The Pursuit of Nurse Practitioner Practice Legislation: A Case Study.

Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized. (1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states? We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions. A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08). As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately. To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.

Independent practice and full practice authority

Nurse practitioners’ workforce outcomes under implementation of full practice authority

Chronic conditions affect over 60% of US adults and drive nearly 90% of the nation's $4.9 trillion in annual health care costs. Nurse practitioners (NPs), particularly in Full Practice Authority (FPA) states, may be critical to improving outcomes and reducing health care burdens. To evaluate whether nurse practitioner FPA reduces hospital readmissions and emergency department visits related to chronic conditions across the United States. A secondary data analysis using restricted Medical Expenditure Panel Survey (MEPS) data (2010-2019) was performed on site at the Agency of Health Research and Quality. We applied incidence rate ratios (IRRs) and difference-in-difference (DiD) models. Primary outcomes included readmission and emergency visit rates for five chronic conditions: high cholesterol (n=33,409), high blood pressure (n=38,858), diabetes (n=13,075), emphysema (n=2,509), and asthma (n=17,018). Covariates included county-level socioeconomic factors and rurality. States with FPA had modestly lower IRRs for high cholesterol (0.9863), high blood pressure (0.9758), diabetes (0.9746), and asthma (0.9710) compared with restricted states. DiD models showed inconsistent effects, with most FPA*Post coefficients lacking statistical significance. However, rural FPA counties frequently showed significantly lower readmission rates, notably for diabetes and high cholesterol. NP FPA is associated with slight reductions in chronic condition readmissions, particularly in rural areas. While DiD models showed limited policy-specific impact, IRR findings support FPA as a promising strategy to enhance chronic disease management and access to care. Future research should address model limitations and explore causal pathways.

Physician shortages lead to longer wait times, shorter patient visits, and lower-quality patient interactions, resulting in a greater risk for misdiagnosis and an overall decrease in the quality of care they provide. In this viewpoint, we reviewed the issues surrounding full practice authority (FPA) for nurse practitioners (NPs) in the United States (US). We summarized evidence regarding the safety, quality, and efficacy of NPs in states that have enacted FPA and describes the role of NPs in closing the gap of unmet healthcare needs of the US population. We also described the success of states with FPA in their legislative efforts while other states are still plagued by barriers to FPA, providing context on the political environment surrounding FPA bills. The analysis of FPA for NPs meeting the healthcare needs of the US population can further inform policy to aid in similar healthcare needs globally.

BackgroundThe physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management.Study designA descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated.MethodsThe patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system.FindingsIn total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care.ConclusionsNPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

The coronavirus disease 2019 (COVID‐19) pandemic ushered in a new era for advanced practice registered nurses, as emergency regulatory and policy changes expanded the nurse practitioner (NP) scope of practice. The legislative changes enabled NPs to bolster the national pandemic response by working to the full extent of their education and training. The changes are only temporary, and many have contemplated the permanent impact of COVID‐19 when healthcare transitions to a postpandemic normal. NPs now have a unique opportunity to educate others about the merit of their role and advocate for permanent legislative changes. In this creative controversy manuscript, we build a case that national NP full practice authority increases access to care and is vital for a sustainable and resilient healthcare system that can react to future pandemic crises.

Nurse Practitioners in Emergency Care

This policy analysis examines the limited practice authority for advanced practice registered nurses (APRN) in the Southeastern United States, focusing on Tennessee while drawing comparisons to Georgia and Alabama. The PICO question that guided this policy analysis is: For advanced practice registered nurses within the southeast region of the United States (P), how does the development of a comprehensive policy recommendation for full practice authority (I), compared to existing reduced or restricted practice authority in the southeast region of the United States (C) affect access to care as endorsed by literature (O)? The literature suggests that despite being equipped with the education, accreditation, certification, and licensure, APRNs in the Southeastern states still have regulatory and nonregulatory barriers to practice, impeding their ability to provide access to care, especially in rural and underserved communities. Moreover, the literature strongly advocates adopting evidence-based recommendations by the American Association of Nurse Practitioners, the Consensus Model, and The Academy of Medicine to modernize the outdated regulatory and nonregulatory barriers impeding APRNs. A policy brief is also proposed to engage stakeholders in advocating for these evidence-based recommendations and securing APRNs' full practice authority. Eliminating these barriers allows APRNs to work to their full ability, resulting in enhanced healthcare access, improved quality, reduced healthcare disparities, and potentially lowered healthcare costs.

Time of Risk or Opportunity for NPs?

Progress Is Its Own Success, but It Is Not the Goal

Autonomous nurse practitioners (NPs) are an effective and useful member of the healthcare team, particularly when given a less restrictive scope of practice at the state level. In Ohio - a midwestern state in the United States - NPs treating worker's compensation (WC) patients are limited in treating the injured worker because of the bureaucratic paperwork WC requires of its providers. Collaboration was initiated with an organisation in Ohio seeking to improve the profession of Advanced Practice Nursing through legislative change. Project and objectives were discussed, as well as a collaboration to get the legislation changed in Ohio regarding the NP Medco-14 form practice issue. This Needs Analysis quantitative study was completed by conducting chart reviews of WC patients assessed by the NP evaluating any disparities between work restrictions recommended by the NP versus the physician. The proposed work restriction instructions given by the NP were reviewed, and the review included only initial injury evaluation patients. The charts were randomly selected from the past schedules of two occupational NPs in rural Ohio. The charts selected at random were based on meeting the study inclusion criteria (first visit patient or new injury patient) in a chosen 3-month block time frame: January-March. Of the 70 random charts reviewed, 100% had no discrepancies between the NP work recommendations and that of the physician. Allowing NPs to sign Medco-14 forms - also known as a return-to-work authorisation form or signed work excuse explaining limited work duties due to injury - will increase patient access to care, which in turn results in better patient outcomes. This study can be used as the foundational needs analysis to propose a legislative change in Ohio to allow NPs to independently sign the Medco-14 for Ohio WC patients. The collaborating organisation is currently drafting a legislative change proposal to modify the current Ohio NP Medco-14 restriction.

REVIEW QUESTION/OBJECTIVE The objective of this review is to examine conceptual and/or theoretical frameworks that are relevant to nurse practitioner education. The specific review question is: What conceptual and/or theoretical frameworks are available that are relevant to the structuring of nurse practitioner education? INCLUSION CRITERIA Types of participants This review will consider studies that include nurse practitioners in any specialty or the education of nurse practitioners in any specialty at the graduate or post-graduate level. Phenomena of interest In this review, we will consider documents that describe or evaluate frameworks, maps or conceptual structures for NP education at the graduate degree or post-graduate degree level. Literature that presents a framework for the graduate education of students in other health care disciplines at the university level will also be considered for inclusion. Frameworks for utilization in other jurisdictions (e.g. Provincial and Territorial regulatory frameworks) and metrics that assist in measuring, describing and organizing key concepts required for nurse practitioner education will be examined. Outcomes of interest for this review will include framework components in either narrative or illustrative form. Context This scoping review will consider studies that have been conducted in the provision of graduate level education of students in health care disciplines. Specific contextual focus will be directed to identify frameworks for educational programming for nurse practitioner students. Frameworks for curriculum development and/or delivery in other disciplines will also be considered.

Reviewed by: Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care Susan L. Smith Julie Fairman . Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care. Critical Issues in Health and Medicine. New Brunswick, N.J.: Rutgers University Press, 2008. xiii + 255 pp. Ill. $45.95 (978-0-8135-4319-2). In the 1980s, I had an excellent health care provider, a nurse practitioner who worked at a health maintenance organization, or HMO, in Madison, Wisconsin. Ida Gear was in high demand among many of the women I knew because of her health care skills and caring approach. Thus, I was delighted to learn more about the history of this health care profession in Julie Fairman's new book on the history of nurse practitioners. Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care not only documents the development of a new type of health care worker but sets it clearly within the wider context of nursing and medicine in the 1960s and 1970s. Fairman's history of the nurse practitioner movement adds an important dimension to scholarship on health care in the post–World War II era, a period of increasing interest among historians. Her insights into professional health relations illuminate some of the central themes in the history of modern health care. Fairman's study of nurse practitioners is attentive to the multiple perspectives regarding how best to provide optimum patient care. In particular, she analyzes the [End Page 235] ideas and concerns of doctors and organized medicine, including the American Medical Association, as well as those of nurses and organized nursing, including the American Nurses Association. Fairman demonstrates that the nurse practitioner movement was the product of nurse–physician relations and attempts at cooperation in both individual clinical practices and larger policy discussions. She shows that the nurse practitioner could be part of a collaborative health care practice with shared responsibility and equity among health professionals. In one especially interesting aspect of her study, Fairman draws on gender analysis to analyze the separate but related paths of nurse practitioners and physician assistants. Physician assistants, most of whom were men, emerged as complementary health workers within the field of medicine. Nurse practitioners, most of whom were women, were specialists with advanced training within the field of nursing. The two types of health care providers performed similar tasks and had similar degrees of autonomy in their work in this borderland between medicine and nursing. However, there were differences, as men became "less-than doctors" and women became "more-than nurses." Physician assistants were men looking for ways to use their health care skills without undertaking the lengthy physician training. Many of them had had military experience as medics and thus sought a parallel profession in civilian life. Nurse practitioners were women looking for more training and ways to expand their roles. Many of them had worked in areas of nursing that offered opportunities for specialization and independent work, such as public health nursing. Fairman's study of the coalition efforts of nurses and physicians in the 1960s and 1970s shows how and why the nurse practitioner movement emerged, but it also raises questions for future research. For example, sprinkled throughout the book are references to the fact that most nurse practitioners were white. Although Fairman does not analyze how "whiteness" shaped the emergence of this health care field, her work provides an excellent starting point for scholars. In addition, research is needed on how and why racialized minority women were drawn to the field and with what results. For instance, the Wisconsin nurse practitioner Ida Gear was an African American woman, and there were no doubt others across the nation. In sum, Fairman provides the first comprehensive investigation of the history of nurse practitioners and in the process reveals much about the complexities of professional health relations, clinical authority, and specialization. Her work makes the case for the benefits of collaboration when there is shared power between nurses and doctors and shows that although it is not easy, it can be done. [End Page 236] Susan L. Smith University of Alberta, Canada Copyright © 2009 The...

The State of Advanced Practice Registered Nursing in Alabama