Restrictive practice environment and nurse practitioners' prescriptive authority

Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review

BACKGROUND

One proposed strategy to expand primary care capacity is to use nurse practitioners (NPs) more effectively in health care delivery. However, the ability of NPs to provide care to the fullest extent of their education is moderated by state scope-of-practice (SOP) regulations.

PURPOSE

The purpose of this study was to examine the impact of state SOP regulations on the following three key issues: (a) NP workforce, (b) access to care and health care utilization, and (c) health care costs.

METHODS

Systematic review.

RESULTS/DISCUSSION

States granting NPs greater SOP authority tend to exhibit an increase in the number and growth of NPs, greater care provision by NPs, and expanded health care utilization, especially among rural and vulnerable populations. Our review indicates that expanded NP practice regulation can impact health care delivery by increasing the number of NPs in combination with easing restrictions on their SOP.

CONCLUSIONS

Findings show promise that removing restrictions on NP SOP regulations could be a viable and effective strategy to increase primary care capacity.

Level of autonomy of primary care nurse practitioners

PURPOSE

The purpose of this descriptive study was to determine the level of autonomy of nurse practitioners (NPs) providing care to patients in a primary care setting.

DATA SOURCES

Data were collected from 48 primary care NPs (PCNPs) who attended a state clinical conference. The Dempster Practice Behavior Scale (DPBS) was used to measure the autonomy of the NPs.

CONCLUSIONS

The total mean score for the DPBS in this study was 127 (SD = 10.25), indicating a very high level of autonomy of the NPs. The Empowerment subscale had the lowest overall mean score, and the Valuation subscale had the highest. There was no statistically significant relationship between level of autonomy and age, years worked as an RN, and years worked as an NP.

IMPLICATIONS FOR PRACTICE

This study provided evidence that PCNPs are highly autonomous professionals and continue to struggle with empowerment. NPs educationally prepared with a better knowledge of legal and political issues will be better suited to influence healthcare reform. NPs, as autonomous professionals, will be more likely to impact and shape future healthcare policy.

Levels of autonomy of nurse practitioners in an acute care setting

PURPOSE

The purpose of this descriptive study was to determine the level of autonomy of nurse practitioners (NPs) providing care to an adult patient population in an acute care setting.

DATA SOURCES

Data were collected from 54 NPs in different specialty areas currently working in a large metropolitan hospital. The Dempster Practice Behaviors Scale was used to measure the autonomy of the NPs.

CONCLUSIONS

The overall mean autonomy score of 117.37 (SD = 14.55) indicates a high level of autonomy of the NPs in this study. Forty-one percent of the participants had very high levels of autonomy, 31.5% had extremely high levels of autonomy, and 19% had moderate levels of autonomy. Demographic variables of age; years worked as an NP, as an RN, and at current job; highest educational level; basic nursing preparation; NP certification; and specialty had no statistically significant relationship with autonomy scores.

IMPLICATIONS FOR PRACTICE

The results of this study provided preliminary evidence of the level of autonomy of NPs providing inpatient care to adult patients in an acute care setting. The findings could lead to future research on the impact of NP services on patient outcomes and clinical productivity in acute care settings.

Children's nurses and nurse prescribing: a case study identifying issues for developing training programmes in the UK

AIMS AND OBJECTIVES

(1) To develop an insight into the opportunities and barriers to nurse prescribing for a case study of children's nurses. (2) To consider the implications of independent nurse prescribing for children's nurses and the potential for nurse prescribing to be developed in acute children's care settings. (3) To use research data to develop a training strategy.

BACKGROUND

Nurse prescribing in the UK is evolving and current initiatives aim to extend the range and scope of prescribing. Children's nursing presents interesting challenges because of off-license drugs. Successful nurse prescribing lies in practice area preparation, local policy and practice development and identifying precourse training needs.

DESIGN

Case study.

RESEARCH QUESTIONS

(1) What opportunities do children's nurses identify as being appropriate for nurse prescribing? (2) Can children's nurses identify the benefits of patient group directives and the different levels of nurse prescribing? (3) What preparation do children's nurses need for nurse prescribing?

METHODS

Focus group of health visitors/district nurses to inform a survey of 500 nurses working in acute and specialist care settings in a large Children's Hospital. Results. Focus group main themes - training, supervision and the development of confidence, record keeping, benefits of nurse prescribing, autonomous practice, the formulary and its use in practice. Response rate was 27%. Senior nurses and specialists identified potential benefits for their practice. Course content needed to focus on children, i.e. children's physiology and pharmokinetics. Children's nurses frequently advise junior medical colleagues on prescribing issues. Patient group directives are a useful alternative to prescribing.

CONCLUSIONS

The results provide an insight into the training needs of children's nurses and specialist nurses which may be used to develop nurse prescribing training and practice. Training may need to be targeted at senior nurses/specialist nurses initially to develop a critical mass to change organizational culture.

RELEVANCE TO CLINICAL PRACTICE

Pertinent for senior nurses responsible for developing children's nursing practice and services for children in acute settings.

Prescribing trends by nurse practitioners and physician assistants in the United States

PURPOSE

As an important step in analyzing the role of nurse practitioners (NPs) and physician assistants (PAs), we examined their prescribing behavior. The intent is to study the characteristics of providers and patients, and the type of prescriptions written by NPs and PAs in primary care and to compare these activities to physicians.

DATA SOURCES

The National Ambulatory Medical Care Survey (NAMCS) database was examined for prescriptions written by primary care clinicians (family and general medicine, internal medicine, and general pediatrics). A representative sample of 88,346 primary care visits over a 6-year period (1997-2002) was analyzed in which a prescription was written by an NP, a PA, or a physician in an urban or rural setting.

CONCLUSIONS

The characteristics of all the patients seen were similar for geographical region of visit, age, and gender, but differed by ethnicity and race. An NP or a PA was the provider of record for 5% of the primary care visits in the NAMCS database. The three clinician types were likely to write at least one prescription for 70% of all visits, and the mean number of prescriptions was 1.3-1.5 per visit (range 0-5) depending on the provider. PAs were more likely to prescribe a controlled substance for a visit than a physician or an NP (19.5%, 12.4%, 10.9%, respectively). Only in nonmetropolitan settings did differences emerge. In rural areas, NPs wrote significantly more prescriptions than physicians and PAs.

IMPLICATIONS FOR PRACTICE

We suggest that NPs and PAs may provide a role that is similar to that of physicians in primary care based on prescribing behavior. The prescribing behavior of PAs and NPs parallels that of physicians by the number of medications per visit, the types of therapeutic classes, and the type of patient. However, in nonmetropolitan areas, prescribing differences emerge between the three types of providers that bear further exploration.

Physician Assistant and Nurse Practitioner Prescribing: 1997-2002

CONTEXT

Physician assistants (PAs) and nurse practitioners (NPs) have licensure to practice in all states and they have prescriptive authority in 47 and 40 states, respectively. However, there have been no published studies from a national standpoint comparing urban and rural settings.

PURPOSE

The objective of this study was to describe the characteristics of providers, patients, and the type of prescriptions written by PAs and NPs and to compare these activities to those of physicians in metropolitan and nonmetropolitan settings.

METHODS

The National Ambulatory Medical Care Survey was used to analyze a representative sample of 149,202 visits to primary care physician offices over a 6-year period (1997-2002) in which a prescription was written by a PA, NP or physician.

RESULTS

A PA or NP was the provider of record for 3% of the primary care visits. The 3 providers wrote prescriptions for 60% to 70% of all visits, and the mean number of prescriptions was 1.3 to 1.5 per visit (range 0-5), depending on the provider. PAs were more likely to prescribe a controlled substance than were physicians or NPs (19.5%, 12.4%, 10.9% respectively). Only in rural areas did differences emerge. In rural areas, NPs wrote significantly more prescriptions than physicians and PAs, and PAs wrote significantly fewer prescriptions than the other providers.

CONCLUSIONS

Overall, PAs and NPs are prescribing in a manner similar to physicians in the type of medications used in their patient management. In nonmetropolitan areas, prescribing differences among the 3 types of providers bear further exploration.

Tracking NP prescribing trends

This article presents the results of three surveys on NP prescribing practices from 1996 to 2001. The data elucidate differences in prescribing practices by practice location, specialty, type of drug, and years of practice. We highlight prescribing trends and identify areas for future research.

The effects of clinical decision making on nurse practitioners' clinical productivity

The degree of clinical decision making and clinical productivity among nurse practitioners (NPs) is of great interest to policy makers and planners involved in providing appropriate outpatient primary care services. The authors performed a statewide mailed survey of all NPs practicing either full-time or part-time in Wisconsin (response rate of 72.1%) to address the following research questions: Do the demographic characteristics, practice attributes, and primary practice settings of NPs impact their level of clinical decision making (e.g., the autonomy to order laboratory and radiological tests or to refer a patient to a physician specialist other than their collaborating physician)? Do NPs' levels of clinical decision making correlate with their outpatient clinical productivity, adjusting for demographic characteristics, practice attributes, and primary practice settings? The multiple linear regression results indicated that having more years in practice as an NP, practicing in the family specialty area (vs. a combined other category, which included pediatrics, acute care, geriatrics, neonatal, and school), treating patients according to clinical guidelines, practicing in settings with a fewer number of physicians, and practicing in a multispecialty group practice versus a single-specialty group practice were associated with greater levels of clinical decision making. However, NPs who primarily practiced in a hospital/facility-based practice, as compared with a single-specialty group practice, had lower levels of clinical decision making. After adjusting for demographic characteristics, practice attributes, and primary practice settings, NPs with greater clinical decision-making authority had greater outpatient clinical productivity. The conclusions discuss the policy implications of the findings.

The contingent nature of advanced nursing practice

This paper examines the issues faced by advanced nurse practitioners in the United Kingdom as they attempt to implement a new role in practice. The discussion draws on evidence gathered during a longitudinal study of a small number of graduates from a Master's degree programme who subsequently took up posts as advanced nurse practitioners. The paper focuses on one of the key findings to emerge from the inquiry, that of the identification of the contingent nature of advanced nursing practice. The data for the study were collected over a 2-year period via interviews, observation of clinical practice and self-report role development diaries. Following analysis it was revealed that, whilst the passage from experienced nurse to advanced nurse practitioner can be considered to be highly individual and complex, practitioners appear to move through three discrete stages during the transitional process. The first of the three stages is represented by a state of 'idealism' on the part of advanced practitioners. During the second phase, termed 'organizational governance', practitioners discover that, in contrast to their initial optimism, the orientation, goal and delivery of their role is controlled by key stakeholders within the organization. The final stage, 'resolution', is only reached when practitioners have been in post for more than 1 year and can be summarized as a state of acquiescence and compromise. A conceptual model is presented which illustrates the contingent nature of advanced nursing practice.