Running head: NURSE PRACTITIONERS AND PRACTICE BARRIERS

Nurse Practitioners and Barriers to Independent Practice

Bosede O. Adedire

Coppin State University

NURSE PRACTITIONERS AND PRACTICE BARRIERS

Over the years, nurses have been at the low end of health care delivery system with
their skills and expertise; their practice has been guided and monitored by other advance health
care professionals and political rulings (Gilliss, 2011; Muxworthy &Bowllan, 2011; Weiland,
2008), either positive or negative. But today, the political table has turned in the favor of
Advance practice nurses, with the privilege given to them to practice as independent primary
care providers (PCP). However, this privilege has been embraced by some organizations, while
some others challenged the movement, by questioning the expertise of advance practice nurses as
independent care providers (Naylor & Kurtzman, 2010, para. 4). Unquestionably, several study
findings have recognized that the unique expertise held by generalist and specialist nurses are
often underutilized across the health continuum (Cheater, 2010; Gilliss, 2011; Muxworthy &
Bowllan, 2011; Lee, 2011; Weiland, 2008), due to different barriers that keep nurses to the
background of health care delivery system. Reviews of literature have examined different
obstacles to practice autonomy of advance practice nurses and have reported different
recommendations that could help alleviate these problems (Cheater, 2010; Gilliss, 2011; Lee,
2011; Naylor & Kurtzman, 2010; Weiland, 2008; Coddington, Sands, Edwards, Kirkpatrick &
Chen, 2011). The purpose of this paper is to further discuss obstacles that restricts independent
practice of advance practice nurses and to highlight recommendations that will lessen, if not
eradicate these barriers to enable advance practice nurses to practice independently to the full
extent of their expertise.
Advanced practice nurse is considered an independent practitioner with full practice
authority when state licenses do not mandate a practice agreement with a physician or another
healthcare provider (Churchman & Doherty, 2010, para. 4). An independent nurse

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practitioner has full prescriptive authority of pharmacologic and non-pharmacologic

interventions without a requirement for collaboration, supervision, or oversight by any other
health care provider" (Wilson, Whitaker & Whitford, 2012, para. 6). Growing health
inequalities, coupled with political and societal needs, primary care has been redefined to
include advance practice nurses as primary care providers (Gilliss, 2011, para. 2), trained to
provide quality health care that reduce disparity in access to quality care and promote cost
effectiveness to improve overall health care delivery system (Cheater, 2010; Gilliss, 2011;
Wilson, Whitaker & Whitford, 2012). The roll out of the Affordable care act has created an
increase in the demand for primary care providers, a need that creates an opportunity for
Nurse Practitioners (NP) to take on this role, not only as PCP, but also with a privilege of
independent practice, an idea that has raised quite a number of controversies. NPs privilege
of independent practice has different impediments that could make the realization of
independent practice difficult to achieve, or perhaps prevent this opportunity from happening.
Road blocks to Nurse practitioners autonomy to successfully practice independently
as primary care provider is multifactorial, one factor is whether state law authorizes NPs to
have full prescriptive privileges to practice as primary care providers. Though many states
allow nurse practitioners to diagnose and treat patients without physician involvement,
however, collaboration or supervision requirements for both the provision of care and the
ability to prescribe medications vary widely in other states (Wilson et al., 2012; Gillis, 2011).
Specific state policies provide guidelines to guide the practice of nurse practitioners, some
states mandate collaboration with other physicians while some other states require full
supervision by other physicians (Gillis, 201, para. 6), which limits the ability of advanced

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nurses to practice and provide patient care independently. Currently in the United States,
seventeen states have adopted full practice authority (American Association of Nurse
Practitioners, 2013).
Similarly, decentralized policy for NP practice set by different states, builds another
barrier on practice flexibility, the most significant of these is states scope-of-practice laws
that define nurses roles, which articulate oversight requirements that govern practice and
prescriptive authorities (Naylor & Kutzman, 2010, para. 6). Advance nursing graduates
students nationwide have sets of core curriculum that must be accomplished by the end of the
program to be qualified to seat for the national board examination, therefore, scope of practice
need to be the same nationwide. Yet, different states have specific guidelines for scope of
practice that differ, to guide the practice of NPs; this approach introduces a problem that
brings confusion into standard of practice guiding practitioners and the public, and generally
on how the profession is viewed by the society and critics alike, especially policy makers and
other health care associations. As a professional body, state boards need to come together to
decide unanimously the standard they need to put in place that will guide the practice of
nurses nationwide, for nursing to build sustainable, nurse-directed, and reliable health care
standards that address the scope of practice of advance nurses nationwide (Coddington,
Sands, Edwards, Kirkpatrick & Chen, 2011, para. 8). The ability to consolidate guidelines that
guide the practice of NPs from state to state such that NPs can practice in any state without
the need to register in each state before practice will remove difficulties to NPs independent
practice (Gilliss, 2011, para. 6), and will further boost the confidence of the society towards
the nursing profession.

NURSE PRACTITIONERS AND PRACTICE BARRIERS

Moreover, NPs contribution to health care has been viewed by some organizations
as not been able to measured up to other health care providers (Naylor & Kurtzman, 2010,
para. 2), since nurses have always been invisible care providers (Gillis, 2011, para. 2).
But with the preparedness of the advanced practice nurses, the conception of nurses being
underprepared must change. Nurses have important contribution to make in ...building a
health care system that will meet the demand for safe, quality, patient-centered, and affordable
care (Institute of Medicine, 2010, p.1). Different organizations and agencies have released
several recommendations to enjoin health associations and the community as a whole to
support independent practice of NPs to prevent envisaged shortage in primary care providers
(American Association of Nurse Practitioners, 2013; Institute of Medicine, 2010), and make
health care accessible to the public.
Another impediment to independent practice of NPs is whether health plans choose to
admit NPs to provider boards as a matter of procedure, whether they agree to admit nurse
practitioners into their payer system. The view of the health plan companies about NPs will
dictate whether they will reimburse NPs for services rendered (Gillis, 2011, para. 4). If the
view of the health plan companies is such that do not recognize the autonomy of NPs as
independent provider, then services provided by them will not be paid for or better still they
will not have names of NPs on their provider list (Cheater, 2010, para. 4), which will further
restrict the practice and autonomy of the NPs because each consumer of health care services
will not be able to choose outside of the health plan formulary and invariably the choice of
health care providers by consumers are also restricted (Coddington et al., 2011, para. 8). There
should be a policy at state and federal level that prohibit health plans from having such

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formularies; consumers should have the sovereignty of choosing who they wish to have as
primary health care provider.
Additionally, in cases where health plan companies recognize NPs independence, their
reimbursement is not comparable to other health care providers (Gillis, 2011, para. 2). Current
literature suggests that NPs are reimbursed lower than physicians even with the provision of
high quality and effective care (Gillis, 2011; Cheater, 2010; Wilson, Whitaker & Whitford,
2011, para. 8). Naylor and Kurtzman (2010) added that Medicare, Medicaid, and private
insurers typically reimburse NPs at rates that are just 7585 percent of what they pay
physicians for the same services... (para. 6). The barrier of non-comparable reimbursement
for similar services rendered by NPs discourages entry into independent practice by some NPs
for fear of financial instability (Gillis, 2011, para. 6). In addition, research shows that costs for
comparable services are generally less across health care setting when provided by NPs
(Cheater, 2010; Churchman & Doherty, 2010; Muxworthy & Bowllan, 2011; Coddington et
al., 2011). Another report indicates that the activities that are reimbursable by a third party
payer are determined by the NPs scope of practice which invariably impacts the autonomy of
NPs (Wieland, 2008, para. 6). For instance, when the scope of practice indicate that the
practice of NPs be one of collaboration or supervised by a physician, reimbursement will not
likely be comparable because the NP will not be able to bill directly for the services they
provide (Muxworthy & Bowllan, 2011, para. 8), since they are being supervised by
physicians which may result in friction among health care providers. Cheater (2010) added
that many NPs who run their own practices have substantial demand for their services but

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remuneration for services rendered is either lacking or not anywhere comparable to other
professional health care providers reimbursement (para. 6).
Likewise, the degree of competition from other health care professionals create
hindrance to NPs independent practice, especially primary care physicians associations and
their definition of primary care providers as physicians only (Gillis, 2011, para. 8). There has
been resistance from medical associations to nurse-led services, physician associations are
against the independent practice of NPs, because they assume it is not the best for the
patient (Lee, 2011, para. 8). However, research studies document that the problem is not with
the patients but with the income that physicians alike assume they are going to lose
(Wieland, 2008, para. 8), and not necessarily what is best for the patient.
Further, the fear on the part of NPs to take on the new role is another impediment that
could create a barrier. The fear of the unknown and possible intimidation from other health
organizations and colleagues could discourage advance practice nurses from venturing into
starting up their own practice. Therefore, exploring options for practice types is very
important, maybe a partnership, Professional Corporation, or a non-profit are important steps
to think about before starting, to help alleviate the anxiety (Muxworthy & Bowllan, 2011,
para. 8). Networking within a community before opening a practice will provide the best
understanding of the practice location and environment. Just like any other business, starting
up something new and leaving a comfort zone can be a challenge for people that have been
dependent on others for instructions and guidance before carrying out their assigned duties.
NPs need to see fear of being independent as a positive instinct to use their expertise and
abilities to practice independently. Sometimes fear is not a bad thing, it is a fuel that everyone

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needs to take them out of their comfort zone, if they need to move up and take leadership
roles and responsibilities. NPs that are considering establishing an entrepreneurial practice
should not be discouraged about initial capital, there are different resources that could help
guide the direction of starting up a practice, Churchman and Doherty (2010) recommend that
a complete community and feasibility assessment be done, then a contact with the Small
Business Administration who can provide information about financing programs that are
available (para. 6). Careful consideration of what is required prior to establishing an
entrepreneurial practice is very important as it takes ongoing commitment (Churchman &
Doherty, 2011, para. 6), to sustain the practice and build practice privileges.
Additional obstacle to NPs independent practice is lack of hospital privileges.
Hospital privileges allow health care providers to have admitting privileges and hospital
medical staff membership, with permission to perform hospital admission assessments
(Weiland, 2008, para. 6). This process enhances continuity of care and effective care
management, but NPs are not allowed hospital privileges in some states, which create a
barrier to effective care delivery and limit their chances with insurance carriers. Muxworthy &
Bowllan (2011) explains that most insurance companies prefer that health care providers have
hospital privileges because they benefit from such hospital privileges, hospital privileges are a
requirement for becoming a preferred provider for some insurance companies (para. 6).
Removing barriers to hospital privileges for NPs is one way to increase access to independent
practice and improve the health care system.
Another impediment is the consumer perceptions and understanding of nurse practitioner
contributions and duties as independent care providers. Widespread acceptance and

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understanding of NP duties as independent practitioners has significant implications for

practice (Codington et al., 2011, para. 5), consumers awareness and knowledge of NPs duties
will create a market for NP practice to grow and evolve. In the long run, when consumers are
given clear unconstrained option to choose their health care provider, it will set the pace for
service reimbursement and NP independence (Gilliss, 2011, para. 2). NPs contribution to the
health care system need to become noticeable to the community, to improve the public's
understanding of NPs independent practice and the unique inspirations they bring to the
health care system.
Above all, approach to resolve barriers to independent practice of NPs, addressed
from a national perspective may encourage creativity needed to approach the increasing need
for primary health care providers. The need for qualified health care professionals has been on
the rise (Gilliss, 2008, para. 2), the United States has a rapidly aging population; nearly 18%
of the aging population will be 65 years old or greater by 2025 (U.S. Census Bureau, 2012).
Also, increasing life expectancies with the introduction of the affordable care act will result in
flare-ups in the number of Medicare and Medicaid beneficiaries who will need primary care
and chronic disease management (Wieland, 2012, para. 3). Naylor & Kutzman 2010 added
that more than thirty million people will gain access to primary care services by 2014 due to
patient protection and affordable care act (para. 4). However, physician shortages,
particularly in primary care, will not be able to meet these demands, as the nation will require
40% more primary care providers by 2020 (Gilliss, 2008, para. 8). This is the time that the
society has been waiting for, to lift unnecessary barriers to NP independent practice, and tap
into the resources that they have always had but never used, or considered its extensive

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usefulness, that is, the services of advance nurse practitioners, to absorb the care and
management of newly eligible Medicare and Medicaid participants, especially those with
chronic illnesses for quality and affordable care.
In conclusion, barriers to independent practice of NPs has implication for practice and
the society as a whole, considering the growing numbers of population that qualify for the
newly established health insurance, there is a need to match up the demand in primary health
care provider need with the supply of expertise that qualify to practice primary care
independently. Sustained obstacles to independent practice of NPs may in the long run impede
access to health care for the uninsured and other vulnerable population, and jeopardize the
nations health.

References

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American Association of Nurse Practitioners. (2013). Fact sheet: Medicare

reimbursement. Retrieved from
www.aanp.org/legislation-regulation/federallegislation/medicare/68-articles/325-medicare-reimbursement
Cheater, F. M. (2010). Improving primary and community health services through nurse-led
social enterprise. Quality in Primary Care, 18(1), 5-7.
Churchman, J. J., & Doherty, C. (2010). Nurses' views on challenging doctors' practice in an
acute hospital. Nursing Standard, 24(40), 42-48.
Coddington, J., Sands, L., Edwards, N., Kirkpatrick, J., & Chen, S. (2011). Quality of health care
provided at a pediatric nurse-managed clinic. Journal of the American Academy of Nurse
Practitioners, 23(12), 674-680. doi: 10.1111/j.1745-7599.2011.00657.x
Gilliss, C. L. (2011). The nurse as social entrepreneur: Revisiting our roots and raising our
voices. Nursing Outlook, 59(5), 256-257. doi: 10.1016/j.outlook.2011.07.003
Institute of Medicine of the National Academies. (2010). The future of nursing leading change,
advancing health. Retrieved from
www.iom.edu/Reports/2010/The-Future-of-NursingLeading-Change-Advancing-Health.aspx
Lee, S. (2011). In support of the abolishment of supervisory and collaborative clauses. The
Journal for Nurse Practitioner, 7(9), 764-769.
Muxworthy, H & Bowllan, N. (2011). Barriers to practice and impact on care: An analysis of
the psychiatric mental health nurse practitioner role. Journal of the New York State Nurses
Association, Volume 42, Numbers 1 & 2, 8-14.

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Naylor, M. D., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary
care. Health Affairs, 29, 893-899.
U.S. Census Bureau, Statistical Abstract of the United States. (2012). Washington,
DC, 2011. Retrieved from: http://www.census.gov/compendia/statab/.
Weiland, S. (2008). Reflections on independence in nurse practitioner practice. Journal of the
American Academy of Nurse Practitioners, 20(7), 345-352.
Wilson, A., Whitaker, N., & Whitford, D. (2012). Rising to the challenge of health care
reform with entrepreneurial and intrapreneurial nursing initiatives: The Online Journal of
Issues in Nursing Vol. 17, No. 2. doi: 10.3912/OJIN.Vol17No02Man05

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PRACTICUM REPORT
NURS 641- PRIMARY HEALTH CARE OF CHILDREN
by
Bosede Adedire