Are advanced practice nurses, particularly nurse practitioners, the remedy for an ailing U.S. healthcare system? As a specialty, we have shown our abilities to appropriately diagnose, treat, and care for patients with a wide range of medical needs. Laurant et al. (2005) cite similar health outcomes for patients regardless of whether care is provided by a primary care physician or nurse practitioner, noting patient satisfaction was higher with nurse led care. In the dermatology setting, Schuttelaar, Vermelulen, Drukker, and Coenraads (2010) report similar findings in a 1-year randomized parallel group study of children diagnosed with eczema when cared for by either nurse practitioners or physicians in a dermatology clinic. It is reasonable that nurse practitioners, as effective and capable providers, would be in demand and well matched with those seeking care. The recent article in the New England Journal of Medicine, "Broadening the Scope of Nursing Practice," by Fairman, Rowe, Hassmiller, and Shalala (2011), encourages a call to action for nurse practitioners, physicians, and other stakeholders involved in reforming the U.S. healthcare system to address restrictions of nurse practitioner practice acts. They present the challenges and opportunities of ready and willing first-line healthcare providers in a frustrating landscape that sometimes blocks access and limits availability of care, made especially frustrating, considering the expanding population of insured Americans. Fairman et al. state, "the critical factors limiting nurse practitioners' capacity to practice to the full extent of their education, training, and competence are state-based regulatory barriers."
THE NEED FOR MORE HEALTHCARE PROVIDERS AND THE SHORTAGE OF PHYSICIANS
There is a need for more healthcare providers, especially given the mandate of the Affordable Care Act. Currently, there are not enough primary care physicians, and there is a shortage of those entering the field to support the expanding need. Studies have shown the safety and effectiveness of primary care, preventive services, and chronic disease care delivered by nurse practitioners. The American Academy of Nurse Practitioners reports that there are more than 135,000 nurse practitioners currently practicing in the United States, with most practicing in primary care or chronic disease care settings.
THE BARRIERS TO NURSE PRACTITIONER PRACTICE
Regulations for nurse practitioner practice vary from state to state. According to presentations at the National Council of State Boards of Nursing Advanced Practice Nurses Summit on January 12, 2011 in San Diego, California, there are 51 scopes of practice for nurse practitioners (50 states and American Samoa), with some being very restrictive whereas others are very broad. According to Fairman et al. (2011), "There are no data to suggest that nurse practitioners in states that impose greater restrictions on their practice provide safer and better care than those in less restrictive states or that the role of physicians in less restrictive states has changed or deteriorated."
Some stakeholders have varying opinions on nurse practitioner practice, particularly physician organizations, which tend to be cautious and want to limit the extent of the nurse practitioner scope of practice, "Despite the robust rationale for broadening nurse practitioners' scope of practice, key medical organizations oppose the idea" (Fairman et al., 2011). Third-party payors vary in their recognition of services provided by nurse practitioners, and some payors limit payments directly to nurse practitioners unless working for a physician or facility. Fairman et al. (2011) state, "Legal considerations also seem to favor such a trend [toward increased scope of nursing practice]. The Federal Trade Commission recently evaluated proposed laws in three states and found several whose stringent requirements for physician supervision of nurses might be considered anticompetitive."
REDUCING BARRIERS TO NURSE PRACTITIONER PRACTICE
The Institute of Medicine (2010) report on the future of nursing also advocates for removing barriers to nurse practitioner practice. Many are following this suggestion. Most states are slowly reducing barriers, particularly in the central United States and sparsely populated areas with limited access to healthcare. However, most state legislatures support physician organizations and are not supportive of nurse practitioner practice changes, despite common sense, financial savings, and evidence to the contrary. Public and peer education about our profession is one way to reduce barriers to nurse practitioner practice. Nursing is aggressively seeking to expand educational preparation of all current and future nurses by promoting RN to BSN education, as well as eliminating master's degree nurse practitioner programs in favor of doctoral programs, to expand and grow the profession's readiness and ability to contribute and to positively impact patient care.
A reasonable approach would be to require national certification as nurse practitioners for the primary care areas of study and then require a specialty certification for those working outside of primary care to help in establishing our core knowledge, qualifications, value in receiving fair third-party payment, and, with additional specialty certification, confirm a specialty-specific competencies. Some have noted the potential impact of increased financial competition between physicians and nurse practitioners should nurse practitioners gain independent practice privileges. This writer questions whether all physicians would maintain interest in oversight of nurse practitioner practice and the responsibility that implies, if financial compensation for that supervisory role becomes limited. Fairman et al. (2011) state, "As health care reform advances, implementation of payment reforms-including global or bundled team-based payments and medical home based payments-may ease professional tensions and fears of substitution while enhancing support for an increased scope of nursing practice."
SPECIALTY NURSE PRACTITIONER PRACTICE
Nurse practitioners in specialty practice, such as dermatology, may or may not be impacted by expanded practice. The government needs additional primary care providers, and nurse practitioner and nursing organizations are supporting initiatives to fill those gaps but are not supporting specialty organizations as aggressively. Therefore, the estimated 1,100 nurse practitioners in dermatology must work together as a specialty and, with the strategic support of the Nurse Practitioner Society of the Dermatology Nurses' Association (DNA), participate actively in discussions that will allow each of us, regardless of where we practice, to maximally utilize our knowledge base and skills for every patient we encounter.
We must work to develop the specialty of dermatology nurse practitioners by expanding our knowledge and creating formal programs to educate future dermatology nurse practitioner colleagues. Physicians, whether in primary or specialty care, should not be seen as the enemy. They are essential, valued, intelligent professionals. They are often our mentors, partners, and friends, who contribute greatly to the science of our profession. Many, if not most, individual physicians support nurse practitioner practice, even if their collective organizations do not, and we should do our best to earn their respect and demonstrate our role as educated, competent, accountable, and unique members of the healthcare team.
CALL TO ACTION
Discussion regarding the long-standing practice of varied and limited scopes of practice for nurse practitioner-delivered care has been on the back burner for decades, and this issue needs to be addressed now. It is wonderful to see the discussion come to the forefront, particularly by those outside the nurse practitioner field. However, this is our battle, and one that we must sort out among ourselves and not allow others to control our professional destiny. Nurse practitioners must, therefore, move forward in working with our state legislators and third-party payor groups to demand change to our state practice acts, reimbursement practices, and healthcare team relationships using a common sense approach, not just for the good of our profession but for the good of the public. We must collaborate with physicians such as Jeff Sussman, MD, whose opinion was indicated by the title of his recent editorial in the Journal of Family Practice: "It's time to collaborate-not compete-with nurse practitioners" (Sussman, 2010). For if we do not move now, while nurse practitioners have the momentum to resolve restrictive barriers to practice, society will miss this opportunity to fully access the skills of more than 135,000 well-educated, certified, and qualified nurse practitioners and other advanced practice nurses as competent healthcare providers.
As specialty care providers, dermatology nurse practitioners, like other specialty nurse practitioners, need a strong working relationship with residency- or fellowship-trained specialist physician and scientist colleagues. Therefore, we should respectfully work with these colleagues and other members at all levels within the healthcare team to maximize our future working and collaborating relationships as we move forward individually and as a specialty. In addition, the Nurse Practitioner Society of the DNA is tasked with representing DNA's nurse practitioner members as we promote collaboration with the American Academy of Dermatology and other dermatology and healthcare provider organizations and governmental agencies in seeking solutions that are in the best interest of the public relating to nurse practitioner practice.
REFERENCES