Nurse practitioners have enjoyed recent gains when it comes to scope of practice laws regulating their ability to practice. Fear over a primary care shortage and changes to healthcare law have led many to point to nurse practitioners as part of the solution to our country’s health care woes. But are advancements in scope of practice laws really making a difference?
Working as a nurse practitioner in the emergency department, I couldn’t give you an accurate assessment of the scope of practice laws in my state based on what I see at work. For billing purposes, a physician signs all of my charts for privately insured patients. To comply with Medicare’s even stricter billing standards, a physician briefly visits my Medicare patients in person so my company can receive full payment for the visit. The state of Tennessee, however, requires a physician sign only 20 percent of my charts and does not require a physician to see any of my patients in person.
Hospital policies further impact my role as an NP. Hospital administrative policies require a physician to review and sign my orders in the emergency department. When I diagnose a patient with a condition requiring admission, a physician must contact the hospitalist and write admission orders, which interrupts flow in the emergency department. This level of oversight is required by hospital administration rather than state law.
Most nurse practitioners have similar experiences in their practice and a recent study in the Journal of Professional Nursing suggests that organizational culture in health care settings often hinders utilization of NPs to the full extent of their abilities. Although state laws are changing, the role of nurse practitioners in daily practice is not keeping pace.
Author of the study, Dr. Lusine Poghosyan, says, “organizational policies can often trump governmental policies, keeping the contribution of the nurse practitioner unrecognized and preventing them from making the fullest contribution possible to effective patient care.” Nurse practitioners participating in the study reported that their role was often poorly understood by senior leadership. Billing considerations were also frequently cited as a factor in limiting the NP scope of practice.
On the positive side, nurse practitioners in Dr. Lusine’s study reported that the longer nurse practitioners worked with physicians, the more they were trusted and given the autonomy to practice independently. This is what I have personally seen in my practice. While organizational policies and billing practices have not consistently changed along with scope of practice laws, administrators and patients are slowly becoming more familiar with the NP role.
Although it can be frustrating for nurse practitioners to be limited in their practice despite legal advancements, practice will slowly evolve to match new state scope of practice laws.