The Advanced Practice Registered Nurse as a Prescriber. Группа авторов
in APRN roles also results from organizational policies that may support or constrain practice. APRNs are responsible for maintaining a high ethical standard in practice, generating knowledge, and appraising and translating evidence to provide quality, comprehensive, patient‐centered care.
Although there has been significant progress in the utilization of APRNs, constraints on consumers’ access to APRNs, legal limitations, and absence of full practice authority in all states continue to limit APRN practice. Constraints on APRNs that limit their practice are most likely due to concerns about professional competition because extensive data exist about APRN quality of care. For decades, studies have demonstrated that APRN care is as or more effective than care delivered by physicians (Brown & Grimes, 1995; Congressional Budget Office, 1979; DesRoches et al., 2017; Dulisse & Cromwell, 2010; Horrocks et al., 2002; Jennings et al., 2015; Landsperger et al., 2016; Laurant et al., 2018; Lenz et al., 2004; Newhouse et al., 2011; Ohman‐Strickland et al., 2008; Prescott & Driscoll, 1980; Safriet, 1992; Simonson et al., 2007; Spitzer et al., 1974; Wright et al., 2011). Many of these studies also validated widespread acceptance of the APRN role and high satisfaction with APRN care.
Increasing demands for APRNs and assessment of their cost‐effectiveness are powerful factors expected to influence the eventual removal of legal barriers remaining in many states. Concurrently, an improved regulatory environment, especially in relationship to prescriptive authority, has helped legitimize and distinguish the APRN role. In states where NPs have full practice authority which includes complete prescriptive authority, the difference between NPs and physician assistants (PAs) is more apparent and often provides an increased incentive to hire NPs. PA practice, which includes prescribing, is always supervised by and is legally linked with a physician. Furthermore, implementation of the Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (see Chapter 4) can assist APRNs to attain full practice authority.
Autonomy is an important professional concept related to full practice authority. The nursing literature on advanced practice confirms it has been difficult to achieve (Ulrich & Soeken, 2005; Weiland, 2008), mainly due to resistance from organized medicine. Even in the presence of team‐based healthcare, some physicians perceive themselves as the apparent leader or supervisor, which reflects a desire to limit and/or control APRN practice for multiple reasons. Physician control of APRN prescribing often has financial benefits for the physician who is paid for “supervision” that is unnecessary given the educational preparation of APRNs in pharmacotherapeutic content. Physician control of nursing practice is inconsistent with true APRN professional autonomy. Autonomy is also a professional and personal sense of the unfettered ability to make decisions in practice when legally granted to a professional through the endorsement of society. “Having genuine NP practice” emerged as the major theme of a qualitative study about NP autonomy that was expressed in four major subthemes: relationships, self‐reliance, self‐empowerment, and defending the NP role (Weiland, 2015). This involved the meaning of the NPs’ practice experience and experience of being an NP. Autonomy extends beyond legal authority. “It is not just in action but in thought that we create our autonomy” (Kaplan & Brown, 2006, p. 37).
DEVELOPMENT OF THE APRN ROLE AND PRESCRIPTIVE AUTHORITY
Prescriptive authority
Prescriptive authority is the legal ability to prescribe drugs and devices, a practice regulated by the states. One aspect of prescriptive authority, controlled substances (CSs), is specifically regulated by the federal government through the Drug Enforcement Administration (DEA) which enforces the Controlled Substances Act of 1970 (Title 21 – Food and Drugs, 1993). Some states have additional regulations and requirements related to prescribing CSs.
Obtaining prescriptive authority for APRNs has presented significant challenges nationwide. Even when prescriptive authority is supported in new legislation, significant roadblocks to implementation often occur, particularly those placed by physicians. In 1971, for example, Idaho became the first state to pass legislation that recognized the NP role and granted prescriptive authority. Although the first Idaho NP entered practice in 1972, opposition from the Board of Medicine resulted in more than one‐dozen drafts of the prescriptive authority rules. The rules were not adopted until 1977, making Idaho the first state to implement prescriptive authority for NPs (personal communication, S. Evans, December 28, 2009). Nearly 30 years later, in 2006, Georgia became the last state to pass a law granting APRNs authority to “order” medications, a variant of prescribing (Phillips, 2007). An example of a current barrier exists in Colorado. After program completion, an APRN must first qualify for provisional prescriptive authority (RXN‐P). Within three years of receiving RXN‐P status, the APRN must complete a 1000 hour mentorship with a physician or APRN with full prescriptive authority (RXN) and develop an articulated plan for safe prescribing to receive full prescriptive authority (Code of Colorado Regulation, 2017).
ADAPTING TO THE APRN’S ROLE AS PRESCRIBER
Transition to the prescribing role
One of the greatest responsibilities for an APRN is that of prescription medication management. Prescribing is not typically a part of the registered nurse (RN) role in most countries including the US, and often requires a major paradigm shift to transition from administering drugs to selecting and prescribing medications. Consequently, the individual APRN’s transition to the prescriber role involves a union between knowledge of pharmacotherapeutics and socialization to the role. APRNs begin gaining knowledge and competencies throughout their graduate education and continue this process through practice. Role socialization to become a prescriber is initiated during APRN education and likewise is part of continuing professional development.
Transition to the prescriber role is part of the larger role transition that the APRN experiences first as a student, then as a novice practitioner, and when scope of practice changes. Schumacher and Meleis (1994) identified five factors that influence role transition. These continue to be relevant for APRNs in today’s practice arena. They are:
1 Personal meaning of the transition
2 Degree of planning for the transition
3 Environmental barriers and supports
4 Level of knowledge and skill
5 Expectations.
Identification of these factors may allow the APRN to prepare ways for a smooth transition, although there are other dimensions of transition that also need to be considered.
Students in APRN programs typically experience a role transition process that involves role confusion and role strain, including tension, frustration, and anxiety (Brykcznski, 2019). Role acquisition extends to the practicing APRN. The first year of practice is an especially challenging one. A study by Brown and Olshansky (1998) identified four stages in the transition to the primary care NP role. These are laying the foundation, launching, meeting the challenge, and broadening the perspective. Table 2.1 describes these stages. The study findings revealed the importance of skillful mentors who serve as a compass to guide the NP and serve as a source of information and support. Access to a mentor can be especially important in respect to adoption of the role of a prescriber, which brings a special set of challenges.
Table 2.1 Nurse practitioners’ experience during the first year of primary care practice
Source: From Brown and Olshansky (1998), reprinted with permission from Wolters Kluwer Health.
| Stage 1: Laying the Foundation |
| Recuperating from school |
| Negotiating the bureaucracy |
|
Looking |