Examining the Role of the Clinical Nurse Specialist in Diagnosing and Prescribing

The roles of advanced practice nurses have been an ongoing debate in many states. In a globalized world, advance nurse leaders are regarded as forefront leaders that provide first-rate healthcare to the public. However, the role of new advanced practice nurses is known to be complex. Advance practice nurses use countless different strategies and nursing theories to improve the wellbeing of their patient. To improve the well being of all patients, there is a growing demand for advance practice nurses worldwide. The advanced practice roles of CNM, CNP, CNS, and CRNA require a toolbox of skills, understanding, and integrative abilities that synthesize advanced practice nursing knowledge" (Buppert, 2011). With the rapid development of the advance practice nurse leader, the national organization of Nurse Practitioners are eager to help ensure the competencies of the diverse roles of APN.

In the Texas, state law prohibits Advanced Practice Registered Nurses (APRNs) including nurse practitioners (NPs) from practicing to the full extent of their education and clinical ability. Currently, Texas law requires than an APRN receive approval from an individual physician prior to engaging in the practice of advanced nursing. This type of complex regulatory scheme is outdated and restricts patients’ access to care, creates geographic disparities in services, and unnecessarily increases health care costs. For example, current law requires APRNs to meet periodically face-to-face with a supervising physician; with few physicians choosing to practice in rural areas, many APRNs who are willing to work in rural areas are essentially forbidden from delivering care to these underserved areas.

First, the state licensure regulates NP practice and it has been a big issue since NPs are not able to practice to the fullest extent despite of their education and training. NPs practice is regulated by state licensure and only about one-third of the nation has adopted full practice authority licensure and practice laws for NPs (Hain & Fleck, 2014). The American Association of Nurse Practitioners (AANP) reports that, under a full practice authority model, NPs are still required to meet

This paper explores the perception of clinical practitioners to the change in policy related to the advanced practice registered nurse (APRN) full practice authority. The author conducts a one-on-one, open-ended interview of 5 nurse practitioners and 5 physicians licensed to practice in Maryland on their perceptions of the recent passage of the Advanced Practice Registered Nurse Full Practice Authority. A literature review was conducted in a policy report by the professional nursing organization, and discussion within the peer-reviewed article supported an overview, regulatory differences among 50 states, including the District of Columbia. Their policy implication for enhancing APRNs role nationally. The author discusses a critical component

staff, the skill level of the nursing staff, and the education/certification of nursing staff” (ANA, 2015). These

According to the Pearson Report, there is a total of 147,295 Nurse Practitioners throughout the United States (Pearson, 2009). However, for NPs in some states the battle continues over some forms of prescriptive authority or physician involvement in NP prescribing, such as the state of Pennsylvania. State regulatory approaches to NP prescribing range from no authorization for prescribing (in Georgia, 2006 legislation passed which recognized NPs as prescribers, but the rules have not been approved at the time of this writing) to unencumbered prescriptive authority (Arizona, DC, Montana, Oregon, Washington, and Wyoming) (Lugo, O’Grady, Hodnicki & Hanson, 2007).

After attending the Arizona State Board of Nursing meeting through live stream on September 18, 2015 at approximately eleven in the morning, I had the opportunity to witness how the board enforces all the rights and regulations of the Nurse Practice Act and upholds the requirements set for each standard. The board consists of the board president Randy Quinn, RN, MSN, CRNA, the boards vice president Carolyn Jo Mccormies, RN, MS, FNP-BC, Kathryn Busby, J.D., Public Member, Lori A. Gutierrez, BS,RN-C,DON-CLTC,CBN, Terri Berrigan, LPN, C-AL who is the board secretary, Patricia Johnson, LPN, M. Shawn Harrell, RN, MS, Charleen Snider, BSN,RN , Dr. Kimberly A. Post, DNP,MBA/HCM,RN,NEA-BC, and Leslie Dalton, MSN, RN. Nine out of the ten board member were in attendance and conducting rulings in this particular meetings.

Nurse practitioners have been practicing and providing care to patients for decades. They are often at the forefront of providing care alongside physicians. They are quickly becoming the primary provider choice for many patients in a world where there is a shortage of good and accessible primary care providers. As health care providers, they have prescriptive authority to diagnose, treat, and evaluate patients. Besides being health care providers, nurse practitioners are mentors, educators, administrators and

by a nurse equivalent is equivalent to care provided by a physician.. In addition, the

Since the inception of the Nurse Practitioner (NP) role in the 1960s, NPs have thrived in the delivery of primary healthcare and nurse case management. Despite patient satisfaction with NPs ' style of care, nurses have been critical of NPs, while physicians have been threatened by NP encroachment on MD practice. Balancing assessment, diagnosis, and treatment with caring defines NPs ' success as primary care providers. Understand the role and Scope of Practice of NPs is sometimes difficult for some to understand. The purpose of this paper is to define the role and history of NP, compare and contrast licensure versus certifications, understand NP Scope Of Practice and Standards of Care, discuss how the State Practice Acts regulate FNP practice, discuss credentialing and privileging, and differentiate between legislative and regulatory processes.

The statutes lay out the rules for collaborative practice and prescriptive authority. A written collaborative practice between the APRN and a physician must be in place for an APRN to work beyond a nursing license. The collaborative physician must be within geographical proximity thirty to fifty miles. There is an exception to the mileage rule for qualifying rural facilities. The physician must review ten percent of all of the APRN’s charts every two weeks and twenty percent of charts/patients that are receiving controlled substances. The written agreement must contain a list of prescriptive medications the physician will allow the APRN to prescribe in agreement with state prescriptive laws. The physician must document a minimum of thirty days of full supervision of the APRN before allowing the APRN to practice without the physician present. And finally, CRNAS are allowed to administer anesthesia without a physician physically present as long as there is one that could be available if

As resistant as some states’ legislative and regulatory bodies are to grant APNs autonomy of practice, the damage being done by over-regulation is clear (Safriet, 1992). Physicians are forced into a position to either supervise the APN’s practice or be constantly consulted for approval of their practice decisions. Safriet (1992) described that in and of itself, this constant supervision may appear to patients that the APN is not competent to provide adequate or care equivalent to that of a physician. If the role of the APN is to bridge gaps in health care by relieving the medical establishment of some of the patient load by performing the same function as a physician in a primary care setting, it seems wholly unnecessary to restrain their scope of practice in those areas. This type of restrictions affect cost and patient care accessibility (Safriet, 1992). This was a problem stated in the article, however 25 years later, populations of patients remain unseen or cared for and APNs continue to be underutilized (Safriet, 1992). Rigolosi and Salmond (2014) cite the American Association of Nurse Practitioners (AANP) when they state that not utilizing nurse practitioners due to practice restrictions costs $9 billion annually in the US (p. 649).

As the young and rapidly-aging population continues to increase, the demands of primary, acute and chronic disease management will also increase. As a result, more health care professionals who provide primary care will be needed to meet these demands. Thus, the emergence of Advanced Practice Registered Nurse (APRN) evolve. APRN is a nurse who has completed a graduate degree and has acquired advanced knowledge and skills. APRNs are grounded with theory, concepts and principles that enable them to assess, diagnose, treat and manage their patients. APRNs can work in conjunction with other health care professionals or independently. APRNs improve access to health care by providing care in the rural and underserved areas. APRNs also reduce the cost to health care (Joel, 2013).

Attaining a high level of education will improve the healthcare system only if nurses are fully utilizing their knowledge and abilities. Many times nurses face challenges in exercising their abilities and knowledge due to institutional policies or government regulations,

These impose severe constrictions on the ability of the nurse to move forward or advance into the areas of practice where traditional nursing practices were not allowed {Institute of Medicine, 2010}. However with the increase in the number of nurses graduating with advance degrees in nursing; the situation is changing. These well educated nurses are leading the charge to confront the complex issues that the rapidly changing health care situation presents. Regulatory barriers must be lifted so that nurses can practice within their scope in order to be reimbursed by private insurance for the services they provide. These changes can be done through the federal and state legislators as well as supervisory agencies and bodies such as congress and licensing regulatory boards. The IOM also recommends that nurses will expand their scope of practice and increase their responsibility through teaching and counseling of patients. {Institute of Medicine,2010}. The use of Advance Practice Registered Nurses and Physician Assistant in providing primary care services will decrease wait time and increase patient satisfaction. The high turnover of nurses transitioning from school to practice also affects the quality of care. These nurses do not have enough experience to make decisions in patient care.{Institute of Medicine,2010}.The IOM and JCAHO{2012} report supports the recommendations for the introduction of nursing residency