As healthcare providers and patient advocates, we are often faced with convincing our charges that a change is needed. Human nature is to resist change. Most of us settle into familiar routines in our lives and jobs and, no matter how inefficient or unhealthy our routines may be, we are very reluctant to disrupt the flow of our conventions. It is the responsibility of the provider to coax the individual toward healthier choices. In order to be the champions for change, we must first understand how change takes place.
We all remember the various theories of change that were reviewed in nursing courses and some may have stuck with us over the years. In recent years, nursing has adapted the Transtheoretical Model from the psychologists (Pender, Murdaugh, and Parsons, 2011). Originally interested in the process of overcoming addictions, Prochaska, Johnson, and Lee (2009) developed a description of change that can be applied to any patient's transition to optimal health choices.
The Transtheoretical Model describes the stages as:
- Precontemplation: Without taking an action, the patient ponders the possible need for change. The patient weighs the benefits of change versus the hardships of change.
- Contemplation: The patient recognizes the need for change and resolves to make a change.
- Planning or preparation: The patient is on the verge of making the change. At this point, the individual may be taking steps toward the alterations in lifestyle..
- Action: In this phase, the patient is in the process in making the change. This phase is usually considered the first six months of the change (Pender et al., 2011).
- Maintenance: The change has taken place and has remained in place for six months. The patient is engaged in sustaining the change.
A DNP will recognize these stages in any sort of practice. Whether it is the long-term smoker giving up cigarettes or the oxycodone addict trying to overcome the addiction, all patient will pass through these stages. Psychologists realize that there are more complex factors associated with these phases (Pender et al., 2011). They speak of the mechanics of that shape these stages in terms of self-evaluation, self-efficacy, consciousness, and reinforcement.
There are, of course, limitations in the Transtheoretical Model. It is broad and it may not apply to every situation. The stages tend to be arbitrary and some researchers resent the generic application of stages (Sharma and Romas, 2008). Despite these shortcomings, providers may better serve their patients by understanding the process of change as they guide the individual through the uncomfortable process of change.
Pender, N. J., Parsons, M. A., & Murdaugh, C. L. (2011). Health promotion in nursing practice. Nola J. Pender, Carolyn L. Murdaugh, Mary Ann Parsons. Upper Saddle River, N.J.: Pearson, c2011.
Prochaska, J. O., Johnson, S., & Lee, P. (2009). The Transtheoretical Model of behavior change. In S. A. Shumaker, J. K. Ockene, K. A. Riekert (Eds.), The handbook of health behavior change (3rd ed.) (pp. 59-83). New York, NY, US: Springer Publishing Co.
Sharma, M., & Romas, J. A. (2012). Theoretical foundations of health education and health promotion (2nd ed.). Boston, MA, US: Jones and Bartlett Publishers.
The last time I wrote about leaving my position in family practice and making the big leap into dermatology. Since then I have spent the last 5 weeks fully immersing myself into learning about dermatology. Needless to say, the last 5 weeks have been challenging and I have learned a lot about what I thought I knew, what I never knew, and what I should've known about dermatology. I have also felt a lot of emotions over the past 5 weeks; happiness, frustration, confusion, apprehension, fear and anxiety, but I am hanging in there because I know the payoff will be worth it in the end.
A point worth discussing is how daunting switching your specialty can be. Now I am expected to be the "expert," the "specialist," but I don't have as many years of experience in this field as I once did in family practice! Suddenly, I find myself thrown from the position of an expert in my previous position to a novice in my current one. If that wasn't enough there are new medications, new treatments, new research studies, a new language, and new disorders to know and learn! Ugh! Who knew dermatology was so broad?
This experience opens my eyes to remembering what it feels like to be a student again, the long nights of studying, and reading, taking notes on everything trying to ensure that you don't miss any significant tidbits of information. The anxiety you felt when your instructor asked you a question and you were unsure of the answer so you feverishly dug into your notes hoping to find what you were looking for (that's me right now).
Everything else aside the change feels like a fresh start. It has renewed my enthusiasm for reading and learning about new disorders and treatment options in a way that makes me excited about what I do again. A feeling I hadn't felt in some time and it is welcomed.
I still have a long way to go but my mentor is "patient" and I am hopeful that before she pulls her hair out I can make it through training.
I'll keep you posted.
In August 2013, California's SB 491 bill - which would allow full practice authority to California nurse practitioners - failed to get out of the Assembly Appropriations Committee. Senator Ed Hernandez took to the stand and fought for the SB 491 bill. Unfortunately, it was turned down and unable to advance in the Committee due to the strong opposition from the California Medical Association who spent over $1.2 million lobbying against the bill. Full practice authority of nurse practitioners is a fervent topic nationwide, especially due to the growing shortage of providers needed to give medical care to the people of the United States. This is especially true in California where it is projected to have a shortage of over 17,000 doctors in the next two years with the current ratio of primary care doctor to patient being 30,000 to 37 million.
This places California 26th in the country for its ratio of primary care doctors to patients. The ratio is further stressed in the many rural areas where only 16 of California's 58 counties have the supply of primary care physicians recommended by the federal government, and some residents of the state never see a primary care physician in their lives. The state is also likely to face an additional 4.5 million to 5 million new Californians that will have access to insurance due to the Affordable Care Act. As California moves forward with the changes in healthcare and an ever-evolving need for primary care providers, the need is dire yet the resistance remains.
Due to California's current status in healthcare, I have never felt more proud to be a doctoral trained nurse practitioner and leading the pay on the push for full-practice authority for NPs in California. For me, the DNP education provided me with more credibility in the stance for full practice authority. It also taught me leadership qualities to educate the opponents on the importance of this for our patients and the healthcare of California as a state, which thereby affects the healthcare of our nation. Not only did my education support the push to full practice authority but it has provided me with far more confidence in proposing this issue with legislators, medical peers, and other NPs who have yet to jump on the bandwagon of the DNP. For those of you that are in states that have full practice authority do you believe that your DNP has supported this?
Those in states that are not quite full practice authority states, do you feel that your DNP is helping in the movement toward full practice authority? Looking forward to sharing ideas and opinions on this topic!
Ultimately, it is the job of the nurse to ascertain the wants and needs of the patient and, if legal, fair, and feasible, meet those wants and needs. In other words, find out what the patient wants (or needs) and give it to them. That job does not change as we move into advanced practice and the DNP is faced with that same task. The challenge comes when the patient can't or won't follow the treatment regimen that is prescribed for them.
Every nursing student is exposed to Maslow's Hierarchy of Needs early in their education. The theory, simply put, is that a person's basic needs must be met before they advance to actualization of more advanced needs (Snell, 2007). In other words, a starving man has little interest in morality and creativity. It is the role of the DNP to assist the patient through those stages, meeting each of the needs to allow the patient to advance to the next level. A patient with an open fracture in the Emergency Department has the very basic needs of comfort, hydration, and volume control. There is little thought of intimacy or other more advanced needs until those basic needs are met. The DNP must not only keep focus on meeting the essentials of survival and comfort but must keep other staff members focused on those requirements as well. We've all seen providers get mired in the logistics of care without actually focusing on the immediate needs of the patient.
It is simple to see how Maslow's Theory can be applied in an emergency situation such as the one related above but it may be less obvious in a primary care setting. Many of us see patients with limited or fixed incomes who only seek medical care when the condition becomes too severe to ignore. These patients, faced with limited coverage or co-pays they can't afford, will often be viewed as noncompliant when, in reality, they are forced to pick between paying the rent and buying groceries or buying medications. Shelter and food are among the basic biological needs that make up the first rung of Maslow's ladder. Until these needs are met, other wants will take a back seat. It may be argued that the medications meet a basic biological need as well but unless the patient is in grievous condition they may not see it that way. They will opt for shelter and food as we all would in similar circumstances.
With our background in nursing and evidence-based practice, DNPs may be uniquely qualified to recognize the basic needs of our patients and to help them overcome the barriers that prevent them from reaching optimal health. Lower priced medications when appropriate, resources from community agencies and lifestyle changes are just a few examples of interventions that will facilitate their return to health. Without losing sight of patient autonomy, the DNP may be able to give the patient the tools they need to balance all of the essentials.
Snell, R. (2007). Compliance/ethics program hierarchy of needs: A less conventional approach to understanding the relationship between compliance and ethics. (Interpretation of the theory, Maslow's hierarchy of needs, a theory of human motivation by Abraham Maslow). Journal of Healthcare Compliance, (1). 33.
Well I have told you about everything that I have gone through at the place where I work. I've been battling for recognition and respect, but when it came down to it I realized it was happiness that I wanted - a place where I could enjoy my profession and the patients I serve without any drama. Sadly, after many hard fought battle, this was not that place.
I have embarked on a new mission. I have left my previous position in the clinic for a more lucrative role in the specialty of dermatology. I am excited, as I have wanted to work in this area for a while, but didn't quite know how to break into the field. By chance (luck, really), the opportunity came to me. I have an excellent mentor to learn from - she has worked in the field for over twenty years, is an expert in her own right, and has created the first and only dermatology residency in the country for ARNPs. What a blessing to have such an opportunity; I could not pass it up.
As an ARNP, sometimes you have to learn when it is time to look toward your future and reflect on whether or not your current position is going to take you to that next level (if that's where you are trying to go). I felt that my former position was not going to help me advance my career in the direction I was hoping for, and so I made the decision to leave. Through it all, I realized no matter how big or small the issue, it's important to speak up. Let yourself be heard, or risk being a pushover (or worse, dissatisfied). If things bother you, you need to be vocal about them - the saying "a closed mouth doesn't get fed" is true!
I am the first DNP that this clinic ever had, and maybe not the last, but at least I helped to create the path for the next DNP a little less treacherous. This whole experience reminds me of a famous Kenny Rogers song. Sometimes you have to "know when to hold ‘em and know when to fold ‘em!" I fold.
Here's to a new and exciting fresh start!
"Epidemiology" and "Health Indices of Urban Populations": these are the names of the two courses I am taking this semester. At first, I thought, What does this have to do with being an DNP?
I am learning that it has a lot to do with being a DNP. You need to know what is happening in the health of the community around you so that you can be prepared to take care of that community. This message could not be any timelier than it is now with the Ebola virus outbreak coming to the U.S. When I heard that the first patient in the U.S. went the ER, told them he was in Africa, had a fever, and was discharged from the ER, I was horrified. How could that happen? Lack of education, a breakdown in communicatior - or something else? What would I have done if I was the NP in that ER?
The Ebola outbreak is another occasion for nursing to show their leadership in healthcare. We need to educate ourselves about this disease and how it can be prevented, because we need to educate the public - who are concerned and asking a lot of questions. We need to keep up-to-date with developments in its spread and in any changes in treatments or diagnoses. We also need to educate the health professionals that we work with to recognize signs and symptoms, so that we do not "drop the ball" again, like what happened in that ER with the first American Ebola patient. I am sure there are nursing leaders who are well-versed in epidemiology and public health that are doing much more to keep the public safe. I know I will do my part, and thanks to the classes that I wasn't sure why I was taking, I will know much more of what my part is.
Since I seem to have lost a host of readers last post in my discussion of what we can learn from history, I will proceed with... more lessons from history. Never fear, I expect the next couple posts will be about nurse entrepreneurship, which seems to garner more enthusiasm.
As philosopher George Santayana said, "Those who cannot remember the past are condemned to repeat it." Until more recently, I would suggest that nursing had done a bit of that.
There are now 19 states which offer an environment for fully independent nurse practitioner practice. This is amazing progress since I became an NP in 1996. I am fortunate to practice in one of those states, and to work in a progressive health care environment in which physicians and nurse practitioners, for the most part, see each other as colleagues. But I have also heard from many NPs whose state professional organizations year after year fight the medical association's hold on the legislature for the ability to practice to the extent of their education.
Take heart, you are not the first and you are not alone. In the late 1800s and early 1900s, optometry was a nascent profession scoffed at by ophthalmologists. The quack word came up. Frequently. In the 1930s and 40s, the idea of the Doctor of Optometry (OD) degree began to take hold. Over time, optometry's emphasis on prevention and treating common eye problems, won them a wide public following. In the 1980s and 1990s, the profession began to gain prescriptive authority slowly, state by state, for eye-related medications. Sound familiar? And does society currently question seeing an optometrist for general eye care?
But there's more. In the late 1800s, osteopathy emerged as an alternative conception of wellness. Initially, the profession was primary focused on outpatient care. In 1950, Missouri became the first state to allow osteopaths (DOs) to practice with the same unrestricted privileges granted to their MD counterparts. The AMA was opposed and presented restrictions such as not allowing DOs to serve as medical officers in the armed services and attempting to prohibit licensure of DOs in California. By 1973, DOs were able to practice autonomously in all 50 states. Despite continued clashes, DOs persevered and gained prescriptive and surgical authority, maintaining doctoral education and residency programs that emphasized the discipline's particulars. Well, that is interesting, isn't it?
In 1948, the American Pharmaceutical Association recommended that colleges begin establishing doctoral programs. While these programs were implemented in the 1950s and 1960s, debate became heated in the early 1990s over the increased educational costs, increased consumer costs, underuse of the pharmacist's preparation, inadequate faculty to train these students, and concerns regarding the quality of these programs. Pharmacists were frustrated that physicians tended to view them as extensions of themselves, as dispensers, rather than health professionals in their own right. In 1997, the American Council on Pharmaceutical Education mandated the PharmD as the sole degree program for accreditation to be implemented in 2000. Something about this is sounding familiar...
Chiropractic history began just before 1900. The AMA encouraged extensive prosecution for practicing medicine without a license and even established a Committee on Quackery. Their plan to undermine chiropractors included media denigration and, among other things, even encouraging high school counselors to discourage pursuit of the career.
Naturopathy also began formally just prior to the 20th century and was closely aligned with chiropractic in the beginning. Although it has a formal doctoral program and often has associated postdoctoral residency programs, it continues to experience skirmishes state by state seeking full recognition and licensure. An historical lack of uniformity in regulation and education continues to plague the profession. Naturopathy also struggles for federal support for education and residencies. Well, I'll be.
Physical therapy, audiology, and other professional health disciplines continue to work towards the implementation of doctoral education across the board.
I have heard from many RNs and NPs (typically in the same states where NP organizations go to all out war every year with MD organizations) who insist that nurse practitioners don't really need parity. I usually blink vacantly (in shock) when this comes up. I couldn't disagree more.
So what can we learn? Nurses must continue to articulate (to payors, to the general public, to governmental and health industry leaders) our singular identify and core values. Our niche is caring and healing. We embody a client-centered empowering evidence-based holistic ethic. Like nearly all the professions mentioned, we have grown up alongside another profession-medicine. (But not only medicine). We are a complementary, yet distinct, profession. We must find consensus and speak with one voice as much as possible. We must get behind the BSN in 10 and APRN Consensus Model for the future of our profession. We must eliminate archaic federal barriers to the care our patients need. We must protect patients' access to us, their primary care providers. Like other health professions, in our development, we must find consistent funding for NP/DNP residencies. I am grateful for an era with a united professional organization that is pushing forward in all these areas.
"History teaches us everything, including our future," said Alphonse de Lamartine, French philosopher and politician, whose work led to the abolition of slavery and the death penalty. It's a well-worn path, but it's worth it.
Brown-Benedict, D. (2008). The Doctor of Nursing Practice Degree: Lessons from the History of the Professional Doctorate in Other Health Disciplines. Journal of Nursing Education. Vol 47, No 10. 448-457.
Agocs, S. (2011). History of Medicine: Chiropractics fight for survival. Virtual Mentor. Vol 13, No 6, 384-388.
When I became a nurse practitioner, I was overwhelmed with the amount of information I had to retain from school. On top of that, keeping up with the most up-to-date research to support my clinical practice was hard, too. Now, as a Doctor of Nursing I am overtaken by the amount of research, policy updates, world news and continuing education I must maintain in order to sustain my credibility in this position. How do we as DNP graduates keep up with the best practice guidelines, politics and news, and still maintain our clinical and personal lives?
Balance has always been one of the most important factors for my life. I can often dive into something and get lost in what I am doing especially when it comes to my career. Because of this one of the most difficult things for me has been balancing my career and personal life and in this keeping up to date with all of the research to support my profession and place as a Doctor of Nursing. How do you all keep up with the policy and clinical practice research and updates?? For me, the best resources have been my daily email updates. I get multiple daily updates from AANP, the American Academy of Pediatrics because I work in pediatrics, and a news update called the Skimm. This way I am able to be in the know with the world happening around me while keeping up with my clinical practice, daily life, and day-to-day news because, as we know, the news certainly affects our clinical practice as I have seen directly with the recent Ebola and Enterovirus outbreaks. We as DNP-trained NPs need to be in the know with the world and our clinical practice and it is for this reason that I would love to know how you all keep up with life, clinical research, politics, and the daily news!
For many DNPs - and nurses in general - politics and policy making are important tasks best left to someone else. As clinical nurse leaders, however, who is better suited to shape help medical policy than the DNP? Nurses are already well placed in various government agencies and organizations, but the grass root effort is often lacking (Milstead, 2013). For the most part, DNPs are experienced clinicians with years of experience taking care of people. We have seen where policy and systems have failed and we have advocated for those left behind by those failures. Despite the perceived shadowy mysteries of politics and legislation, becoming involved in the making of policy requires no special training or elevated connections. It can be as simple as joining your professional organizations or as complicated as running for office.
The controversial struggle to revamp and modernize healthcare policy has been well publicized. The Affordable Care Act (ACA) is thought by many to be the first great step in leveling the ground to allow everyone to have equal access to healthcare. That controversy continues and is likely that further work will need to be done. It is the duty of DNPs to be sure that nurses in general, and Advanced Practice Nurses (APNs) in particular, are not left out of the final versions of healthcare reform. The APN has major role to play in the provision of primary and specialized care. It is our responsibility to see that we are empaneled in those functions.
The DNP's first step in becoming involved is to join your professional organizations. Once the membership is established, the easiest way to have impact on decision making may be to become active in your local chapter. These groups often have the ear of local and state politicos and volume of membership alone may be influential.
The DNP can influence policy by being a well informed source for peers and layman. This doesn't mean that the DNP needs to preach to the masses. It is enough to be able to relay the facts accurately when needed and to be sure that the inquisitive are educated on the issues.
Healthcare is a concern to most people but, until recently, has received very little attention by lawmakers (Rozner, 2009). While it is assumed that the DNP will vote, it is equally important to know where the candidates stand on the healthcare issues and to relay to those candidates one's own view of the issues based on experience and expertise.
Of course, in an ideal world, each DNP would be a spokesman and lobbyist in the making of policy and, thankfully, there are DNPs in those roles. In reality though, it is just as important that we influence policy by knowledge, awareness, and communication. As long as the DNP remains knowledgeable and is able to communicate that knowledge when needed, the DNP is a part of the policy making process.
Milstead, J. A. (2013). Health policy and politics: a nurse's guide / [edited by] Jeri A. Milstead. Sudbury, MA: Jones and Bartlett.
Rovner, J. (2009). Health Care Policy and Politics A to Z. Washington, D.C.: CQ Press.
Sometimes being the first of your kind is exciting, and sometimes it can be daunting and confusing. When I received my DNP I felt empowered, but I did not know where I would find my niche in an organization where there were no other doctoral-prepared NPs or PAs. My niche became a satellite clinic where I am the sole provider for health services to clients between the ages of 2 and above. I have a supervising physician that does not work with me because we work opposite shifts. I run the clinic autonomously 5 days a week. I have increased the number of patients establishing at the clinic and the reputation of the clinic over the last year.
The fact that I am a DNP makes it even better, because it showcases the degree (which is still largely unknown in this area) and my ability as an NP to deliver high quality care without supervision or oversight. This may seem to some as not so big a deal, but in my organization this is an anomaly. None of the other NPs work and run an entire clinic independently. I am in charge of the day to day grind and manage a small group of staff that assists me in making sure I am able to deliver top-notch, high quality care. What makes it even better is that with the current legislative climate in Florida surrounding independent practice for NPs (legislation that did not pass) my clinic may also serve as a model for legislators to use as a means to get important health policy passed in the future.
In July, I was visited by a local representative with the Florida house to tour the facilities and to see what NPs actually do. We discussed the important role that NPs can play in increasing access to care for Floridians. We also discussed the doctoral degree and NP education and how I hoped that it would help boost lawmaker confidence in our educational preparation while moving towards independent practice in our state. I hope that this tour helped the legislator to see all the good work that NPs do in our communities, what really happens in the office, and how involved the supervising physician really is. The overly-exaggerated role of the supervising physician seemed to be heavily weighed when deliberating in legislative committee hearings this past session. What a reality check this could be.
It is important as a DNP to be engaged and visible in health policy by partnering with local and state representatives and educating them on the DNP to bring recognition and awareness to the title. We need to be able to clearly articulate the significance of our role, educational preparation, and potential to impact health care if utilized in a manner in which we were intended. This is vital to our existence and potentially could expand opportunities for us in the future.
BSN nurses are getting DNP degrees. What do you think about this? Personally, I am not happy about this fact. I have had my BSN since 1987 and my MSN since 1992. I don't think that a nurse who has had their BSN for only 5 years should be getting the same degree, a DNP, as I am getting when I complete this program.
In trying to rationalize this to myself, I understand that the BSN students have to go through the MSN-level courses before they can take the DNP courses. The problem with this, though, is that the BSN nurses do not practice as an MSN nurse before they go on to get their DNP. Are there other professions that prepare their students this way?
I guess what will make the difference between an experienced RN and a new RN with a DNP is the way that they practice. I just hope that nurse leaders, employers, other practitioners, and patients will notice that there is a difference between these two groups of DNP nurses.
With the recent death of Robin Williams, mental health has certainly been in the forefront of many minds. It has been highlighted in the news media, conversations and, of course, the hearts of the many fans of the late actor. But what are we doing about this issue in our healthcare system - especially as primary care providers - and how can we as Doctors of Nursing directly handle mental health in our system?
One in 4 adults experience mental illness and one in 17 adults suffer from severe mental illness, including schizophrenia, major depression, or bipolar disorder.1 About 20% of teens experience severe mental illness in a given year and about 13% of children ages 8 to 15 suffer from a mental health diagnosis.2 Only about 1/3 of these patients needing mental health care are able to receive it in today's healthcare arena.3,4 Serious mental illness costs our health system about $193.2 billion in lost earnings a year and disorders like depression are the number three cause of hospitalization in the U.S.5 As primary care providers, we are the main hubs for patients with mental illness and likely the most accessed resource of patients suffering from these disorders. Yet most of us received little training in mental health and we are confronted with the barrier of insurance reimbursement for mental health diagnoses or screening.
As Doctors of Nursing, we have an amazing opportunity to use our platform to improve the care of mental illness in our country. With the leadership skills gained through our education and the public policy didactic that many programs offers, we have the potential to make changes to improve the care being provided and those offered. One step is on educating ourselves on the care of mental illness. I have seen many providers lift their hands in the air and refer to someone else when a patient comes in suffering from mental illness because they are scared to address these issues. We have to educate ourselves in order to become proficient in this area of care in order to make the first step in changing the treatment of these diseases. With this education we can implement improvements in quality of care, increased screening and detection of illnesses, and ultimately improve the outcomes of patients suffering from mental illness. The second is in the realm of academia. More than one lesson has to be focused on the care of mental illnesses, the medications to be used, and appropriate screening needed to be initiated in primary care. Doctors of Nursing, especially those working in academia, have the potential to change curriculum and improve the education of mental illness in our training. The third is educating insurance companies on the necessity to authorizing care of mental illness in primary care and referring when the care is out of our scope of practice. If we as primary care providers continue to lift our hands up in the air and say this isn't mine to deal with when treating a patient with mental illness, we will continue to have poor outcomes in all areas of health for the vast majority of our patients, because the large percentage are suffering from some sort of mental illness.
Following Robin Williams's death, I read an article entitled "Robin Williams Didn't Kill Himself" 6 and as I read the title I said to myself, "wait, yes he did." When I read further into the article the author stated, "Robin Williams did not kill himself, his disease did." This is the truth for so many Americans suffering from mental illness. Their disease is diminishing their quality of life; they aren't doing it to themselves. Their diseases are killing them, not themselves. We as Doctors of Nursing have a very special place in today's healthcare arena to limit this diminishing quality of life and limit the amount that these diseases are killing our citizens, relatives and patients.
1. National Institutes of Health, National Institute of Mental Health. (n.d.). Statistics: Any Disorder Among Adults. Retrieved March 5, 2013, from http://www.nimh.nih.gov/statistics/1ANYDIS_ADULT.shtml
2. National Institutes of Health, National Institute of Mental Health. (n.d.). Any Disorder Among Children. Retrieved March 5, 2013, from http://www.nimh.nih.gov/statistics/1ANYDIS_CHILD.shtml
3. Substance Abuse and Mental Health Services Administration. (2012). Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings NSDUH Series H-42, HHS Publication No. (SMA) 11-4667). Rockville, Md.; Substance Abuse and Mental Health Services Administration, 2012.
4. National Institute of Mental Health. (n.d.). Use of Mental Health Services and Treatment Among Children. Retrieved March 5, 2013, from http://www.nimh.nih.gov/statistics/1NHANES.shtml
5. Insel, T.R. (2008). Assessing the Economic Costs of Serious Mental Illness. The American Journal of Psychiatry. 165(6), 663-665.
6. http://popchassid.com/robin-williams-didnt-kill/. (2014). Robins Williams Didn't Kill Himself.
Since the Affordable Care Act (ACA) first made headlines, a frequent topic in the media has been the shortage of primary care providers (PCPs) to accommodate the influx of newly insured patients. At the time of its implementation, it was estimated that there would be a shortfall of 45,000 to 60,000 PCPs to provide care for the millions of newly insured Americans (Rosenberg, 2012; "Survey reveals", 2012). The concerns continue. Recently USA Today cited that the demand for primary care providers cannot be met (Krasselt and O'Donnell, June 30, 2014).
While many of these articles note that NPs and PAs are qualified to serve as PCPs, a recent survey of Health Maintenance Organizations (HMOs) by the National Nursing Centers Consortium (NNCC) revealed that 25% of the HMOs do not credential NPs as PCPs. Compounding this problem, it was also revealed that many companies will credential the NPs but will not reimburse them directly or that the company will place restrictive stipulations in their contracts.Some will not list the NPs among their published list of credentialed PCPs for that HMO ("Survey reveals", 2012).
Health insurance without health care is of little value. The seemingly obvious answer is that the federal government can mandate that NPs (and PAs) must be empaneled as PCPs. Even if that occurred, the disparity between the scopes of practice of various states must be evened out. Currently, only 18 states allow independent practice by NPs while the remaining 32 states require physician oversight of diagnosis, treatment, and/or the prescription of medications (Cassidy, 2012). In order to fulfill their potential as PCPs, NPs must have some continuity of practice from state to state. While some of us may rue the entrance of the federal government into healthcare, that die has been cast. Federal intervention may be necessary to achieve the stated goals of the ACA.
There is, of course, opposition to the expansion of the role of NPs in primary care. The American Medical Association (AMA) has argued that the doctor shortage is not a reason to turn over primary care responsibilities to the NPs. They have contended that each NP should be supervised by a physician at all times (Mahar, 2010). The American Academy of Family Physicians (AAFP) suggests that NPs as independent practitioners creates a "two tier" system with the Physicians offering the highest level of care and the NPs representing the "less qualified" tier (Rosenberg, 2012). The implication is that the NP cannot be trusted to work alone.
Nurse practitioners stand trained and ready to offset the upcoming shortage of primary care providers that will result from the implementation of the PPACA. Facing an access to care debacle, it would be unwise to ignore the ready supply of providers trained in primary care and, in many cases, already employed in primary care offices.
This article was condensed from:
Reddish, W. (July 2014). Policy paper: NPs as PCPs. Unpublished Doctoral Paper for Maryville University.
Cassidy, A. (October 25, 2012). Nurse practitioners and primary care. Health Affairs. 31(11) Retrieved from http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_79.pdf
Krasselt, K. and O'Donnell, J. (June 30, 2014). Supply won't meet growing demand for primary care. Retrieved from http://www.usatoday.com/story/news/politics/2014/06/29/primary-care-shortage-health/11101265/
Mahar. M. (2010). The battle over letting nurse practitioners provide primary care. Retrieved from http://takingnote.tcf.org/2010/04/the-battle-over-letting-nurse-practitioners-provide-primary-care.html
Rosenberg, T. (October 24, 2012). The family doctor, minus the M.D. Opinionator, Exclusive Online Commentary from The Times. Retrieved from http://opinionator.blogs.nytimes.com?2012/10/24/the -family-doctor-minus-the-m-d/?nl=opinion&emc-edit-ty-20121024
Survey reveals that more health insurers recognize nurse practitioners as primary care providers. (2012, September 25). PHMC: A Non-profit Institute for Public Health. Retrieved from http://www.phmc.org/site/index.php?option=com_content&view=article&id=768:survey-reveals-that-more-health-insurers-recognize-nurse-practitioners-as-primary-care-providers&catid=67:2012&Itemid=1574
I had an interesting experience last week when a patient of mine that I referred to ENT within my clinic called to ask to be referred to another provider. Apparently, this patient - who thinks very highly of me and my work ethic - went to see the specialty provider, referenced me as Dr. Cash and the ENT proceeded to bash me instead of addressing the patient's main reason for being there. This turned the patient off, and she called and spoke with one of our patient advocates about the situation.
I don't feel that it is right for a provider to bash another provider in front of a patient, let alone a provider that they have never met or spoken to. I would never bash a colleague in front of a patient or a staff member - and I would hope that other providers would be respectful of my knowledge, credentials and the fact that my patients are very satisfied and well-cared for. This is not the first time that this has happened at the clinic where I work.
You see, this has happened with our compliance officer as well (who is an RN). She came out to my office for compliance week and then went on a tirade to the radiology tech about how I wasn't a real doctor and that she was going to make sure that she put an end to me calling myself doctor. Luckily, my radiology tech stood up for me, and said that they were referencing me as Dr. Cash because I had received previous approval by the board to do so. Of course this didn't make her happy and it showed all over her face during our encounter.
I found out the next day during my annual review that she sent an email about it to our clinic director (who is also an RN) who only briefly mentioned the incident to me without any detail. The phrase "nurses eat their young" is true. I thought that I had gotten past this, given years of experience. Apparently it still applies, because some are not accepting of the changing paradigms in healthcare, especially the role of the DNP and the title and credentials that come with it.
I guess I just expected more from my own. I mean, I expect it from the physicians, but the nurses too?
Evidence-based practice...we heard about it throughout nursing school and into our master's degrees; you hear the phrase in almost every health profession and in discussions regarding our current healthcare system. However, it wasn't until my DNP education that I truly understood the process of using the evidence to guide care and the importance of being a leader in this type of practice.
One of the most important acquisitions from my DNP education was the need for this evidence-based practice in today's healthcare environment. With the Affordable Care Act in full swing, there is a dire need for cost savings and improvement in patient outcomes to reflect on the cost spending. Just as changes have been made in the hospitals with the decreased reimbursement or even fining for services that are not supported by the evidence, the time will come when the same is true for primary care. The opportunity exists for leaders to guide care and support the healthcare system that is in need of evidence-based practice. This is exactly what our DNP education sought out to do: improve patient outcomes through research. Although a doctoral degree is not necessary to take part in evidence-based practice, the DNP education supports the leadership of this movement.
It is to this that I request those with a DNP to respond. The DNP degree was developed with the intention of improving clinical patient outcomes through research. Simply put, the focus is on improving the knowledge of clinicians in relation to clinical practice outcomes by using the research to provide higher quality of care. We must be leaders in this undertaking. Not only to improve patient outcomes, but also to provide a trickle effect on the entire healthcare system. As the parable of the fisherman teaches us, "Give a man a fish and he eats for a day; teach a man to fish and he eats for a lifetime."
We as doctoral-level trained nurses must be the teachers and leaders in our healthcare system through evidence-based practice as well as the guidance of using the evidence to support patient care. We must lead our peers - including nurses, physicians, legislators, etc. - in the practice of evidence-based care in order to not only improve the health of our patients, but also the well-being of our entire healthcare system.