Role of the Family Nurse Practitioner (FNP) - Essay Example

Role of the Family Nurse Practitioner (FNP) Role of the Family Nurse Practitioner Millions of Americans are unable to access healthcare either because of expense or because of lack of availability. The dynamics of the healthcare system as it presently stands has forced many to seek primary care services. At this time only one-fourth of medical students select family practice, pediatrics or general medicine. This creates a gap in healthcare that is crucial to be filled. FNP's are very much qualified to step in and fill this role. This paper will discuss the role of the FNP, as well as the legal, educational, and licensing requirements related to it (Sherwood, Brown, Wardell, 1997). Sherwood (1997) tells us that environments are still somewhat restricted and that practice varies from state to state which causes some difficulty in efficient use of the NP where needed. The University of Texas Health Science Center defines Advanced Practice Nursing as "as a registered professional nurse who is prepared for advanced practice by virtue of knowledge and skills obtained through a post-basic or advanced education program of study acceptable to the State Board of Nurse Examiners"(Sherwood, et. al., 1997 pg3). The FNP is qualified to be the first person seen on entry to the healthcare system. This is usually client oriented and comprehensive, allowing for a continuum of care based on the collaborative practice studied and provided by the FNP. The focus of the practice is wellness and maintenance which allows the client to see the same practitioner longer before having need to be referred out to a specialist. Alternatively, Bennett defines a FNP as a healthcare professional who works directly with families and physicians to provide the best level of care. FNP's differ from physicians in that they practice in many settings. They possess advanced Masters level nursing degrees which has provided them with special training and experience to assess, treat, counsel, and monitor patients. They perform a collaborative practice in which they work with healthcare professionals as a team. They are able to order testing, refer patients and treat non-life threatening conditions (Bennett, 2004). The Texas Board of Practice on this same thought states that the APN acts independently and/or in collaboration with other health care professionals to deliver health care services (Texas Board of Practice, Section 221). They accordingly accomplish comprehensive health assessments with the goal of managing common acute illnesses, appropriate referral, managing chronic conditions that have remained stable. In this description there are included; Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwives and Certified Nurse Anesthetists. The role originated in the University of Colorado in 1965. In 1974 the American Nurses Association published educational guidelines for credentialing of a NP. Since then, there have been many changes in the program and of course since there are so many types of programs available, there are concerns as to the quality and effectiveness of those programs. That curriculum includes advanced physiology, pharmacology, and clinical practice emphasizing a particular role. Texas strengthened even more of the program in the sense that they increased content for path physiology, pharmaco-therapeutics, practice roles, and preceptorship (Bennett, 2004). In most cases, registered nurses are required to obtain a Masters degree in nursing and have at least one year of RN experience before they are allowed to enter a Nurse Practitioner program, however, that is not always true. Nurse Practitioners can come from a variety of backgrounds. There are programs that admit students into graduate study without prior experience as a nurse. When that happens they must have a Baccalaureate in a field other than nursing and are required to complete an accelerated program which incorporates a Bachelors in nursing going straight into a Masters level NP program (Rich, Jorden, & Taylor, 2001). There are many studies presently available showing the results of the different types of programs presently available. In those studies, educational background and prior experience as an RN are two factors investigated. The two classifications of nurses in most studies are listed as experienced and inexperienced. Some studies (Rich, et.al, 2001), show that traditional students have an average of eight years of experience as registered nurses while non-traditional students have an undergraduate degree in something other than nursing. Needless to say, there is much debate at this time about how these programs should be built and what their future will look like. There is presently considerable discussion as to what the program really needs to look like and what those changes need to be. This discussion stems through not only the mandatory education piece but the number of clinical hours required. Many faculty that are presently teaching in NP programs are in major discussion as to whether or not there needs to be a specific number of clinical hours required and whether those hours need to be more or less than five hundred (Bray, & Olson, 2009). The feeling is that the required number of hours has a great deal of effect on students, faculty, programs, and preceptors, to name a few. This debate continues beyond the school doors as regulatory agencies, in the end, are responsible for the quality of Nurse Practitioner that graduates and begins care of patients. Those professional standards must be maintained by these agencies. The role of the regulatory agency is to protect the public. The clinical hours that are now required are required by these agencies for both accreditation and for licensure (Bray et.al., 2009). The ideal student for NP that many schools would like, of course is a Bachelors nursing graduate who has had 3-5 years of clinical nursing experience. This nurse would then enter a Masters NP program and receive at least 500 hours of clinical practice as well as regular study. All of this may change, but at this point the discussion rages on. Defining successful entry into a program in the literature, at this point, is not consistent. The one consistent finding is that the performance of the nurse practitioner improves as she continues to gain knowledge and experience. Nursing programs that are graduating Family Nurse Practitioners must be accredited by the Commission on Collegiate Nursing Education or the National League for Nursing Accrediting Commission (Bray et.al., 2008). As part of the accreditation process, CCNE has incorporated guidelines from the National Task Force on Quality Nurse Practitioner Education determined in 2008. These guidelines include a minimum recommendation of 500 hours for clinical requirements. There is one thing for sure. The Family Nurse Practitioner program continues to change. That change is affected by legislative requirements and the maturation of the role. The scope of the practice and the needs of the public have also affected it greatly. With the healthcare environment changing the way is and as rapidly as it is, the role will continue to change as well as the requirements for entry and graduation from a school. Schools are responding to the healthcare changes as rapidly as possible with needed curriculum changes, as well as an expansion in the numbers of programs available. There are several non-traditional practice roles. Those roles all meet the needs for healthcare in a little different way. There is contrast among these roles yet there are also some things that are the same. There are, for example, the family practice physician, the physician assistant, the chiropractor, and the clinical nurse specialist, all of which have been a part of the controversies arising over the FNP role. The Family Practice Physician is specially trained to have a unique attitude with skills and knowledge that qualify him for a comprehensive view of medical care, health maintenance, and preventive services. to each member of a family regardless of sex, age or type of illness. He is qualified as a patient advocate and sees himself as a patient advocate. He determines the appropriate use of referrals is licensed and has, of course, prescriptive ability. By contrast, the FNP comes from the nursing perspective, truly allowing a patient advocate perspective. There is also prescriptive ability and they are licensed. The FNP does require oversight by a physician (American Family of Physicians, 2009). The chiropractor believes that all illness is related to the nervous system, based on the fact that the nervous system coordinates all the body's functions. Disease results from nerves that are in poor alignment, and manipulation of these structures promotes health. There is the belief in preventative measures. It is difficult to compare the FNP to this position as the FNP is a very holistic approach to the patient and family and this is a rather restricted view of the patient. Clinical Nurse specialists are experts in evidence based nursing practice in a wide range of specialty areas. Their position engages in teaching both for staff and patients as well as mentoring, consulting, researching, and management of clinical systems. They influence patient outcomes and reduce hospital costs and length of stay. They are clinical experts. They take a certification exam and are licensed. Unlike the FNP role, they do not see patients outside the hospital setting and they do not have prescriptive rights. Their concentration is in one area such as orthopedics or cardiac while the FNP is interested in the overall health of the patient. Comparison of the physician assistant role and that of the nurse practitioner becomes a little more complicated. The chart that follows compares the physician assistant and FNP. Category Physician Assistant Nurse Practitioner Philosophy/Model Medical/physician model, disease centered. Emphasis on biological or pathological aspects of health, assessment, diagnosis and treatment. Team approach with physicians. RN with advanced education and training in a clinical specialty who can perform delegated medical acts with physician supervision. Education Affiliated with Medical schools. Previous health care experience required. Entry level Bachelors degree. Appox. 1000 didactic and over 2000 clinical hours. Trained as generalists Emphasis is on diagnosis, treatment and surgical skill. Most programs are transitioning to Masters degree. Affiliated with Nursing schools with BSN prerequisite for most schools, the program is biophsychological based on biological, behavioral, natural and humanistic sciences. NPs choose specialty training track. There are approx 500 hours of didactic and 500-700 hours of clinical. The emphasis is on patient education, diagnosis, treatment and prevention. Masters prepared Certification/Licensure Separate accreditation and certification. Recertification requires 100 hours of CME every 2 years and exam every 6 years. All PAs are licensed by their state Medical Board Nursing accreditation and multiple nursing certification agencies. Masters Degree required to sit for exam; national certification is voluntary and utilized for advanced nurse prescribers within their specialty training. Recertification requires 1500 direct patient contact hours and 75 CEUs every 5-6 years. No exam. NP's practice under their basic RN license. Scope of Practice The supervising physician has discretion in delegating tasks. Written guidelines are required for prescriptions, but does not require onsite supervision. Nursing care is provided as an independent function; however, protocols and written or verbal orders are required for delegated medical acts including prescriptions-such acts require general MD supervision. Third Party Coverage PA's are eligible for certification as Medicaid and Medicare providers, and generally receive favorable reimbursement from commercial payers. NP's are eligible for certification as Medicaid and Medicare providers, and generally receive favorable reimbursement from commercial payers. References http://academic.son.wise.edu/wistrec www.wapa.org. www.aapa.org www.ana.org. www.nonpf.org. In the State of Texas, advanced practice nurses must be recognized by the Board of Nursing as APN's. The NPA allows the BNA authority to regulate professional nursing. The SOP is related to the educational preparation, continued experience and specialty area. The APN acts independently or in collaboration with the rest of the healthcare team. NP's are eligible in the State of Texas for Medicaid reimbursement at 85% of the physician rate. If joint related protocols are used 100% of the rate will be paid. They are also able to gain insurance payments, as well as Medicare payments. NP's in the State of Texas have RX authority which is provided by the BNE. The nurse must be fully authorized to practice as an NP in the State of Texas. They must also practice in a qualifying site which are sites that serve the underserved populations, physician primary care practice sites, or facility based practice sites. The physician who is the delegating physician must spend some time at the clinic where this nurse is practicing. It must be once every ten days in a medically underserved area to at least 50% of the time in a primary care clinic. This time can be reduced if the NP and the physician can demonstrate that they truly do have a true collaborative relationship. NP's can receive, request and distribute drug samples. They can prescribe controlled substances under separate application and permit (Pearson, 2002). The State of Hawaii defines the NPA as either having a "masters degree in nursing as specified in rules adopted by the BON or a current certification for specialized and advanced practice from a national certifying body recognized by the BON" (Pearson, 2002). NP's in the State of Hawaii are reimbursed by Champus, Medicaid, and several other programs. The rate of reimbursement ranges from 85-100% of physician rates, depending on the agency involved. Prescriptive authority in the State of Hawaii became effective in 1998. Prescriptive authority in Hawaii is not supervised, however there is a documenting process in which the NP must document that she has a collegial working partnership with a physician. There is the right to provide controlled substances but only from a specific formulary list. Receiving the right to have prescriptive authority requires 30 hours of advanced pharmacology, 1000 hours of clinical practice, and national certification. Masters and non-Masters NP's can prescribe controlled substances under the protocols agreed to by physician (Pearson, 2002). Florida NP's are certified by the BON. As of 2000 they required 500 hours of supervised clinical for their initial certification. They are allowed to perform diagnosis, treatment, and operation by protocol. The supervision must be well documented by written protocols. A physician must be willing to sponsor this nurse as an NP. Protocols that are developed must be filed with the BON yearly as well as providing a signed statement from the physician that he will continue to supervise. These nurses receive reimbursement from Medicaid, Champus, Medicare and some insurance companies at approximately 80% of the physician rate. Prescriptions can be written under the protocol of the supervising physician but controlled substances were not allowed until recently and that is still very well controlled (Pearson, 2002). NP's are certified in the State of Mississippi by the BON. An appropriate NP program must be completed and the NP must nationally certify as well as provide documentation of a collaborative relationship with a physician. NP's must practice based on the BON scope of practice. The NP is allowed to see patients, make diagnosis, certify wellness and teach as in many of the other states. In the case of reimbursement though, they are reimbursed at 90% of the physician level which is somewhat of an improvement over most states. They are allowed to write prescriptions by approved protocols and practice guidelines. NP's cannot at this time write for controlled substances and DEA numbers are not given (Pearson, 2002). The State of Tennessee practice under a board NPA and BON administrative rule which authorizes them to have a more expanded role. The protocols that allow them to prescribe are developed jointly by the nurse and the physician. Medical board rules are adopted jointly by the BON. Physicians must sign and review 30% of charts within 30 days of being seen by the NP. The BON has the only authority to allow or disallow any nurse to prescribe medications. Tennessee law mandates reimbursement of NP's by insurance. This is done through a managed care anti-discrimination law. Therefore the NP's are reimbursed at 100% of the physician level. NP's are allowed to prescribe as long as they have a certificate of fitness to prescribe from the BON of the State of Tennessee. This requires a Masters or Doctorate of Nursing, three academic quarter hours of pharmacology or its equivalent; and certification in the appropriate nursing specialty area. This ability includes prescribing schedules I-V controlled substances. Nurse Practitioners in the State of Texas are granted legal authority to practice by the BON. An NP is a RN with advanced education and clinical training in a health care specialty. They are primary healthcare providers and their level of education is very serious. Nurse Practitioners in the State of Texas are able to do physical exams, treatment, and procedures, They order and interpret lab and diagnostic studies, manage family planning services, provide healthcare during pregnancy, determine health risk levels, do psychological counseling, coordinate health services and do health education. New applicants for this endeavor must accomplish several things. They must have a current and valid Texas RN license with completion of an accredited advanced practice nursing educational program. They must have a valid US social security number and they must sit for national certification for the FNP role. They show completion of 400 hours of practice in the advanced practice role and population focus area within 24 months of completion of their education program. They must complete 20 contact hours of continuing education in advanced practice within 24 months of completion of their program. These nurse must also demonstrate completion of advance practice assessment with clinical components, pathophysiology, pharmacotherapeutics, APRN role preparation, clinically major course toward their role, completion of a practicum and 500 non duplicated clinical hours. All of this and there is more if they want to have prescriptive services. Prescriptive authority can only be applied for by those who have a full or provisional APN. They must hold a current State of Texas RN license or Multi-State Compact license. To get a DEA#, they must have full authorization to practice in the State of Texas and authority to prescribe medications. They must then do the special application for controlled substance for the State of Texas. When they get permission to prescribe controlled drugs, they will have full authority to prescribe dangerous drugs. They will be limited in controlled substances by the limit to schedule three, four and five drugs. The prescription cannot exceed thirty days and no refills are allowed prior to consult with the delegating physician. They do not have the right to provide a controlled substance for a child less than two prior to consulting with the delegating physician Legislation for Nurse Practioner's is moving very quickly. Every year there are added practice guidelines or things that are further regulated. It is up to the Nurse Practitioner to do that. One of the ways she might is to keep up with the Annual Legislative Update which is done by The Nurse Practitioner and covers the changes in every State. NP legal authority to practice expands all the time. The goal is to continue to serve the nations citizens in healthcare. It has been a long struggle for the NP to become an understood and supported part of healthcare and autonomy in this position is still developing but welcome. In conclusion, there are many changes in healthcare in general and certainly in the realm of the APN. There has been a long struggle to get the autonomy now claimed by these professionals. Confusion remains as to the overall abilities, education, and legalities of various types of advanced practice and how each fits into the needs of today. Many studies show that over the next few years those divisions will become more clear and Nurse Practitioners will have a more clear road ahead of them. In the meantime, it remains important to stay vigilant as to legal and legislative rules and their changes. Only we can protect our practice. References Bednar, S., Atwater, A., Keough, V. (2007). Educational preparation of nurse practitioners and physician assistants: an exploratory review. Advanced Emergency Nursing Journal DOE: 10.1097/01. Retrieved Jan. 11 from http://ovidsp.tx.ovid.com Bennett, M. (2004). Te rural family nurse practitioner: the quest for role-identity. Journal of Advanced Nursing. 9. 145-155. Bray, C., Olson, K. (2009). Family nurse practitioner clinical requirements: is the best recommendation 500 hours Journal of the American Academy of Nurse Practitioners 21. 135-139. Retrieved Jan 11, 2010 from http://www.ebscohost.com Dickinson, A., Spency, D., Smythe, E. (2006). The family--practitioner relationship. Research. Journal of Child Health Care. 10(4). 309-325. Pearson, L. (2002). Fourteenth annual legislative update: how each state stands on legislative issues affecting advanced nursing practice. The Nurse Practitioner. 27(1). 10-53. Retrieved Jan. 11 2010 from http://ovidsp.tx.ovid.com. Rich, E., Jorden, M., & Taylor, C. (2001). Assessing successful entry into nurse practitioner practice: a literature review. Journal of the New York State Nurses Association. 32(2): 14-18. Retrieved Jan. 11, 2010 from http://web.ebscohost.com/ Sherwood, G, Brown, M., & Wardell, F. (1997). Defining nurse practitioner scope of practice: expanding primary care services. The Internet Journal of Advanced Nursing Practice. 1(2). Retrieved Jan. 11, 2010 from http://www.ispub.ocm/journal Williams, N. (2009). Bringing the family healthcare. Nursing New Zealand. 15(5). 5-8. http://academic.son.wise.edu/wistrees http://www.bon.state.tx.us/practice/apn-scopeofpractice.html www.wapa.org. www.aapa.org www.ana.org www.nonpf.org Read More