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The healthcare profession is in constant demand of healthcare providers; luckily mid-level practitioners are willing to step up and fill this void. The number of nurse practitioner (NP) programs has increased significantly throughout the last couple of years. The problem does not lie in finding a program to attend or even the job availability after completion of a masters degree program, it lies in the restrictions one faces day to day in practice due to the limitations set forth by the board of nursing itself. This paper will discuss two current issues related to healthcare delivery and health care policy, it will describe two strategies that can be implemented to improve these issues, as well as present the current state of health cost, discuss implications related to access of care and quality of care, and outline one legal and one ethical aspect for consideration in health care delivery. Lastly, it will describe how the adult-gerontology acute care nurse practitioner can use five specific professional nursing qualities to influence evidence-based practice.
The first topic to address pertains to the lack of a defined role that can be associated with the adult-gerontology acute care nurse practitioner (AG-ACNP). The nurse practitioner role originates in a pediatric and family practice type of setting the emergence of an acute care nurse practitioner is a newer role that is becoming more and more popular. Although, there is no universal clear interpretation of what an AG-ACNP scope of practice consist of, there are rules and regulations that vary from state to state that are designed to define NP practice (Lugo, O’Grady, Hodnicki & Hanson, 2007; Pearson, 2007). The advanced practice nurse (APN) rules and regulations for practice are determined by what nursing licensure one holds, yet numerous states go further by defining specific requirements and limit who can use an advanced practice nursing title under the states protection (Hamric, Spross, &Hanson, 2005, p.407). The problem is many states do not make a distinction between the various NP practice specialties such as, (family, pediatrics, adult, geriatric, acute care) (Hamric, Spross, &Hanson, 2005,p. 407). They also do not provide a skills list, a task list, or a list acceptable procedures the NP can perform within his or her specialty scope of practice (Hamric, Spross, &Hanson, 2005, p. 407). This is why there is such ambiguity pertaining to what the role of an AG-ACNP actually consists of. It has been reported by other practicing AG-ACNP that hospital administrators and even physicians are unsure what differentiates an AG-ACNP from a family nurse practitioner (FNP), to them they are all one and the same (Hamric, Spross, &Hanson, 2005, p. 430). This becomes problematic due to the fact this will limit the AG-ACNP scope of practice drastically. Therefore it is extremely important to educate all staff on the purpose of one’s role, the education required to achieve the role, the training that went into the education, and how the AG-ACNP can be utilized in a manner that is safe and efficient. When describing the role one must outline what their practice consist of including: the nursing paradigm; interview/ survey skills; physical examination to create a plan of care that addresses the patient’s holistic issues along with medical diagnosis; interventions that manage disease processes along with promote health; to create a discharge plan that will address medical care as well as nursing; and execute all AG-ACNP role capacitates applicable to one’s practice (Hamric, Spross, &Hanson, 2005, p. 430-31). Through education and role promotion great strides can be made in developing powerful collaborative agreements with physicians and other members of the healthcare team to achieve superlative patient outcomes (Hamric, Spross, &Hanson, 2005, p. 431).
The second issue pertains to the restricted prescriptive authority. In the state of Oklahoma NPs are allowed to prescribe schedule III – V of controlled dangerous substances (CDS) and may only prescribe a thirty-day supply without refills (Oklahoma Board of Nursing [OBN], 2012). In an emergency room type of setting where patients need to be seen for acute injuries there are going to be instances where short-term narcotic prescriptions are going to be necessary. Due to NPs not having full prescriptive authority this mandates that a physician must be within the same vicinity in order for the patient to receive the appropriate medication. Another issue related to medication is that NPs are not allowed to order and push rapid sequence intubation drugs in respiratory emergencies. This limitation is not only harmful for the patient but also to the profession itself. One is less marketable if they cannot perform basic emergency room task such as rapid sequence intubations. The bias that NPs are not competent in this skill but then allow physicians assistants the privilege to do so is absurd when both are mid-level practitioners. Then again it goes back to the governing body, the board of nursing is going to have to be more open to change and advocate for more autonomy to secure the future of the profession. The only way change will occur is taking it straight to the capitol and lobbying for what one wants to change. The Emergency Medicine Physicians (EMP) group based out of Tulsa Oklahoma went to the state capitol this year and stated the importance of NPs role in intubation and the need for rapid sequence drugs to be given in order for one to effectively perform their job. Although, all of the medications were not permitted for use such as the paralytics, they did allow etomidate and versed to be added to the list of drugs NPs can administer in an acute care setting. In order for more autonomy like full prescriptive authority to come about it is going to take groups of NPs and healthcare advocates lobbying to demonstrate the significant impact the change can have on the community. All in all, permitting NPs to have full practice authority along with prescriptive authority has the possibility of opening doors to allow more access to healthcare in rural areas with the overall hopes of improving Oklahoma’s health and wellness (Langley, 2015).
The second topic of discussion deals with appraisals of complex issues regarding healthcare delivery. In 2014 the United States health care spending grew 5.3, reaching $3.0 trillion or $9,523 per person (Centers for Medicare and Medicaid Services [CMS], 2014). It is no surprise there has been an influx of healthcare spending since the Affordable Care Act (ACA) has passed and been in action the last couple of years. Since more people are becoming insured and seeking medical services the health care cost are out of control therefore the reimbursement system once based on quantity, is now going to value based purchasing and quality of care. The implications related to the accessibility to care are to improve comprehensive care and promote quality health care services (Office of Disease Prevention and Health Promotion [ODPH], 2016). There four parts of access to care these include: coverage, services, timeliness, and workforce (ODPH, 2016). All four factors are needed to insure people reach their full potential of optimal health and quality of life (ODPH, 2016). One significant aspect related to the quality of care one receives is that it is now based upon value and care coordination instead of quantity and care reproduction as compared to the past (CMS, 2014). The goal in reforming the system is to emphasis quality of care system-wide with the goal of simultaneously reducing health care costs (CMS, 2014). The shift in healthcare reimbursement has opened doors to legal and ethical dilemmas. Due to value-based modifiers taking effect facilities that have high rates of nosocomial infections along with high readmission rates will be penalized by means of payment (Page & Fields, 2011). This payment penalty could be taxing on a facility and lead to falsification of documentation, to avoid paying these fines. If falsification of documentation occurs this could raise a legal issue of fraud. Also, this is an ethical dilemma the staff may be faced with or feel pressured to do from supervisors or administration. The ethical principle of fidelity would be violated. As nurses it is our job to advocate for the patient and be truthful and honest in all that we do. We should uphold fidelity in all that we do from patient care to documentation it is all correlated to our basic virtue of caring.
The last topic of discussion is how the adult-gerontology acute care nurse practitioner can use five nursing qualities including: caring, competence, communication, leadership and professionalism to influence evidence-based practice. First of all, caring is at the core of our profession it is why we do what we do. The adult-gerontology acute care nurse practitioner differs from other healthcare practitioners in that they use theoretical frameworks to shape evidence based practice, such as Jean Watson’s Caring Theory, still incorporating caring but also evaluating outcomes. At the end of the day what’s most important is providing patients with optimal outcomes this can be achieved by building a pragmatic framework based on core nursing values (American Nurse Association [ANA], 2010, p. 4). Secondly, just as a registered nurse (RN) is expected to demonstrate competency throughout their practice no less is expected of an NP. Throughout ones pursuit of higher education, they are expected to perform task and think critically within their scope of practice. As a new NP they will be certain competencies to be evaluated before one can perform these task independently, such as a certain number of intubtations or central lines, to be performed in supervision of a physician to insure the NP is performing the task competently and with the best interest in mind for the patient. As evidence based practice evolves in years to come so will competencies and standard protocols for practice. The American Nurses Association clearly defines competencies as situational and ever changing; it is can both an end result and ongoing process (ANA, 2010, p.12). Thirdly, skilled communication is another important element in providing safe and efficient patient care. It is important that an NP be just as competent in communication as they are clinical skills in order to provide optimal care (ANA, 2010, pg. 5). If the pathway of communication fails during obtaining information during the patient interview or through discussing treatment options with a supervising physicians this can result in a negative patient outcome. Leadership is also a quality one must possess in order to be a successful NP. There are two important qualities of leadership one being authenticity and the other being transformational (ANA, 2010, pg. 6). To be an authentic leader is to embrace a positive perspective in employees and the work environment (ANA, 2010, pg. 6). One must be fully engaged and portray themselves in a manner that displays their commitment in achieving greatness in all work related areas. Then there is transformational leadership that allows one to lead with the intent of accomplishing future needs (ANA, 2010, pg. 6). By being both a authentic and transformational leader will allow one to face new challenges of evidence based practice in a positive creative manner. Lastly, there is professionalism; this quality encompasses what we are as a profession. Being a professional comes with the responsibility of engaging in professional role activities, such as leadership (ANA, 2010, pg. 10). The professional is expected to display competency in activities related to ethics, education, evidence-based practice and research, teamwork, effective communication, leadership, application of resources, professional evaluation, and overall environmental health (ANA, 2010, pg. 10). All in all, these five qualities work together synergistically to influence the ever-evolving evidence-based practice.
In closing, it is important for the AG-ACNP to have a clearly defined role in the healthcare system in order to be utilized to the full potential in which we were trained. Also, it is important for more progress to be made on allowing less restrictive supervision when it comes to AG-ACNP, in order to allow accessible care to a broader population of Americans in rural areas. Now that the healthcare expenditures are continuing to increase the new healthcare changes related to value based purchasing and reimbursements based on quality of care are in place we might face issues with falsification of documentation to avoid costly fines along with legal issues that might arise in auditing systems. Although the changes that are and will be taking place in the healthcare delivery system are brought forth with the best intentions to help maintain a healthy state of living, like everything else the transformation process will not be easy and will meet much resistant along the way. As an AG-ACNP it is important to keep the five core nursing qualities in mind while trying to positively influence the transforming future of healthcare.
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