Advanced practice registered nurses are an important resource in the healthcare industry because they contribute to disease management and prevention. However, institutional, regulatory, and state barriers to APRN practice persist today leading to increased healthcare costs limited access and compromised quality of care offered.
Regulatory Barriers
State laws and regulations limit the ability of APRNs to properly provide the necessary care needed by a patient. For example, practice and licensure laws limit the capability of APRNs in the provision of at least one of the four main functions of APRNs in at least half of all 50 states in the US (Kleinpell et al., 2022). Reduced or restricted practice means that available manpower in most healthcare organization are overloaded with patients which compromises the quality of care provide, access, and the charges incurred by a patient.
State Barriers
The requirement for supervision of APRN personnel in some states limits their effectiveness and efficiency. The lack of complete uniformity in nursing practice education is another barrier that limits APRNs. A lack of uniformity means that a license issued in one state may not need to be reviewed in another state for an APRN to practice. By requiring the supervision of APRNs, added costs for the payment of the supervising physicians are added to the costs charged to patients and thus increase the cost of healthcare. Supervision also limits the APRNs work because of an inherent fear of being under supervision which affects access to healthcare. However, with the stringent supervision of APRNs, the quality of care offered to patients could improve dramatically.
Institutional Barriers
APRNs face hospital and other organizational barriers including organizational bylaws that limit the scope of their work, and provider credentialing policies, among others (Kleinpell et al., 2022). These barriers lead to problems in access because APRNs often work in a limited capacity. The quality of healthcare is also compromised as nurses are assigned a large number of patients that they cannot effectively serve without compromising the quality. If APRNs are allowed and assigned their patient, it would unburden nurses and lead to an improvement in the quality of healthcare provided.
Finally, because APRNs are not considered qualified enough to handle some complex duties, hospitals often put the costs of their services at a prohibitively high price to deliberately attract certain patients whom they can effectively serve at the expense of others. Restricting the scope of work and other institutional barriers inhibits the work of APRNs leading to the sub-optimal deployment of this resource. Consequently, because APRNs work under the shadow of physicians, they cannot be used to improve access, reduce costs, and improve healthcare
Status of the APRN consensus model’s implementation in Mississippi
The APRN consensus model was created as a way to eliminate APRN non-conformity across the fifty states on four issues namely: regulation, licensure, accreditation, and certification. States have always passed different laws regarding advanced practice registered nurses. This meant that there was a complete lack of uniformity and thus a lack of mobility for APRNs (Burrows, 2018). This lack of mobility had a negative impact on patients including shortages of healthcare workers despite excesses in some jurisdictions. Thus, the APRN consensus model was developed to among other things establish uniformity which could solve long-standing healthcare personnel problems across states (Buck, 2021). In Mississippi, the implementation of the APRN consensus model is significantly below the national average according to the National Council of States Boards of Nursing (NCSBN).
According to the NCSBN report on the implementation of the APRN consensus model, Mississippi scored 14 points against highs of 28 for the best-performing and lows of 9 for the worst-performing (NCSBN, 2022). Mississippi’s low score is a result of zero scores independent practice (CRNA, CNM, CNS & CNP) and independent prescribing (CRNA, CNM, CNS, & CNP). The score also noted that Mississippi has failed to achieve work towards uniformity in roles, licenses, and certification. However, there is progress towards the implementation of the APRN consensus in Mississippi in areas such as education, and APRN titles. The specific APRN roles recognized in Mississippi include Certified Registered Nurse Anesthetist (CRNA), Certified Nurse Midwife (CNM), and Certified Nurse Practitioner (CNP) which means that the Clinical Nurse Specialist (CNS) role is yet to be recognized in the state.
However, as the depressed APRN consensus implementation has shown, Mississippi does not allow independent practice and independent prescribing (NCSBN, 2022). Thus, while the APRN Consensus model seeks to ensure uniformity in APRNs, some states have gone ahead to implement the recommendation in the model to the benefit of their citizens. However, some states such as Mississippi have cherry-picked parts of the recommendation and implemented them while ignoring the others. This mode of implementation of the consensus model means that problems with healthcare costs, access to health, and the quality of healthcare services offered in Mississippi may persist longer than in some other states that are ahead of the curve.
In the state of Mississippi, to practice as an APRN, one must have a graduate degree and pass a national certification program. Further, APRNs are often referred to as Nurse Practitioners and not by their universally recognized name of advanced practice registered nurses (APRNs). Further, while the state still uses the term “licensure,” it no longer issues paper licenses or certifications. In addition, Mississippi nurse practitioner (APRN) roles do not allow for independent practice and independent prescribing.
Mental Health Status of Healthcare Providers
Healthcare workers provide their services in the most difficult work environments making them more vulnerable to mental health issues when compared with other professionals. The COVID-19 pandemic made an already worsening situation regarding mental health worse. At the start of the pandemic, physicians would work for long hours without rest making them vulnerable to stress and burnout. The psychological status of a healthcare provider greatly impact the services that quality of the services that they offer. In many states, overworked physicians and nurses offer the bare minimum leading to poor health performance. The deterioration of services due to mental health issues with physicians has brought physician mental health to the fore. In most cases, some doctors suffer burnout, stress, and vicarious traumatization which impacts their service delivery and necessitates state and federal responses to physician mental health issues.
While burnout and stress are normal even under better circumstances, vicarious traumatization can paralyze a healthcare organization. Vicarious traumatization is described as secondary traumatic stress. It is derived from a sense of sympathy that physicians feel for their patients with primary trauma. Some of the common symptoms include irritability, loss of appetite, numbness, sleep disorder, and fear among several others (Søvold et al., 2021).
These symptoms are made worse by interpersonal conflicts and trauma responses they could remain at subclinical levels if they are managed on time. Hence, to help doctors respond to their client’s needs, their mental health especially as it relates to burnout, stress, and vicarious traumatization must be addressed.
At the federal and state levels, several policy actions can be taken to relieve doctors of these mental health issues. The most policy action taken would be the full implementation of the APRN consensus model. The APRN consensus model calls for the creation of uniformity in the four main roles of APRNs such that an APRN from one state can practice in other states. Such an implementation would allow the redistribution of healthcare workers with the purpose that excess APRNs would be redistributed to areas where there are shortages. When adequate staffing is achieved, it can reduce some burden on physicians and nurses allowing them adequate time to relax and refresh to avoid burnout and stress.
In addition, the state together with the federal government can create a mental health fund specifically designed to help physicians and nurses cope with the stress they face when offering health services to the general public. These funds would ensure that facilities are established where a doctor can access necessary help when in distress.
Proposed APRN Legislation in Mississippi
In Mississippi, House bill number 113 sponsored by Rep. Donnie Scoggin seeks to expand the scope of nursing practitioners (APRNs). Currently, as in other states, nursing practitioners are required to work under the direct supervision of physicians. However, if this bill passes, it will exempt them from direct supervision after working for 3600 hours (Empower Mississippi, 2021). Easing these restrictions is expected to reduce physician shortages in the state. While advancing this legislation, Rep. Donnie argued that nurse practitioners in Mississippi offered the same quality services as physicians.
Thus, it was unfair for them to have a lifetime physician supervisor whose cost is covered by patients. He also noted that by restricting supervision to just 3600 hours, eligible APRNs would be able to offer their service more freely which would reduce costs and improve access to healthcare.
Nurses and APRNs’ successful participation in healthcare policy (legislative) initiatives.
In June 2021, due to advocacy by nurse groups in Michigan, the state legislature passed a bill that eliminated physician supervision of nurse anesthetics. Proponents of this legislation argued that if the law was adopted at the national level, it could open opportunities for nurses (Lagattolla, 2021). The legislation was praised by nursing groups as they touted its benefits in terms of improved access to healthcare and flexibility extended to healthcare providers. In addition, the nursing groups in Michigan are pushing for the Nurse Licensure Compact legislation to be enacted. This legislation allows APRNs to have a multistate license that allows them to practice in compact states. According to nursing groups in Michigan, the compact states now stand at 38 states representing three-quarters of the states in the US. With the possibility of the other states joining the pact, the Compact license could be a game-changer in the improvement of access to healthcare and cost reductions.
References
Buck, M. (2021). An update on the Consensus Model for APRN Regulation: More Than A Decade of Progress. Journal of Nursing Regulation, 12(2), 23–33. Web.
Burrows, K. H. (2018). Health policy, laws, and regulatory issues. Essential Knowledge for CNL and APRN Nurse Leaders. Web.
Empower Mississippi. (2021). HB 1303: Expand the scope of practice for nurse practitioners. Web.
Kleinpell, R., Myers, C. R., Likes, W., & Schorn, M. N. (2022). Breaking down institutional barriers to advanced practice registered nurse practice. Nursing Administration Quarterly, 46(2), 137–143. Web.
Lagattolla, A. (2021). New nursing legislation shows how advocacy pays off. Nurse. Web.
NCSBN. (2022). APRN Consensus Model by State. National Council of State Boards of Nursing. Web.
Søvold, L. E., Naslund, J. A., Kousoulis, A. A., Saxena, S., Qoronfleh, M. W., Grobler, C., & Münter, L. (2021). Prioritizing the mental health and well-being of healthcare workers: An Urgent Global Public Health Priority. Frontiers in Public Health, 9. Web.