Discussion Responses
Bright future 2019
Discussions.docx
Discussion 1
A collaborative agreement (CA) is specific to each state and is an outline of different aspects that are expectations and parameters that are between the nurse practitioner (NP) and the primary supervising physician (PSP). The official definition of the CA is listed under the 21 NCAC 32M. 0101 definitions section as "the arrangement for the NP-physician continuous availability to each other for ongoing supervision, consultation, referral, and evaluation of the care provided by the NP" (NC Medical Board, 2012a). The CA, as outlined by the NC Board of Nursing (2019), will address a plan for how the role of the NP will be used with specificity to that particular facility type. The CA can be individualized towards the particular NP based on their experience in the NP role and may provide elements of expected referencing guidelines for patient care and must incorporate a description of the arrangement of how the PSP and NP will practice together (NC Board of Nursing [NCBON], 2019). Since the CA can be written based on the NP's experience and the confidence the PSP may have in the NP's clinical judgment and abilities, the PSP can take the liberties to allow for the NP to have some freedoms within the practice under their authority, but the NC Board of Nursing is very clear that there must be a structured CA that defines the patient population, prescribing authority, requirements for documentation, and a quality improvement process that must meet the minimum guidelines defined by the board of nursing (NCBON, 2019).
North Carolina is highly restrictive for the NP. The physician collaboration issues identified as an issue, in my opinion, are the restrictive nature of the agreement and the necessity to have a back-up supervising physician within the contract (NCBON, 2019). The restrictive nature of the agreement can be considered as demeaning to the NP. The intensity of the NP education requirements and the board examination completion allows for the NP to enter the workforce with at least the minimal requirements to practice safely. It can be considered reassuring to the NP have the supervising physician watching over the care of the patient, but NC restricts all aspects of patient care. Restrictions are placed on consultations and all methods of treatment from laboratory testing, procedures, and medications. The other issue is the back-up supervising physician that is needed for practice. It may be hard enough to find a PSP but then the NP must have a physician willing to be a back-up to the primary.
This assignment has been a real eye-opener and very beneficial for me. I actually feel it is important to take a stand against the restrictive nature of NC. Conover & Richards (2015) released an extensive research report on how if NC would take a less restrictive stance, economically it would be better for the state and for the patient's benefit. The biggest barrier to the NP in NC being able to practice without the rule of a supervising physician, I believe, is the supervising physician. I have read several articles that have been released, though not scholarly based, that describes the PSP at a parasite feeding on the NP. One article was from an NP in NC that has her own practice and even employs two other NPs. She states that the PSP receives $1000 a month from her ($500 per NP) for signing off as the PSP. She also says that she has been in practice since 1999, longer than the PSP, and her every 6-month required meeting is a waste, as she feels like she does not need any input from the PSP to manage her patients, nor does ever get any feedback from the PSP at the meetings that are of any benefit. Page 49 of the NC Medical Board's Practice Statements (2019b) state that the PSP is not to provide this type of service of governing as a hired or contracted PSP, but instead only for the legally required purpose of supervising the care of the patient. The North Carolina Nurses Association (NCNA) is working hard to cut through the bureaucratic red-tape in an attempt to improve access to the healthcare providers in rural areas, increase consumer choice while lower healthcare costs, and eliminate the inefficiencies of the PSP (Kreider, 2020). In conjunction with the NCNA, the NC Council of Nurse Practitioners (NCCNP) is working tirelessly with state legislators to make changes in NC (North Carolina Nurses Association, 2020). I am already a member of the NCNA and plan to become a member of the NCCNP and try to do my part in this effort.
References
Conover, C.J. & Richards, R. (2015). Economic benefits of less restrictive regulation of advanced practice registered nurse in North Carolina: An analysis of local and statewide effects on business activity. Duke University, Center for Health Policy and Inequalities Research. Retrieved from http://ushealthpolicygateway.com/wp-content/uploads/2018/01/Report-Final-Version.pdf
Kreider, K. (2020). North Carolina NPs: The fight for full practice authority. Nurse Practitioners Schools. Retrieved on April 25, 2020, from https://www.nursepractitionerschools.com/blog/north-carolina-np-practice-authority/
NC Board of Nursing. (2019, May 21). Collaborative practice agreement. Retrieved on April 25, 2020, from https://www.ncbon.com/practice-nurse-practitioner-collaborative-practice-guidelines
NC Medical Board. (2012, September 1a). Subchapter 32M: Approval of nurse practitioners. Retrieved on April 25, 2020, from https://www.ncmedboard.org/images/uploads/rules/21_NCAC_32M_0101-approved_by_RRC.pdf
NC Medical Board. (2019b). Position statements. Retrieved on April 25, 2020, from https://www.ncmedboard.org/images/uploads/other_pdfs/PS_November2019.pdf
NC Nurses Association. (2020). Networking: Council of nurse practitioners. Retrieved on April 25, 2020, from https://ncnurses.org/networking/councils-and-commissions/nurse-practitioner-council/
Top of Form
In Virginia, a practice agreement between a nurse practitioner and physician must include the following provisions (O’Connor, 2018):
• Provisions for the periodic review of patient records by the supervising physician;
• Provisions for particular situations that require input by the supervising physician;
• Provisions for what the NP should do in case of a patient emergency and when a referral should be made;
• Categories of drugs and devices the NP may prescribe;
• Guidelines for the availability and ongoing communication between the NP and the supervising physician;
• A provision for periodic joint evaluation of the services being provided and of patient outcomes;
• A provision for the periodic review and revision of the practice agreement; and
• Signature of both parties.
Barriers
There are some significant barriers for NPs, including variations in the scope of practice regulations across states and the degree of physician supervision (Peterson, 2017). Barriers in collaboration include lack of knowledge of NPs scope-of-practice. Some physicians believe that nurse practitioners lack competence to provide quality care, which is reflected in the traditional medical hierarchal model of practice that promotes physician dominance over the healthcare team (Hain & Fleck, 2014). A collaborative model of care embraces the ideas and skill set of all members of the team.
Another barrier to NP-physician collaboration are payer policies. Restrictive scope of practice may lead to stricter payer policies limiting NPs ability to practice independently and they are essentially forced to be in practice as employees of physician practice (Yee et al., 2013). Because commercial health plan payment policies don’t always recognize NPs as primary care providers, these payers may be resistant to paying NPs for services they provide. The NP then has to bill ‘incident-to’ a physician’s services which means the billing for care delivery is under the physician’s name (Hain & Fleck, 2014). Even if the NP is allowed to have full practice authority, payers may impede NPs from practicing independent of a physician by not paying directly or reimbursing at a lower rate (Yee et al., 2013).
Addressing Issues
One of the main issues I noticed when researching barriers is the varied NP practice authority according to state. In order for this issue to be resolved, practice authority needs to be the same in every state. This would eliminate any confusion on state practice and licensure restrictions. Currently, every state is categorized into one of three practice authorities: full practice, reduced practice, or restricted practice. Virginia is under restricted practice, which means that state law requires career-long supervision, delegation, or team management by another health care provider in order for the NP to provide patient care (State practice environment, 2019).
References
Hain, D., & Fleck, L. M. (2014, May 2). Barriers to NP Practice that Impact Healthcare Redesign. Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No2-May-2014/Barriers-to-NP-Practice.html
O'Connor, K. (2018, September 26). Practice Agreement Requirements for Virginia Nurse Practitioners. Retrieved from https://www.nixonlawgroup.com/nlg-blog/2018/9/26/practice-agreement-requirements-for-virginia-nurse-practitioners
Peterson M. E. (2017). Barriers to Practice and the Impact on Health Care: A Nurse Practitioner Focus. Journal of the advanced practitioner in oncology, 8(1), 74–81.
State Practice Environment. (2019, December 20). Retrieved from https://www.aanp.org/advocacy/state/state-practice-environment
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).
