Nurse Practitioner Autonomy in Florida

Abstract

The aim of this paper is to propose the amendment to the Floridian law that restricts nurse practitioner practice so that they can get the full authority to practice in primary care settings autonomously. Having obtained minimum education in nursing, namely a master’s degree, nurse practitioners can provide effective and safe disease prevention, diagnosis, and management services that reach and sometimes surpass that of physicians.

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In the state of Florida, a primary care physician serves 1,537 people – a number that is higher than its equivalent in the US, where one physician serves 1,463 patients. The shortage is likely to worsen in the future due to the increase in the proportion of the aging population and health insurance coverage. To maintain the status quo in Florida, considering the fact that the state already faces the physician shortage, it will require an extra 4,671 primary care physicians by 2030, yet it had only 12,228 professionals in 2010.

Although the state can solve this by utilizing the nurse practitioners, its laws restrict the autonomy of their practice as it is required that the practitioners work only under the supervision of a physician and any violation is punishable. Amending these regulations will increase cost savings and improve the health of the community as well.

Keywords: nurse practitioner, autonomy, state of Florida

Introduction

The health care system is facing a massive shortage of primary care providers at a critical time when these providers are required to improve the state of health of all Americans by all means. Donelan et al. (2013) explain that the United States (US) acknowledges the devastating shortage of primary care physicians that is occurring at a time when the proportion of the aging population is increasing, which indicates that the chronic disease burden is worsening. Furthermore, the implementation of the Affordable Care Act has already increased and will continue increasing American access to healthcare services (Donelan et al., 2013).

This is because millions of people who were initially unable to acquire primary care services due to their inability to pay for them can now benefit from the insurance policies. The combination of increasing demand and shortages of primary care providers makes nurse practitioners gain independent roles in providing quality healthcare services in most parts of the US.

Qualified nurses are crucially important when it comes to supplementing the physician shortage to some extent because they provide similar services to the ones offered by primary care physicians. The practitioners emerged in the 1960s, a period in the history of the country when physician shortage was a huge menace to the healthcare system (Donelan et al., 2013). During this time, Medicaid and Medicare programs were expanding at an alarming rate, increasing access to health care services to a level that the physicians could not curb the excessive demand.

Since then, nurse practitioners have been adopted into the workforce, so out of the 180,233 practitioners in 2011, an estimated 30-35% of them work in the primary care settings (Fairman, Rowe, Hassmiller, & Shalala, 2011). However, some of the states in the country are yet to grant the nurse practitioners full practice authority. Some of the main arguments on whether or not to give them a right to independent practice revolve around the necessary knowledge and experience in order to deliver high-quality services. This paper seeks to argue that nurse practitioners in the state of Florida should be given full autonomy to practice in primary care settings.

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Problem Statement

In the state of Florida and in the US in general, nurses are mainly responsible for driving the healthcare system forward. The nursing accounts for the largest segment of the healthcare workforce constituting more than three million professionals who work to provide patient care, and their large number substantially contributes to the realization of the objectives of the 2010 Affordable Care Act (IOM, 2010). The primary caring role of nurse practitioners has resulted in immense benefits such as improved health outcomes among populations and significant cost reduction. These professionals can provide quality services as they have gained at the very minimum a master's degree in nursing and can further obtain a professional license to practice (IOM, 2010).

The specialized education and training they receive are principally centered in primary care settings, which improves the clinical competency. Naylor and Kurtzman (2010) explain that many of the nurse practitioners work in primary care facilities including the areas of midwifery, gerontology, pediatrics, and adult health. Therefore, these are professionals who have the necessary knowledge and experience to offer care without limitation to their autonomy.

However, the state of Florida and some other states in the country limit their practice by denying them full practice authority, which is something that many states have abolished. The IOM (2010) assert that legislative barriers prevent nurses from effectively responding to ever-changing healthcare settings, which should be overcome to make sure that these professionals lead change and advance health. State legislations are the most threatening issue because they deny that the nurses have an opportunity to practice and realize their full potential.

According to Donelan et al. (2013), research studies have revealed that the nurses provide disease prevention, diagnosis, and management services at safe and effective levels just like the physicians do. Nevertheless, the state of Florida limits these functions, since its laws require that the nurses work only under the supervision of doctors, although they have the capacity to work independently. These legislative restrictions should be abolished to give these practitioners full authority to perform their functions in primary care.

Literature Review

Shortage of Primary Care Providers

The US and its states are experiencing a severe shortage of primary care providers, which is likely to worsen in the future. Bodenheimer & Pham (2010) assert that only 37% of the medical doctors in the country serve the primary care sector, yet this sector takes at least 56% of all the visits directed to the primary care physicians. This case shows how strongly the shortage impacts this sector. In 2008, Americans have made more than 977 million visits to doctors, and 462 million of these visits were in primary care (Petterson et al., 2012).

These figures are so high for the small number of physicians, given that many other people may have failed to secure an appointment with primary care providers, possibly due to their inability to access care or physicians' failure to serve the large population. Ignoring factors for access to the patient health care facilities, the current population of patients in the US requires extra 89,983 primary care physicians to address the shortage (Green, Savin, & Lu, 2013).

In Florida, the lack of them is evident from the high ratio of physicians to the population of Floridians in the primary care sector. The Robert Graham Center (2015) reports that the current ratio of population in Florida to practicing primary care physicians is 1537:1, which is far beyond the national average of 1463:1. This shortage can only be alleviated by granting other professionals like the primary care nurse practitioners and physician assistants opportunities for autonomous practice.

The already existing shortage of primary care physicians is projected to increase due to the American population growth. Vleet and Paradise (2015) restate that the demand for these primary care providers will increase in the coming years. For instance, the Health Resources and Services Administration foresees the shortage of at least 20,400 primary care physicians by 2020 (Petterson et al., 2012). The National Governors Association (2012) insists on similar findings which predict that by 2019 the demand for primary care physicians will increase by 15-25 million visits every year, which will additionally need more than 4,000 to 7,000 medical doctors to meet the ever-increasing demand.

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The state of Florida is also among the most impacted regions of the country considering these shortages. For Florida to sustain the current status quo, it will require an extra 4,671 primary care physicians by the end of 2030, which is a 38% increase from the 12,228 practicing physician in primary care settings in 2010 (Robert Graham Center, 2015). This projected increase in the shortage of primary care providers will adversely affect the healthcare sector and, most importantly, the human population that requires health care services.

The population growth and increase in health insurance coverage are the major reasons for the dramatic increase in the lack of primary care providers in both the state of Florida and the United States as a whole. The American population will rise by more than 15% from 2010 to 2025 with the aging population above 65 years of age increased by 60%, while those younger than 18 years of age will increase by 13% (Petterson et al., 2012). Petterson et al. (2012) further report that with about 209,000 physicians in 2010, the country requires extra 52,000 specialists in primary care by 2025, 8,000 of which will meet the demands of the expanding insurance coverage, 10,000 – of the growing aging population, and 33,000 – of the whole growth of the American population.

Similarly, in Florida, the situation will be critical in the nearest future. The state requires an increase in the number of primary care physicians by 66% to cater for the growing population, 19% to cater for the increasing utilization of care by the aging population, and 14% to curb the effects of increased healthcare coverage by 2030 (Robert Graham Center, 2015). This increase in population growth and utilization of health care services will require extra measures to enlarge the number of primary care service providers, particularly by allowing nurse practitioners to assume their autonomous role when performing their duties.

Floridian Nurse Practitioner in Primary Health Care

Although the visits to physicians and nurse practitioners have little variation, the nurse practitioners have an increased capability of delivering high-quality services with better outcomes than their physician colleagues. In their study, Martinez-Gonzalez et al. (2015) found that 84% of clinical trials had no substantial differences between the care provided by nurses and that of physicians, while the remaining 16% asserted that nurses achieved better patient outcomes. Apart from providing medical care, nurses have the ability to stay with their patients longer than doctors, which is something that increases the level of patient satisfaction and triggers better treatment outcomes.

Nurses also surpass physicians in the provision of primary care, since they deliver care comprised of education and counseling – these are the aspects that positively impact treatment adherence (Van Camp, Van Rompaey, & Elseviers, 2013). Other than offering quality care, the availability of nurse practitioners has been increasing while this factor speaking of physicians has been decreasing. Garment (2013) explains that primary care medicine programs have reduced by 3% from 1995 to 2006 while nurse practitioner programs have grown by a whole 61%. Therefore, the availability of the nurse practitioner and high-quality primary care delivery should be a reason to grant this profession a legal mandate to practice independently.

In Florida, most of the primary care services are provided by nurse professionals. Vleet and Paradise (2015) report that in 2012, more than 127,000 nurse practitioners offered healthcare services and 60,400 of them served in the primary care sector. Just like in other states, over 90% of these professionals are prepared in primary care settings (Vleet & Paradise, 2015). The IOM (2010) recommends that these professionals should serve to the extent of their knowledge and this is only achievable when the state laws allow them autonomous full practice authority. However, the state has not given them this right, because they are currently struggling with restrictive state licensing and regulations.

Many states have given their nurse practitioner the autonomy to practice, but this can only be feasible in Florida if the Floridian Nurse Practice Act is amended. Currently, twenty states in the US have given their nurse practitioners full authority to practice, nineteen have allowed nurses to operate through a collaborative agreement with physicians, but they restrict the practice in at least one domain such as treatment and prescription (Vleet & Paradise, 2015).

However, the state of Florida is among the remaining states that completely prevent these professionals from having independent practice. The law requires that the members of the nursing board of the state provide eligibility criteria to become a certified practitioner (Vleet & Paradise, 2015). It is unfortunate that the Act only allows nurses to take specialized or advanced nursing actions under the supervision of physicians, and in case a nurse practitioner performs activities prohibited by the law, then the punishment is unavoidable.

Proposal for Change

The Floridian Nurse Practice Act that restricts nurse practitioners’ authority to practice, and thus it should be amended. The nurses need autonomy to make decisions and offer high-quality services since it is an essential component of their profession. Kramer and Schmalenberg (2008) discovered that some physicians rated the autonomous decision-making process as the highest indicator of competent performance among nurses. Furthermore, the IOM (2010) emphasizes that if nurses ought to deliver limitless primary care services, they should have the full authority to practice both their education and training to the full extent. Therefore, the importance of gaining autonomy for independent practice is no longer a secret to hide.

Furthermore, amending the law will allow nurse practitioners to become independent primary care providers, which is something that will improve the problem of primary care provider shortage. This issue is much worse in the rural areas of Florida and the country in general compared to the urban regions. In the US, the mean of 100 primary care physicians serve 100,000 locals, but the number of doctors serving the same population in rural areas reduces to 46 (Bodenheimer & Pham, 2010).

In Florida, 30% of the population lives in the countryside where severe shortages of physicians are strongly experienced. However, a nurse practitioner traverses these areas. Giving these nurses full authority to deliver primary care services will be of great benefit to both the urban areas and most importantly, the underserved rural regions. In fact, they provide quality care, and allowing them to practice independently will be a significant step for the society who will enjoy the better services they provide.

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Cost and Benefit Analysis

The services of nurse practitioners are cheaper than those provided by physicians. This can help community members who lack adequate resources to seek primary care services from physicians. Most states that allow these practitioners full authority to practice pay them lower (75-95%) than the physicians for the same service (Vleet & Paradise, 2015). On the one hand, the average costs of a nurse practitioner visit are 20-35% lower than that of the physician visit, which can increase the cumulative cost savings of the state by 0.6–1.3% between 2010-2020 (Naylor & Kurtzman, 2010). This means that substituting physician visits by nurse practitioner visits can result in substantial savings that can help the economy grow.

On the other hand, the benefits of amending the law and giving the practitioners the full authority to practice will improve the health of the communities. The practice of a nurse practitioner in primary care without physician involvement will not only increase the availability of quality care in the society but also reduce unnecessary hospital admissions, which equally improves the economy through cost reduction. Nurse practitioners use structured protocols, so together with non-pharmacological ones the outcomes of their services are better than those of physicians (Martinez-Gonzalez et al., 2015). In addition to this, their contribution to the primary care sector improves the health of the population that serves as a healthy workforce for the state and the nation as a whole, which equally improves the economy.

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Conclusion

The state of Florida should amend the Nurse Practice Act to give the nurse practitioners full authority to provide high-quality primary care autonomously. The state, just like the US, faces severe shortages of primary care providers and due to the growth in the aging population and health insurance coverage, the shortage is likely to worsen in the coming years. The rural areas are the most impacted by the fact that physicians rarely choose to prefer working there while nurses traverse these regions. Introducing some amendments to the law regarding providing the nurses with a right to practice independently will help address the shortage.

Furthermore, this medical staff has proven to offer quality care with better outcomes, sometimes surpassing that of their physician colleagues, which makes the IOM recommend their practice considering their education and training. Additionally, the work of these practitioners is cheaper than the physicians’ services. Using them in primary care settings will increase costs savings and improve the community’s health, which is beneficial to the economy.

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