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Nurs Admin Q Vol. 38, No. 2, pp. 192–194 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Regulatory Issues Column
Views on Scope of Practice Is It Time for a Continuum-Based Population-Driven Model? Kathy Malloch, PhD, MBA, RN, FAAN; Joey Ridenour, RN, MN, FAAN
H
ISTORICALLY, the scope of practice laws have established the legal framework that controls the delivery of health care services and have been legislatively determined and managed by each health care discipline. Medicine, nursing, pharmacy, physical therapy, and many other regulated professions carefully carve out their scopes of practice to meet the perceived needs of society. In light of numerous challenges to the current delivery of health care, calls from national organizations to change how we deliver health care has a direct relationship to the individual roles and scope of practice of the professions. In particular, the Institute of Medicine and Robert Wood Johnson report1 calls for assurance that nursing is practicing to the fullest measure of its defined scope of practice and for the removal of barriers to full practice (Institute of Medicine). The Affordable Care Act2 requires modifications to the
Author Affiliations: KMLS, LLC, Glendale; College of Nursing, Arizona State University, Phoenix; College of Nursing, Ohio State University, Columbus; and API Healthcare, Inc, Hartford, Wisconsin (Dr Malloch), and Arizona State Board of Nursing, Phoenix (Ms Ridenour). The authors declare no conflict of interest. Correspondence: Kathy Malloch, PhD, MBA, RN, FAAN, KMLS LLC, 7116 W Behrend Dr, Glendale, AZ 85308 ([email protected]). DOI: 10.1097/NAQ.0000000000000030
current delivery model of care to one that is continuum-based and integrates patient care services on the basis of unique patient populations. Furthermore, the anticipated shortage of professionals reinforces the need for an innovative or different approach to providing continuum-based, safe, and effective patient care. To be sure, the intersections of health care disciplines have overlapped for many decades and too many are often seen as blurred rather than cleanly delineated. The overlaps in scope of practice among the professions often lead to confusion for both the patient and the health care professionals. Physicians and advanced practice nurses both provide assessment, diagnosis, and interventions in numerous patient care venues. Nurses and nursing assistants often provide the similar services such as activities of daily living. Both registered nurses and licensed practical/vocational nurses administer selected medications. Perhaps the time is now for disciplines to begin to shift from competition for practices and to decrease territorial tendencies to a model that is driven by the needs of patient populations. Physician John Rowe noted recently that it is a “little embarrassing to see the medical guys” who make a big deal of evidence-based medicine, be against the call for nurse practitioners to practice to the full extent of their education and training.3 The evidence continues to support nurse
192 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/NAQ
NAQ-D-13-00082
February 19, 2014
23:28
Views on Scope of Practice practitioners as effective practitioners for basic primary care services. In many practice settings, registered nurses do not regularly practice to their full scope of competencies and education due to traditional practices and physician resistance.4 Registered nurses were found to perform essential functions only 38% of the time.5 The Table presents a sampling of the role delineations of the professions as well as those professionals competent to perform the work. The goal of any revision to current scopes of practice should essentially emphasize the achievement of the following behaviors, recognizing that the work of health care professionals range from higher level knowledge and judgment to less sophisticated, more routine care:
Table. Health Care Role Delineations and Associate Professionals Role performance delineations √ Engagement √ Diagnosis √ Assessment √ Ordering √ Prescribing √ Dispensing √ Facilitating/organizing √ Communication and coordination of care services √ Educating/teaching patients and families/ knowledge updating √ Integration and supervision of staff √ Monitoring √ Evaluating √ Measuring quality outcomes √ Modifying treatments Health care professionals √ Physicians √ Advanced practice nurses √ Physician assistants √ Registered nurse √ Licensed practical nurse √ Pharmacist √ Social worker √ Licensed practical/vocational nurse √ Nursing assistant
193
1. 2. 3. 4.
Decrease use of acute care services Increase community services Increase family engagement Increase throughput management/setting to setting 5. Support team autonomy/transitional care teams 6. Be evidence driven 7. Optimize technology oversight/integration 8. Require interprofessional team work competency 9. Simplify processes at the bedside/ community for patients; least number of caregivers with the highest quality for each patient Consider the following scenarios in which the needs of patient populations are identified first; then the health care workers are assigned on the basis of the congruence of patient needs and health care worker competence. This approach is the reverse of current practice in which providers are available to address patient care needs prior to patient assessment of need. SCENARIO 1: COMPLEX MULTISYSTEM PATIENT Needs: engagement, assessment, ordering, prescribing, dispensing, facilitating, coordinating communication, interventions, activities of daily living (ADL) assistance, integration and supervision of staff. Health care workers: Physician, advance practice nurse, pharmacist, social worker, registered nurse, nursing assistant. SCENARIO 2: CHRONIC DISEASE PATIENT Needs: engagement, assessment, ordering, prescribing, dispensing, facilitating, coordinating, communication, interventions, ADL assistance, integration and supervision of staff, knowledge updating. Health care workers: Advanced practice nurse, pharmacist, social worker, registered nurse, nursing assistant.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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194
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NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2014
SCENARIO 3: SURGICAL PATIENT Needs: engagement, assessment, ordering, prescribing, dispensing, facilitating, coordinating, communication, interventions, ADL assistance, integration and supervision of staff, education. Health care workers: Physician, physician assistant, pharmacist, registered nurse, nursing assistant.
These scenarios are intended to stimulate discussion and serve to challenge our long-held assumptions about how patient care needs are addressed. By no means is this an inclusive list of professional performance delineations or health care workers. It is an early attempt to meet the needs of the emerging expectations in the health care reform model defined by the Affordable Care Act.
REFERENCES 1. Institute of Medicine. The Future of Nursing: Leading Change, Improving Health. Washington, DC: National Academies Press; 2011. 2. Affordable Care Act. http://www.hhs.gov/ healthcare/rights/law/index.html. Accessed January 1, 2014. 3. Domrose C. Healthcare reform brings the focus back to nurses as primary care providers. http://news .nurse.com/apps/pbcs.dll/article?AID=/20130826/
NATIONAL05/108260035&t. Accessed August 29, 2013. 4. D’Amour D, Dubois C, Dery J, Clark S, Tchouaket ER, Rivard M. Measuring actual scope of nursing practice: a new tool for nurse leaders. J Nurs Adm. 2012;42(5):248-255. 5. Nathenson P, Schafer L, Anderson J. Relationship of RN role responsibilities to job satisfaction. Rehabil Nurs J. 2007;32(1):9-14.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
NAQ-D-13-00082
February 19, 2014
23:28
Nurs Admin Q Vol. 38, No. 2, pp. 192–194 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Regulatory Issues Column
Views on Scope of Practice Is It Time for a Continuum-Based Population-Driven Model? Kathy Malloch, PhD, MBA, RN, FAAN; Joey Ridenour, RN, MN, FAAN
H
ISTORICALLY, the scope of practice laws have established the legal framework that controls the delivery of health care services and have been legislatively determined and managed by each health care discipline. Medicine, nursing, pharmacy, physical therapy, and many other regulated professions carefully carve out their scopes of practice to meet the perceived needs of society. In light of numerous challenges to the current delivery of health care, calls from national organizations to change how we deliver health care has a direct relationship to the individual roles and scope of practice of the professions. In particular, the Institute of Medicine and Robert Wood Johnson report1 calls for assurance that nursing is practicing to the fullest measure of its defined scope of practice and for the removal of barriers to full practice (Institute of Medicine). The Affordable Care Act2 requires modifications to the
Author Affiliations: KMLS, LLC, Glendale; College of Nursing, Arizona State University, Phoenix; College of Nursing, Ohio State University, Columbus; and API Healthcare, Inc, Hartford, Wisconsin (Dr Malloch), and Arizona State Board of Nursing, Phoenix (Ms Ridenour). The authors declare no conflict of interest. Correspondence: Kathy Malloch, PhD, MBA, RN, FAAN, KMLS LLC, 7116 W Behrend Dr, Glendale, AZ 85308 ([email protected]). DOI: 10.1097/NAQ.0000000000000030
current delivery model of care to one that is continuum-based and integrates patient care services on the basis of unique patient populations. Furthermore, the anticipated shortage of professionals reinforces the need for an innovative or different approach to providing continuum-based, safe, and effective patient care. To be sure, the intersections of health care disciplines have overlapped for many decades and too many are often seen as blurred rather than cleanly delineated. The overlaps in scope of practice among the professions often lead to confusion for both the patient and the health care professionals. Physicians and advanced practice nurses both provide assessment, diagnosis, and interventions in numerous patient care venues. Nurses and nursing assistants often provide the similar services such as activities of daily living. Both registered nurses and licensed practical/vocational nurses administer selected medications. Perhaps the time is now for disciplines to begin to shift from competition for practices and to decrease territorial tendencies to a model that is driven by the needs of patient populations. Physician John Rowe noted recently that it is a “little embarrassing to see the medical guys” who make a big deal of evidence-based medicine, be against the call for nurse practitioners to practice to the full extent of their education and training.3 The evidence continues to support nurse
192 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/NAQ
NAQ-D-13-00082
February 19, 2014
23:28
Views on Scope of Practice practitioners as effective practitioners for basic primary care services. In many practice settings, registered nurses do not regularly practice to their full scope of competencies and education due to traditional practices and physician resistance.4 Registered nurses were found to perform essential functions only 38% of the time.5 The Table presents a sampling of the role delineations of the professions as well as those professionals competent to perform the work. The goal of any revision to current scopes of practice should essentially emphasize the achievement of the following behaviors, recognizing that the work of health care professionals range from higher level knowledge and judgment to less sophisticated, more routine care:
Table. Health Care Role Delineations and Associate Professionals Role performance delineations √ Engagement √ Diagnosis √ Assessment √ Ordering √ Prescribing √ Dispensing √ Facilitating/organizing √ Communication and coordination of care services √ Educating/teaching patients and families/ knowledge updating √ Integration and supervision of staff √ Monitoring √ Evaluating √ Measuring quality outcomes √ Modifying treatments Health care professionals √ Physicians √ Advanced practice nurses √ Physician assistants √ Registered nurse √ Licensed practical nurse √ Pharmacist √ Social worker √ Licensed practical/vocational nurse √ Nursing assistant
193
1. 2. 3. 4.
Decrease use of acute care services Increase community services Increase family engagement Increase throughput management/setting to setting 5. Support team autonomy/transitional care teams 6. Be evidence driven 7. Optimize technology oversight/integration 8. Require interprofessional team work competency 9. Simplify processes at the bedside/ community for patients; least number of caregivers with the highest quality for each patient Consider the following scenarios in which the needs of patient populations are identified first; then the health care workers are assigned on the basis of the congruence of patient needs and health care worker competence. This approach is the reverse of current practice in which providers are available to address patient care needs prior to patient assessment of need. SCENARIO 1: COMPLEX MULTISYSTEM PATIENT Needs: engagement, assessment, ordering, prescribing, dispensing, facilitating, coordinating communication, interventions, activities of daily living (ADL) assistance, integration and supervision of staff. Health care workers: Physician, advance practice nurse, pharmacist, social worker, registered nurse, nursing assistant. SCENARIO 2: CHRONIC DISEASE PATIENT Needs: engagement, assessment, ordering, prescribing, dispensing, facilitating, coordinating, communication, interventions, ADL assistance, integration and supervision of staff, knowledge updating. Health care workers: Advanced practice nurse, pharmacist, social worker, registered nurse, nursing assistant.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/NAQ
194
NAQ-D-13-00082
February 19, 2014
23:28
NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2014
SCENARIO 3: SURGICAL PATIENT Needs: engagement, assessment, ordering, prescribing, dispensing, facilitating, coordinating, communication, interventions, ADL assistance, integration and supervision of staff, education. Health care workers: Physician, physician assistant, pharmacist, registered nurse, nursing assistant.
These scenarios are intended to stimulate discussion and serve to challenge our long-held assumptions about how patient care needs are addressed. By no means is this an inclusive list of professional performance delineations or health care workers. It is an early attempt to meet the needs of the emerging expectations in the health care reform model defined by the Affordable Care Act.
REFERENCES 1. Institute of Medicine. The Future of Nursing: Leading Change, Improving Health. Washington, DC: National Academies Press; 2011. 2. Affordable Care Act. http://www.hhs.gov/ healthcare/rights/law/index.html. Accessed January 1, 2014. 3. Domrose C. Healthcare reform brings the focus back to nurses as primary care providers. http://news .nurse.com/apps/pbcs.dll/article?AID=/20130826/
NATIONAL05/108260035&t. Accessed August 29, 2013. 4. D’Amour D, Dubois C, Dery J, Clark S, Tchouaket ER, Rivard M. Measuring actual scope of nursing practice: a new tool for nurse leaders. J Nurs Adm. 2012;42(5):248-255. 5. Nathenson P, Schafer L, Anderson J. Relationship of RN role responsibilities to job satisfaction. Rehabil Nurs J. 2007;32(1):9-14.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
