether a collaborative agreement is obligatory. Physicians are not willing to work together with NPs because they believe that their knowledge is unacceptable to deliver high-quality care. Schadewaldt, Mclnnes, Hiller, and Gardner (2013) note that recognizing the unique role of each provider and understanding one’s contribution facilitates collaboration. A healthy collaborative relationship can improve patients’ outcome by reducing waiting time, shortening treatment period and promoting the prescription process. Collaboration between NPs and physicians can facilitate independent practice by the former and build trust by gaining knowledge on NP’s role. The scope and role of NPs should be appreciated to promote effective collaboration, which in turn increases patients’ outcomes.
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Patients have raised concern about the qualification of the NPs due to their unfamiliarity with the NP’s roles. The acceptance of NPs by patients depends on how the other health professionals approach them. According to Schadewaldt, et al. (2013), most of the health care providers do not introduce NPs to the patients as professional colleagues, doing so only when no doctor is available. As a result, patients do not trust the NPs in addressing their health care needs. Some individuals request physicians to reconsider NP’s prescription because of fear that it may be inappropriate. They feel that NPs lack adequate training and knowledge to handle their conditions partly due to of physicians’ hesitations about NPs’ decision-making and capabilities.
The role of NPs is expanding to improve access to care and overcome challenges in healthcare providers’ workforce. Despite the ability of NPs to deliver high-quality primary care, the lack of knowledge regarding their practice creates barriers to the integration of their expanded roles in health care settings. NPs and other healthcare professionals, mainly physicians, disagree about their respective roles in primary care. NPs play a crucial role in bridging the gap created by the increasing demand for primary care and the shortage of physicians. Collaboration between NPs and other healthcare professionals increases NPs’ independence of clinical practice and recognition of their competence in improving health outcomes, which in turn assists in the integration of extended NPs’ scope of practice in primary care settings.