Barriers to Nurse Practitioner Full Practice Authority (FPA): State of the Science
Keywords:
Full practice authority, autonomous practice, independent practice, barriers, legislation, nurse practitioner, primary care, health policy, leadership, scope of practiceAbstract
Purpose: To explore the various barriers to full practice authority (FPA) of nurse practitioners (NP) in the United States, and to identify the specific legislative barriers to FPA.
Background: FPA for NPs is cited as a way to reduce the provider shortage in the U.S, increasing access to healthcare. However, the majority of states across the country restrict the NP ability to provide primary care. As of 2015, only 21 states offer NP’s full practice authority.
Data Sources: A comprehensive literature search was conducted using data bases by PubMed, and MeSH, EBM Search, CINAHL, and Google Scholar. Thirty articles were chosen for synthesis.
Results: Several barriers impede the ability of NPs to practice autonomously including lack of formal business or marketing education, reduced reimbursement rates, and lack of recognition from public and other health professionals about their preparation. The most common barrier is restrictive legislation halting NP practice at the level of their full knowledge and preparation. No articles were found identifying specific barriers to implementing FPA legislation.
Implications: There is a gap in the literature identifying specific barriers to implementing successful legislation to remedy this problem. Understanding how NPs, NP organizations, legislators, and policy-makers are working to overcome these barriers and attain full practice authority in their respective states will help other states in their efforts to obtain similar legislation.
References
American Association of Nurse Practitioners [AANP]. (2013). Fact sheet: Medical reimbursement. Retrieved on May 3, 2015 from http://www.aanp.org/practice/reimbursement/68-articles/325-medicare-reimbursement
American Association of Nurse Practitioners [AANP]. (2015). State practice environment. Retrieved on May 15, 2015 from http://www.aanp.org/legislation-regulation/state-legislation-regulation/state-practice-environment/66-legislation-regulation/state-practice-environment/1380-state-practice-by-type
Bodenheimer, T., & Pham, H. H. (2010). Primary care: Current problems and proposed solutions. Health Affairs, 29(5), 799-805.
Bryant-Lukosius, D., DiCenso, A., Browne, G., Pinelli, J. (2004). Advanced practice nursing roles: Development, implementation and evaluation. Journal of Advanced Practice Nursing, 48(5), 519-529. doi:10.1111/j.1365-2648.2004.03235.x10.1111/j.1365-2648.2004.03234.x
Cronenwett, L., Dracup, K., Grey, M., McCauley, L., Meleis, A., & Salmon, M. (2011). The doctor of nursing practice: A national workforce perspective. Nursing Outlook, 59(1), 9-17.
Carter, M. A., Owen-Williams, E., & Della, P. (2015). Meeting Australia’s Emerging Primary Care Needs by Nurse Practitioners. The Journal for Nurse Practitioners, 6(11), 647-652. doi: http://dx.doi.org/10.1016/j.nurpra.2015.02.011
Demarco, V. & Schneider, G. E. (2000). Elections and public health. American Journal of Public Health, 90(10), 1513-1514.
Dubois, J., Green, R., & Aertker, J. (July, 2013). Characteristics of nurse practitioners in independent practice in a practice restricted state. Presented at Sigma Theta Tau International’s 24th International Nursing Research Congress, Prague, Czech Republic.
Duncan, C. G. & Sheppard, K. G. (2015). The full practice authority initiative: Lessons learned from Nevada. The Journal for Nurse Practitioners, 6(11), 610-617. doi:10.1016/j.nurpra.2015.01.020
Fairman, J. A., Rowe, J. W., Hassmiller, S., & Shalala, D. E. (2011). Broadening the scope of nursing practice. New England Journal of Medicine, 364(3), 193-196. doi:10.1056/NEJMp1012121
Gilman, D. J., & Koslov, T. I. (2014). Policy Perspectives: Competition and the regulation of advanced practice nurses. Federal Trade Commission, Washington, DC. Retrieved on August 6, 2014 from http://www.ftc.gov/reports/policy-perspectives-competition-regulation-advanced-practice-nurses
Gutchell, V., Idzik, S., & Lazear, J. (2014). An evidence-based path to removing APRN practice barriers. The Journal for Nurse Practitioners, 10(4), 255-261. doi: 10.1016/j.nurpra.2014.02.005
Hansen-Turton, T., Ware, J., Bond, L., Doria, N., & Cunningham, P. (2013). Are Managed Care Organizations in the United States Impeding the Delivery of Primary Care by Nurse Practitioners? A 2012 Update on Managed Care Organization Credentialing and Reimbursement Practices. Population Health Management, 16(5), 306-309. doi:10.1089/pop.2012.0107
Institute of Medicine [IOM]. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Keating, S. F., Thompson, J. P., & Lee, G. A. (2010). Perceived barriers to the sustainability and progression of nurse practitioners. International Emergency Nursing, 18(3), 147-153. doi:10.1016/j.ienj.2009.09.003
Kuntz, K. R. (2011). “Deadly spin” on nurse practitioner practice. Journal of the American Academy of Nurse Practitioners, 23(11), 573-576.
Lowe, G., Plummer, V., O’Brien, A. P., & Boyd, L. (2012). Time to clarify–the value of advanced practice nursing roles in health care. Journal of Advanced Nursing, 68(3), 677-685. doi:10.1111/j.1365-2648.2011.05790.x
MacDonald, J., Edwards, N., Davies, B., Marck, P., & Guernsey, J. R. (2012). Priority setting and policy advocacy by nursing associations: A scoping review and implications using a socio-ecological whole systems lens. Health Policy, 107(1), 31-43. doi: 10.1016/j.healthpol.2012.03.017
MacLean, L., Hassmiller, S., Shaffer, F., Rohrbaugh, K., Collier, T., & Fairman, J. (2014). Scale, causes, and implications of the primary care nursing shortage. Annual Review of Public Health, 35, 443-457.
Miller, M., Snyder, M., & Lindeke, L. (2005). Nurse practitioners: Current status and future challenges. Clinical Excellence for Nurse Practitioners, 9(3), 162-169.
Naylor, M. D., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29(5), 893-899.
Nevada State Board of Nursing. (2014). Adopted regulation of the state board of nursing: LCB file no. R114-13. Retrieved on July 30, 2014 from http://nevadanursingboard.org/wp-content/uploads/2014/05/R114-13A.pdf
Patchin, R. J. AMA responds to IOM report on future of nursing. Retrieved on May 15, 2015 from http://www.ama-assn.org/ama/pub/news/news/nursing-future-workforce.page
Petterson, S. M., Liaw, W. R., Phillips, R. L., Rabin, D. L., Meyers, D. S., & Bazemore, A. W. (2012). Projecting US primary care physician workforce needs: 2010-2025. The Annals of Family Medicine, 10(6), 503-509. doi: 10.1370/afm.1431
Plager, K. & Conger, M. (2007). Advanced practice nursing: Constraints to role fulfillment. The Internet Journal of Advanced Nursing Practice, 9(1), 1523-6064. Retrieved on Jun 12, 2014 from http://ispub.com/IJANP/9/1/3418
Russell, K. A. (2012). Nurse practice acts guide and govern nursing practice. Journal of Nursing Regulation, 3(3), 36-42.
Scott, D. (2014). APRN update. Retrieved on May 3, 2015 from the Nevada State Board of Nursing website http://nevadanursingboard.org/wp-content/uploads/2014/04/APRN-Update.pdf
Summers, L. (2012). Clinical privileges: Opening doors for APRN’s. Retrieved on May 6, 2015 from http://www.theamericannurse.org/index.php/2012/02/07/clinical-privileges-opening-doors-for-aprns/
VanBeuge, S. S. & Walker, T. (2014). Full practice authority- effecting change and improving access to care: The Nevada journey. Journal of the American Association for Nurse Practitioners, 26, 309-313. doi: 10.1002/2327-6924.12116
Weiland, S. A. (2008). Reflections on independence in nurse practitioner practice. Journal of the American Academy of Nurse Practitioners, 20(7), 345-352.
Yee, T., Boukus, E., Cross, D., & Samuel, D. (2013). Primary care workforce shortages: Nurse practitioner scope-of-practice laws and payment policies. National Institute for Health Care Reform Research Brief, (13).
American Association of Nurse Practitioners [AANP]. (2015). State practice environment. Retrieved on May 15, 2015 from http://www.aanp.org/legislation-regulation/state-legislation-regulation/state-practice-environment/66-legislation-regulation/state-practice-environment/1380-state-practice-by-type
Bodenheimer, T., & Pham, H. H. (2010). Primary care: Current problems and proposed solutions. Health Affairs, 29(5), 799-805.
Bryant-Lukosius, D., DiCenso, A., Browne, G., Pinelli, J. (2004). Advanced practice nursing roles: Development, implementation and evaluation. Journal of Advanced Practice Nursing, 48(5), 519-529. doi:10.1111/j.1365-2648.2004.03235.x10.1111/j.1365-2648.2004.03234.x
Cronenwett, L., Dracup, K., Grey, M., McCauley, L., Meleis, A., & Salmon, M. (2011). The doctor of nursing practice: A national workforce perspective. Nursing Outlook, 59(1), 9-17.
Carter, M. A., Owen-Williams, E., & Della, P. (2015). Meeting Australia’s Emerging Primary Care Needs by Nurse Practitioners. The Journal for Nurse Practitioners, 6(11), 647-652. doi: http://dx.doi.org/10.1016/j.nurpra.2015.02.011
Demarco, V. & Schneider, G. E. (2000). Elections and public health. American Journal of Public Health, 90(10), 1513-1514.
Dubois, J., Green, R., & Aertker, J. (July, 2013). Characteristics of nurse practitioners in independent practice in a practice restricted state. Presented at Sigma Theta Tau International’s 24th International Nursing Research Congress, Prague, Czech Republic.
Duncan, C. G. & Sheppard, K. G. (2015). The full practice authority initiative: Lessons learned from Nevada. The Journal for Nurse Practitioners, 6(11), 610-617. doi:10.1016/j.nurpra.2015.01.020
Fairman, J. A., Rowe, J. W., Hassmiller, S., & Shalala, D. E. (2011). Broadening the scope of nursing practice. New England Journal of Medicine, 364(3), 193-196. doi:10.1056/NEJMp1012121
Gilman, D. J., & Koslov, T. I. (2014). Policy Perspectives: Competition and the regulation of advanced practice nurses. Federal Trade Commission, Washington, DC. Retrieved on August 6, 2014 from http://www.ftc.gov/reports/policy-perspectives-competition-regulation-advanced-practice-nurses
Gutchell, V., Idzik, S., & Lazear, J. (2014). An evidence-based path to removing APRN practice barriers. The Journal for Nurse Practitioners, 10(4), 255-261. doi: 10.1016/j.nurpra.2014.02.005
Hansen-Turton, T., Ware, J., Bond, L., Doria, N., & Cunningham, P. (2013). Are Managed Care Organizations in the United States Impeding the Delivery of Primary Care by Nurse Practitioners? A 2012 Update on Managed Care Organization Credentialing and Reimbursement Practices. Population Health Management, 16(5), 306-309. doi:10.1089/pop.2012.0107
Institute of Medicine [IOM]. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Keating, S. F., Thompson, J. P., & Lee, G. A. (2010). Perceived barriers to the sustainability and progression of nurse practitioners. International Emergency Nursing, 18(3), 147-153. doi:10.1016/j.ienj.2009.09.003
Kuntz, K. R. (2011). “Deadly spin” on nurse practitioner practice. Journal of the American Academy of Nurse Practitioners, 23(11), 573-576.
Lowe, G., Plummer, V., O’Brien, A. P., & Boyd, L. (2012). Time to clarify–the value of advanced practice nursing roles in health care. Journal of Advanced Nursing, 68(3), 677-685. doi:10.1111/j.1365-2648.2011.05790.x
MacDonald, J., Edwards, N., Davies, B., Marck, P., & Guernsey, J. R. (2012). Priority setting and policy advocacy by nursing associations: A scoping review and implications using a socio-ecological whole systems lens. Health Policy, 107(1), 31-43. doi: 10.1016/j.healthpol.2012.03.017
MacLean, L., Hassmiller, S., Shaffer, F., Rohrbaugh, K., Collier, T., & Fairman, J. (2014). Scale, causes, and implications of the primary care nursing shortage. Annual Review of Public Health, 35, 443-457.
Miller, M., Snyder, M., & Lindeke, L. (2005). Nurse practitioners: Current status and future challenges. Clinical Excellence for Nurse Practitioners, 9(3), 162-169.
Naylor, M. D., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29(5), 893-899.
Nevada State Board of Nursing. (2014). Adopted regulation of the state board of nursing: LCB file no. R114-13. Retrieved on July 30, 2014 from http://nevadanursingboard.org/wp-content/uploads/2014/05/R114-13A.pdf
Patchin, R. J. AMA responds to IOM report on future of nursing. Retrieved on May 15, 2015 from http://www.ama-assn.org/ama/pub/news/news/nursing-future-workforce.page
Petterson, S. M., Liaw, W. R., Phillips, R. L., Rabin, D. L., Meyers, D. S., & Bazemore, A. W. (2012). Projecting US primary care physician workforce needs: 2010-2025. The Annals of Family Medicine, 10(6), 503-509. doi: 10.1370/afm.1431
Plager, K. & Conger, M. (2007). Advanced practice nursing: Constraints to role fulfillment. The Internet Journal of Advanced Nursing Practice, 9(1), 1523-6064. Retrieved on Jun 12, 2014 from http://ispub.com/IJANP/9/1/3418
Russell, K. A. (2012). Nurse practice acts guide and govern nursing practice. Journal of Nursing Regulation, 3(3), 36-42.
Scott, D. (2014). APRN update. Retrieved on May 3, 2015 from the Nevada State Board of Nursing website http://nevadanursingboard.org/wp-content/uploads/2014/04/APRN-Update.pdf
Summers, L. (2012). Clinical privileges: Opening doors for APRN’s. Retrieved on May 6, 2015 from http://www.theamericannurse.org/index.php/2012/02/07/clinical-privileges-opening-doors-for-aprns/
VanBeuge, S. S. & Walker, T. (2014). Full practice authority- effecting change and improving access to care: The Nevada journey. Journal of the American Association for Nurse Practitioners, 26, 309-313. doi: 10.1002/2327-6924.12116
Weiland, S. A. (2008). Reflections on independence in nurse practitioner practice. Journal of the American Academy of Nurse Practitioners, 20(7), 345-352.
Yee, T., Boukus, E., Cross, D., & Samuel, D. (2013). Primary care workforce shortages: Nurse practitioner scope-of-practice laws and payment policies. National Institute for Health Care Reform Research Brief, (13).
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2015-10-19
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