Recently critical policy issues have emerged concerning nurses’ prescriptive privileges and autonomy on account of conflicting state medical health care and organizational perspectives. These issues are essentially intertwined in nature and have been found to affect health care delivery potential for advance practicing nurses. “In the United States, a considerable variance in state regulation of prescriptive privilege exists. According to the 2007 Pearson Report, 39 states require physician involvement in NP prescriptive authority and 11 states and the Districts of Columbia allow for independent prescriptive authority” (Plager & Conger, 2007). This shows how the issue has developed to a level where different states show significant variations on account of admitting Advanced Practice Nurses to exercise significant autonomy in terms of prescriptive privilege. In essence, “APNs lose autonomy where physician oversight is required for prescribing medications. In states in which physician oversight is not required, APN practice can be very independent” (Plager & Conger, 2007).
Moreover, there is need to streamline the assigned roles given to advanced practicing nurses and physicians by merging some of the common functional entities in which they involve themselves. “Since the APN was likely to be in practice alone, they needed to have the educational background with respect to pharmacology and dispensing of medications that would complement their ability to assess, evaluate and treat their patient, including prescribing their required medications” (Verklan, 2008). The need to infuse this training requirement similar to the physicians was elementally aimed at merging functions of the two professional entities. However, it is evident that in as much as the Advanced practice nurse has been given this knowledge, there still exists significant barriers limiting its application, which fundamentally undermines its initially intended purpose. As a result, there exists a different view point on the issue, which calls for the need to implement a functional policy clearly stipulating the role of advanced practice nurses in the prescription of medicine by increasing their autonomy in the clinical setting.
Section 2: Position
APNs need to be granted sufficient prescriptive privileges, which fundamentally implies granting then significant autonomy to operate with limited oversight authority from the physicians. This will give the nurses more authority to operate past the current barriers that undermine the essence of curative health care fundamentals. “Over a decade ago, educators recognized that the scope of the advanced practice nurse (APN) would continue to expand, mainly as a result of the shortage of healthcare professionals providing care to underserved populations” (Verklan, 2008). Hence, the infusion of APNs provides a critical solution to current health problems seen in the population. The training curriculum of the advanced practice nurse entails pharmacodynamics and pharmacokinetics of common medications, which includes therapeutic/adverse effects, metabolism, distribution and subsequent elimination of the medications (Verklan, 2008). This shows that advanced practice nurses have significant knowledge of the manner in which drugs work.
Moreover, there is need to merge functions of physicians and nurses in order to better care provision. According to Forchuk and Kohr (2009), “The move to a more interdisciplinary model of health care, with less hierarchical power structures, has opened the way for a more efficient approach to delivering health care in a timely fashion”(p.6). In the present medical practice the role of advanced practice nurses is increasingly being recognized. According to Forchuk and Kohr (2009), “Physicians are recognizing the value of these relationships with colleagues who provide their level of expertise to situations and conditions that may not be within the realm of education or experience of the busy (and often overloaded) physician” (p.6-7). This position is also widely shared by other medical fraternities, for instance, the Mental Health Association of America, nursing fraternities, and some physician medical groups like Texas physicians fraternity. The positive recognition by these groups points towards a positive direction.
Section 3: Ethical Dimensions
There are various ethical dimensions impacting positively upon the successful implementation of the proposal under the current clinical setting. In as much in some states, advanced practice nurses are not allowed to handle prescriptions without formal supervision by a physician, the practice is silently going on in certain medical institutions, especially private practice settings. “Interestingly, a significant number of APNs who prescribe do so in private practice settings where physician (doctors) employ APNs to complement their medical practice and in some cases share ownership of the practice” (Hemingway, S. et al, 2004). This shows that there is need to create a more formal policy framework that will recognize these faults by not necessarily stopping the act but providing a legal framework for its practice. Since, already the law is being broken in some settings, in order to protect the population and enhance curative health care it is important to grant advanced practice nurses sufficient prescribing rights.
Despite the fact that the advanced practicing nurse plays a significant role in patient care and in fact spends more time with the patient, he or she has a better understanding of the accompanying effects on the patient. Hence, by not giving them sufficient autonomy to prescribe medications especially for common ailments, which they have handled for a long time, this undermines their professional qualification as members of the medical practitioners’ fraternity. Moreover, putting barriers on the autonomy of advanced practice nurses has a fundamental effect on the resultant patient-nurse relationship in some instances. Verklan (2008) expresses this in a rather ironic tone, “Does the patient relationship change or does the patient view the APN as a less important healthcare provider if the APN does not have prescription privileges or had a supervising physician? Does the APN who does not prescribe medications see more patients per clinic day than the one who does?” (Verklan, 2008).
Section 4: Consequences of Failure
Supposing the proposed policy initiative to allow the advanced practice nurses and physicians practice in a more integrated manner, which promotes equal autonomy on account of prescriptions, are negatively received, there are bound to be significant problems in the achievement of primary health initiatives. This is especially with regard to the potentially negative impact this will have on patient access to medical care. “The requirement for physician oversight interferes with patient access to care; constraints independent practice, and create economic barriers for APNs” (Plager & Conger, 2007). The impact on patient is especially seen in pediatric care settings and maternal health fundamentals (focusing on antenatal and postnatal care). This will primarily occur because of the technicalities involved in ensuring physicians attend to these groups, which are elementally large in number; hence, It will be necessary to incorporate the advanced practice nurse’s assistance.
Furthermore, the failure to incorporate significant autonomy on the advanced practice nurse also fundamentally affects the collaborative potential found in normally operating healthcare setting. “Physician oversight is often masked by describing it as collaboration with a physician, but this practice is not true collaboration it is one sided” (Plager & Conger, 2007). Hence, focusing on the palliative care environment where the advanced practice nurse plays a fundamental role, the inclusion of the physician as an oversee will hamper the individual output from the nurses, which will have a negative effect on health care provision for this delicate group. It is therefore important to fundamentally recognize the important role of the advanced practice nurse in the palliative care setting where he or she spends significant time with the patient; hence, it will only make more sense if they were given distinct autonomy to give critical medical prescriptions instead of relying upon the physician’s intervention, a factor that would result in more lives being saved.
Section 5: Barriers and Solutions
The incorporation of the proposed policy initiatives will significantly experience legal barriers and institutional barriers. The fact that different states have independent regulations stipulating rights bestowed upon nurses, this primarily occurs against a background of legal provisions. For instance, looking at the state of Illinois law provision on the approval of advanced practice nurses to provide medication will lead to significant friction arising. According to the Illinois Department of Financial and Professional Agreement, “Pursuant to Section 1305.40 of the Rules of the Administration of the Illinois Nurse Practice Act: A collaborating physician who delegates limited prescriptive authority to an advanced practice nurse shall include such delegation in written collaborative agreement” (Department of Financial and Professional Regulation. (2010). These legal provisions have a potentially negative influence in the implementation of the new policy requirements.
Moreover, the currently existing licensing requirements found in some states, for instance, the state of Illinois introduce significant institutional barriers. In the state of Illinois there are special licensing procedure needed for the prescription of controlled substances by the APN. In this setting “An APN who has been given controlled substances prescriptive authority shall be required to obtain a mid-level practitioner controlled substances license in accordance with 77 III. Admin. Code Part 3100” (Department of Financial and Professional Regulation, 2010). This already has an impact in certain institutional settings where there is strong control over these substances as seen in mental health institutions. In order to overcome these barriers it will be important to incorporate the policy strategies foster corporation with lead states and federal health agencies with an aim of promoting their essence in the achievement of desired population health potential. In addition, it will also be critical to foster partnerships with certain institutional settings where special regulations are required as seen in the case of controlled substances.
Section 6: Potential conflicts and Solutions
Potential conflicts are bound to arise from physician and pharmacist fraternities. This is fundamentally based on the fact that the training curriculum introduces stereotypical role definitions assigned to each group; hence, this affects the formal acceptance from these groups that advanced practice nurses have any role in the approving of critical medication to patients. These can be attributed to the potential neglect of mentorship, little knowledge on the roles played by advanced practice nurses, and lack of significant support coming from hospital administrators and physicians (Forchuk & Kohr, 2009). These will eventually lead to the occurrence of significant frustrations on the advanced practice nurses’ side in convincing their colleagues to accept them as equal members of the medical fraternity. It is also important to note that conflict is bound to arise in the fulfillment of rewards scheme in recognition of their newly acquired roles the fact that they will be prescribing medications to patients.
In order to offer a solution to the arising conflicts it will important to recognize and acknowledge the new roles by each party, and this needs to be done in a well prepared framework to avoid misses occurring. Hence, solving the conflicts will entail instituting a proper communication mechanism that pursues a top-down approach so that the key stakeholders in healthcare provision offer their support for the new policy dispensation. According to Forchuk & Kohr (2009), “Role clarity, strength in nursing focus, and support from administrators and physicians are required for prescriptive authority to be fully enacted.” This will give nurses more freedom and will elevate their status quo amid other health practitioners, which will have a positive impact in the emancipation of health care delivery.
Section 7: Conclusion and Call for Action.
First, he advanced practice nurse needs to play a fundamental role in the prescription of drugs in pediatric, maternal, adult, mental, and palliative heath care settings. I n as much a similar role is played by physicians, the advanced practice nurses need to be given sufficient autonomy to operate the newly acquired roles with significant freedom. More focus needs to be given in the development of new training curriculum and stakeholder involvement that will see into that the policy is actually implemented.
Secondly, there is need for physicians to continue playing their normally assigned roles, which includes prescribing drugs in appropriate instances. They also need to recognize that advanced practice nurses have undergone similar training initiatives; hence, they are capable of prescribing drugs under appropriate circumstances, and this does not need to be supervised as it hampers its functional aspects.
Finally, the implementation of the policy needs to be done in a fashionable manner that allows smooth transition between the old framework and the new framework. The top-down approach should be used to facilitate this in order to avoid any chances of missing links occurring in the long run. Once every role is properly understood, tested for a significant time period of time, and having undergone assessment at the end, the new policy framework should be approved by relevant authorities/fraternities/stakeholders in the healthcare industry. According to Verklan (2008), “In addition, advances in science and knowledge make it very difficult for one professional specialty to be the sole expert with respect to patient treatment. Thus, there is more overlap between the APN and the physician so that skills are more appropriately used to provide optimal care to meet the needs of the patient.” (Verklan, 2008).