Primary care is in short supply across the US, and nurse practitioners are increasingly stepping in to provide this much needed care. Studies show that NPs provide high-quality primary care, which improves access to care in underserved areas and reduces costs of care.
University of Pennsylvania researchers have called for modernization of the way Medicare pays for training nurses. A recent study highlighted a successful new model of cost-effectively training more advanced practice nurses to practice community-based primary care.
The findings come from a five-state demonstration of an innovative model of graduate nurse education (GNE) authorized by the Affordable Care Act. Each GNE site, managed by one teaching hospital hub, combined the training capacity of entire communities across health systems, hospitals, private medical practices, clinics, long-term care facilities, and universities.
The University of Pennsylvania School of Nursing’sCenter for Health Outcomes and Policy Research (CHOPR) and the Hospital of the University of Pennsylvania (HUP) led the largest demonstration site, which included nine universities, multiple health systems, and more than 600 community health care providers in the region.
Penn Nursing is calling for Medicare to adopt and fund the nurse training model nationally, shifting Medicare funding from diploma nursing programs that produce entry-level RNs to permanent, national funding of training for advanced practice registered nurses (APRNs).
To learn more about Penn Nursing’s call to action for Medicare to adopt a national nurse training model to help alleviate the national shortage of primary care providers, visit here.
I am privileged. I have been to the other side and experienced that the grass is greener. The majority of my career as a Neonatal Nurse Practitioner (NNP) has been in a Level 3 NICU with all the bells and whistles of high acuity, ECMO, high-risk deliveries, transport, and high patient volume. However, I then gained the privilege to also work as a NNP in a Level 2 Special Care Nursery (SCN). What a difference! But also, how similar!
The job tasks are identical … morning signout, collection of data from the medical record, physical exams, and writing notes. I touch base with the bedside nurse, case management, social worker as needed, and any ancillary staff. Consults are typically by phone. Sporadically, we may physically see an ophthalmologist, ENT, or cardiologist; but these occasions are not usual and customary. In addition, I can stand in one spot with full visual assess to all patients; as long as the census does not exceed 7 in the ‘main unit.’ The unit has evolved from a one room unit with one light switch, where either all lights were on, dimmed, or off equally. The SCN now is a state of the art unit of 7 individualized spaces to offer developmentally appropriate care, more patient privacy, and family-centered care. It is phenomenal!
Now, one may be thinking what a piece of cake. Well before we slice the cake, the grass really is not always greener. You see, regardless of the nursery level, the families are all experiencing a crisis. Acuity and level of nursery does not matter! The hopes, dreams, and vision these families had for their pregnancy, birth, and hospital experience are all shattered in the blink of an eye. The level of medical acuity has no direct correlation to the level of crisis for families. Due to lower medical acuity and lower patient volume, I am afforded the privilege of being able to take more time with families. I have the pleasure of sitting next to them, listening with my ears and eyes, to be in the moment with them. I can truly experience what the crisis or fears are. I feel a great sense of connection with the families. Regardless of the nursery level, these families become our family during their infant’s hospitalization. The communication, both active and passive, are vital for these families to emotionally survive this experience.
I have never experienced cross-trained nurses prior to working in a Level 2. This certainly is another privilege! This has positively enhanced my perceptions of the significance of the staff nurse presence in the delivery room, nursery, and postpartum area. In a Level 2, there is a staff of one NNP per 24-hour shift with attending back-up. The attending does rounds and meets with us daily, is present for all high-risk deliveries, and is always just a phone call away. This was a change coming to a Level 2. I realized how much I depend on my colleagues by just randomly shouting out to a fellow practitioner … ”What do you think?” Here, there is no one to just ‘bounce’ something off. However, it does afford me the opportunity to strengthen my knowledge by needing to know the answer ‘why’ and utilizing resources to confirm, learn, or discover answers. Because of the lack of colleague presence, the cross-trained nurses are a life-saver. They have a different level of competency, assessment, and confidence. It was awkward at first coming from a staff of 20 nurses per shift to having only 1 or 2 nurses. It truly reinforces the impact of communication and establishing rapport with others. Since there are fewer nurses, you work with people more infrequently, so communication, planning, and evaluating are essential—especially when those emergent situations do occur.
I still have the privilege of experiencing transport in a Level 2. The exception is that instead of going to receive the infant, I am sending them out. What an eye opener! This is where experience, confidence, and collaboration are vital. I remember my first meconium that clinically decompensated and overhearing, ‘I can’t remember a baby being this sick here.’ What a powerful lesson! This has afforded me another privilege of truly understanding the significant impact on providers and staff in managing these infants in an environment where resources may be more limited or staff may not be routinely used to managing these infants. I feel I have gained a level of inner strength, confidence, and resilience in handling distress in the clinical setting. It also reinforces the magic of nursing. Just like a Level 3, in a Level 2 the level of teamwork is there with everyone pulling together to do what is needed. Though a sick patient who requires transport is not usual and customary, the nurses are able to stabilize and do what is needed to optimize patient outcome. As a NNP, it is a humbling experience. Typically, as I stated previously, on transport I would pick up these infants to ‘give them what they needed.’ Recognizing you can’t fix this and need help is a character builder and essential professional trait.
In summary, I am privileged to experience the green grass on both sides of my world. I am so appreciative for my Level 2 experience because I am more proficient in looking outside of the box. I am not only a better practitioner, but a better listener, communicator, and mentor as well. I certainly have gained more than I can ever give back. And with that …I will go slice that piece of cake!
In honor of National Nurses Week (May 6-12, 2018), our Nurses of the Week are Ana Verzone and Jackie Baer, two nurse practitioners who have dedicated their careers to caring for the neglected and underserved populations in America’s rural regions.
According to The National Rural Health Association (NRHA), the US is facing a major rural health care crisis, with nearly one third of the country’s rural hospitals having closed or at serious risk of closure. This leaves rural populations at risk, often putting the lives of the poor, elderly, and chronically ill in jeopardy.
Both Verzone and Baer credit Jonas Philanthropies – an organization devoted to improving our nation’s healthcare through advancing the nursing profession – for the work they do today. As graduates of the Jonas Scholar program, they were awarded scholarships to achieve their Doctor of Nursing Practice (DNP) degrees. Over 1,000 nurses across all 50 states have received funding support from the Jonas Scholar program to further their doctoral education.
To shed light on the current rural health care crisis, we interviewed Verzone and Baer on their thoughts on the issue, and how they are both personally working to provide care to those most in need.
Q+A with Ana Verzone, FNP, CNM, and Jonas Scholar
Ana Verzone is a nursing educator and practitioner who has brought care to the most remote communities across the globe, from Alaskan villages to Nepal, where she conducted her doctoral research on improving communication between rural clinics and emergency rooms. Verzone now teaches future generations of nurses at Frontier Nursing University and the University of Alaska, helping to address the nationwide shortage of nursing faculty and rural primary care providers.
- Tell us about your background in nursing.
I love to travel, and before I became a nurse, I was a professional mountaineering guide in Nepal, amongst other places. While passing through a rural village I met two nurse practitioners conducting research on the impact of high altitude on health – they were incredibly inspiring. Knowing I wanted to serve others, I decided to follow their paths and become a nurse. I earned a Master’s in Nursing from the University of California, San Francisco and then worked at San Francisco General Hospital in the emergency department.
I knew continuing my education would empower me to help underserved communities, as well as eventually teach. Thanks to Jonas Philanthropies, an organization that supports doctoral nursing students through its Jonas Scholar program, I was able to pursue my doctorate as a way to give back to the profession I became so passionate about, and to address the shortage of nursing faculty in America. With support from this scholarship, I was able to improve care in remote regions of Nepal, continue my work in remote Alaskan villages, and teach the next generation of future nurses.
Today I work as adjunct faculty at Frontier Nursing University, where I received my Doctor of Nursing Practice (DNP) degree. I have also taught in the University of Alaska’s nursing program.
- How did you develop a passion for rural health care?
My mother was a first-generation immigrant, and my father was second-generation. I grew up in a poor environment that exposed me to the great need in underserved communities and inspired me to find ways that I could help improve nursing care in these areas with a sustainable impact. I have worked in private settings, but my heart was always in providing primary care to the less fortunate, because otherwise these communities would have no other options. Rural areas remain the most at risk; they continue to be neglected and there’s still much work to be done.
- How are you personally working to combat the rural health care crisis?
I am currently a member of the National Quality Forum’s (NQF) Measure Applications Partnership (MAP) Rural Healthcare Workgroup. This is a multi-stakeholder group that aims to identify appropriate quality measures and measurement gaps relevant to vulnerable individuals in rural areas, and provide recommendations regarding the alignment and coordination efforts of measurement in the rural population. This Workgroup will ensure the perspectives of rural residents and providers—those who are most affected and most knowledgeable about rural measurement challenges and solutions—have adequate representation on MAP.This group will provide recommendations to the federal government for Medicare/CMS’s measurement standards.
Of note: NQF is the only consensus-based healthcare organization in the nation as defined by the Office of Management and Budget. This status allows the federal government to rely on NQF-defined measures or healthcare practices as the best, evidence-based approaches to improving care. The federal government, states, and private sector organizations use NQF’s endorsed measures, which must meet rigorous criteria, to evaluate performance and share information with patients and their families.
My doctoral project focused on improving emergency transports from rural outreach clinics to large referral hospitals in Nepal and was very successful. The protocols I initiated during my project are continuing even though my project itself is complete. I remain committed to rural Alaskans, and continue to serve this population. I also make sure to volunteer in rural areas internationally, so I can keep my finger on the pulse of these issues on a global level. I travel with my family when I do this, since it’s important to me that my daughter also grows up exposed to these issues. My husband is a physician assistant, so he can also actively participate in these trips on the healthcare side as well.
I also hope to improve the quality of healthcare delivered in rural areas by committing to train the next generation of advanced-practice nurses to excel in rural settings. This is important to me especially as a Jonas Scholar, as Jonas Philanthropies empowers nurses to take leadership and faculty roles, to ultimately advance the nursing profession and improve care for our nation’s most vulnerable citizens. Frontier Nursing University, where I currently work, is committed to training advanced-practice nurses that want to serve rural populations, and my work at the University of Alaska supported training students in the specific needs of rural Alaskan regions. Rural areas often require a practitioner to have a wider breadth of skills (primary care practitioners in particular) and have fewer resources available. There are challenges such as geographic isolation or small practice size, limited time, staff, and infrastructure for internal quality improvement efforts. Advanced-practice nurses are a critical part of the solution for these issues.
Q+A with Jackie Baer, APRN, DNP, FNP-BC, and Jonas Scholar
Jackie Baer is a nurse practitioner who runs a free clinic in rural South Carolina, serving 3,000 uninsured patients per year. After witnessing the similarities in healthcare conditions for the poor in rural South Carolina compared to mission camps she served in Venezuela, Baer decided to leave her work in the privatized healthcare sector to serve the rural communities who need it most.
- Tell us about your background in nursing.
I began my nursing career in 1993, and after earning my Nurse Practitioner degree in 1998, I was still called to continue my higher education in nursing. With help from Jonas Philanthropies’ Jonas Scholar program, an organization that seeks to advance the nursing profession through the higher education of leaders in the field, I earned my Doctorate in Nursing Practice (DNP) degree at the University of South Carolina. The Jonas Scholar program took a big financial burden off my doctorate education, allowing me to grow as a nurse and connect with a network of nurse leaders that I wouldn’t have had otherwise.
Throughout my career, I’ve worked in many different arenas: ER, research nurse, home-health, rehab, and even a city jail. The different settings have helped me develop a passion for primary care and preventative medicine. In 2003 I started the first rural health clinic in Johns Island, South Carolina—a very destitute and underserved community. My clinic provides primary care to many in my community, keeping open late into the evening and providing weekend hours to accommodate the working poor.
- How did you develop a passion for rural health care?
In early 2000 I was a single mother and still relatively early in my nursing career. I took a mission trip to Venezuela and was so inspired by the patients who could maintain health and happiness even with a few resources. When I returned to the US, I stumbled upon Johns Island by accident; I got lost while traveling the Sea Islands of South Carolina and came upon the island and its federally qualified healthcare clinic serving the poor. I stopped by to ask for directions, but as fate would have it, I was inspired by the clinic’s work with the local community and began working there shortly after.When I moved to Johns Island and eventually opened the first rural health clinic in the county, I immediately recognized there were similarities to Venezuelan migrant camps and rural communities in South Carolina. Having spent part of my career working in private care, it was heartbreaking to see a great disconnect between how private patients and patients in poor, rural communities are treated. I believe each patient should be given the same care, which is what drives me to continue my work at my clinic today.
Being a nurse in rural healthcare is so much more than providing care—it’s about being an advocate for my patients. I’m helping people who are in great need, and recognizing not everyone has a roof over their heads. That’s why I chose to be a nurse, not a doctor. It’s not just about writing a prescription or providing an operation, it’s more about listening and providing care. Nurses are taught to care for the heart, mind, and the soul. I try to write few prescriptions and instead focus on life skills versus pills. Looking back, I feel that I have not only impacted my patients but improved the health care of families with early diagnosis and intervention. My doctorate thesis was on weight loss in obese African American women and it continues to be a great success for the community I serve.
- How are you personally working to combat the rural health care crisis?
At my clinic, we see around 3,000 patients a year who would otherwise not have primary care options. I feel a very strong connection to my community and am happy to provide a service to the poor. I am blessed to have a 73-year-old supervising physician at the clinic. But if she leaves or heaven forbid something happens to her, my clinic closes! In fact, one physician wanted to charge me $1,000 per month to supervise me in giving medically assisted treatment to patients. The red-tape and financial burden of these agreements continue to overwhelm me.
Health policy change is critical. In South Carolina, I continue to struggle with “agreements” due to outdated laws. Winston Churchill said, “History has a lot to teach and we are doomed if we fail to learn from it.” The National Council of the State Board of Nursing conducted a study in 2018 and found that states with “full practice” authority—the ability for advanced practice registered nurses (APRNs) to work to the full extent of their education—have better outcomes, save taxpayers money, and provide increased care access to rural communities. As doctors continue to leave our rural communities, the opportunity for APRNs is great, but the obstacles in the scope of practice limit success. As a nurse practitioner in rural South Carolina, I work day-by-day under these “agreements,” but could literally be gone tomorrow. Sadly, the injustice in healthcare continues for those that are poor and underserved.
As a highly trusted profession, nursing needs a mammoth legal presence in the state legislature to make sure laws are simple and clear. With fifty years of conclusive data, nursing will win but only if we have a team of lawyers advocating on our behalf. I believe that if “full practice” has improved outcomes for our Veterans, why not for rural America?
If you want many of the same benefits and responsibilities of doctors without losing the things you love the most about nursing, then you’ll definitely want to consider becoming a pediatric nurse practitioner. These pediatric pros are unlike registered nurses because they have an advanced degree — typically a Master of Science in Nursing (MSN) — and are able to prescribe medication, diagnose illness, and mentor patients and their parents. Because of this, NPs are stepping up as primary care providers in many corners of the globe, providing a solution to the primary care shortage and bringing quality care at a fraction of the cost.
1. Obviously…. The Kids!
According to the American Association of Nurse Practitioners (AANP), only about 5% of NPs specialize in pediatric acute and primary care, while 60% specialize in family practice. That’s a pretty small number when you consider all the great benefits of working with kids. It also means that there’s a demand for NPs who specialize in pediatric care. But the best part about being a pediatric NP is that you get to make a difference in the lives of kids and their families. Oh yeah, and you get to wear fun scrubs!
In a patient satisfaction survey, nurse practitioners outscored physicians, suggesting that patients are happier with care administered by NPs. – Source
2. You’ll Be a Master
If higher education is your goal, then the NP route is for you! Nurse practitioners in any setting, whether they work in women’s health, mental health, or pediatric environments, must obtain an MSN, but pediatric nurse practitioners must also be certified by the Pediatric Nursing Certification Board. So not only will you have an advanced degree, you’ll have a specialized certification that will earn you respect in any health care setting. These credentials also earn you the privilege to prescribe medications, diagnose patients, and perform evaluations that are vital to pediatric care.
Nurse practitioner is ranked as one of the top 20 best-paying jobs for women, with a median yearly wage of $80,000 and a mean yearly wage of over $100,000. – Source
3. Money, Money, Money
Naturally, with a higher level of education and specialization comes a higher pay. According to the AANP, the mean salary for a full-time nurse practitioner in 2017 was $105,546. These competitive wages mean that the return on investment (advanced education) is pretty high compared with other medical professions. Because there is a shortage in primary care in the United States, many hospitals and medical systems will pay for full-time employees to become nurse practitioners.
4. It Keeps You on Your Toes
The average nurse practitioner sees three or more patients an hour, so if you get bored easily, this field is for you. Just make sure you invest in some super-comfortable nursing clogs, because there’s a good chance you’ll be running around almost all day. Pediatric nurse practitioners are constantly seeking additional training and certifications since the field is ever-changing. There are also a wide range of environments where you can work and several different ways to advance in the field, so it never becomes stagnant.
According to U.S. News and World Report’s Best Job Rankings, nurse practitioners ranked number two for top health care jobs in 2017, just behind pharmacists. – Source
5. You Could Be Your Own Boss
As far as nursing careers go, nurse practitioners as a whole arguably have the most autonomy. But how much autonomy you have really depends on which direction you take your career — and there are many! Pediatric nurse practitioners are able to start their own private practices in some states. Currently, 22 states allow full practice authority, meaning NPs are able to practice without the supervision of a physician. The medical community is pushing for more autonomy for nurse practitioners throughout the U.S. to help address care shortages.
6. The Benefits Are Great
In addition to higher wages, nurse practitioners get some great additional benefits compared with registered nurses. If you choose to start your own pediatric practice, work as a school nurse practitioner, or work under a physician in a pediatric doctor’s office, then you’ll be able to take advantage of a regular 9 to 5 schedule. Of course, if you decide to start your own practice, you’ll have to pay out benefits to yourself and your employees.
The total tuition costs required to prepare a primary care nurse practitioner are less than the cost of one year of medical school. – Source
7. There’s a Great Demand
Did we mention the shortage of primary care in the United States? The AANP reports that the demand for pediatric nurse practitioners is constantly rising and that the role could help address a forthcoming physician shortage. The Bureau of Labor Statistics reports that the professional will grow much faster than others, with an expected growth of 19% by 2020. Like any career in the medical realm, nurse practitioners are needed more in some areas than others. California, Texas, New York, Florida, and Pennsylvania have the greatest demand and hire the most nurses.
8. Job Security? Guaranteed
Of course, any profession that has a high demand will likely have a higher job security. That’s definitely the case for pediatric nurse practitioners. The most secure jobs in the current employment market are those that can’t be automated. Nurses as a whole are some of the most robot-proof jobs; As of right now, no robot or automated system would be smart enough, safe enough, or thorough enough to do the work that human caretakers do. So, for now, taking this career route is a totally safe bet.
According to the American Association of Nurse Practitioners (AANP), the number of nurse practitioners (NPs) currently licensed to practice in the United States has reached a record high. The release of new data shows that more 248,000 nurse practitioners are now practicing, compared to an estimated 120,000 in 2007.
Thanks to a rise in the number of nurse practitioners nationwide, patients are seeing the benefits of high quality, comprehensive, patient-centered health care services being provided by NPs. An additional 23,000 new NPs graduated from programs in the 2015-2016 academic year alone, up 15% from the prior year.
AANP President Joyce Knestrick, PhD, APRN, CFNP, FAANP, released the following statement in response to this new data: “This is an important milestone for patients as well as for NPs. Provider shortages, especially in primary care, have become a growing concern, but the growth of the NP profession is addressing that concern head-on. Couple that with news that NPs conducted an estimated 1.02 billion patient visits last year alone, and it’s easy to see why millions of Americans are making NPs their providers of choice.”
In addition to a rise in NPs, an estimated 85% of new graduates have been trained in primary care, with nearly two out of three NPs entering the workforce having graduated from family nurse practitioner programs. The Bureau of Labor Statistics projects that the NP profession will have grown 36% by 2026.
To learn more about the growth of the nurse practitioner profession in the US, visit here.
Many physicians’ offices, hospitals, and urgent care clinics often have nurse practitioners (NPs) working in them. Although it’s usually the patients who aren’t sure what this kind of nurse does, we know that some of our readers may not know as well—at least not all the minutia involved with this kind of job and career path. Considering that more nurses are choosing to become NPs, knowing this information is important—especially in helping you decide if this is where you want to go next.
We interviewed Joyce Knestrick, PhD, APRN, C-FNP, FAANP, a family nurse practitioner and president of the American Association of Nurse Practitioners (AANP), to learn more about what exactly a nurse practitioner is and does. An edited version of our interview follows.
What is a nurse practitioner and what type of work does s/he do? What additional duties and responsibilities are they able to do because of their additional education?
The first thing to know is that NPs provide primary, acute, and specialty health care to patients of all ages and walks of life. We operate in all types of care settings from hospitals to home care, and urgent care clinics to the VA. NPs conducted over a billion patient visits in the last year alone. Many of your readers have probably seen an NP at some point, and we have developed a solid reputation of being close to our patients. The profession’s track record of patient-centered health care and outstanding outcomes have been well established over 50 years of research. NPs assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans—including prescribing medications.
NPs complete a master’s and/or a doctoral degree program, along with having completed advanced clinical training beyond their initial professional RN preparation. If an NP wants to go on to specialize in an area of care, it requires additional education and training.
With over 234,000 NPs across America, each having to undergo rigorous national certification, periodic peer reviews, clinical outcome evaluations, as well as adherence to a code for ethical practices, we’ve quickly become the primary care provider of choice for millions of Americans from rural areas to dense urban ones. About 16% of the profession works in communities of less than 10,000 and over 36% work in communities with a population less than 50,000.
Are there currently any barriers to practicing as a nurse practitioner? If so, what are they?
Yes, there are several barriers to practice for NPs all across the country. Currently, 22 states, plus the District of Columbia, allow NPs to practice to the full extent of their education, training, and licensure. While that may be over 40% of the country, AANP believes every state should enact laws enabling what we call “full practice authority.”
Every state is unique with its own set of public policy and political challenges, but we are committed to removing the barriers between NPs and their patients by drawing on the expertise of NPs who serve at the intersection of health care policy and patient care with the goal of achieving better health and improved access to care, at a lower cost.
We’ve identified several states as priorities this year. Any of you readers who are interested in helping to reduce barriers to practice for NPs should visit AANP.org and look for our state policy guide.
To make it easier for people to understand many of the nuances surrounding the FPA issue, we’ve assigned each state a color (see our map here).
Green states, which we’ve already mentioned, allow NPs to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications and controlled substances—under the exclusive licensure authority of the state board of nursing. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, and National Council of State Boards of Nursing.
Yellow states are called “reduced practice states,” and they reduce the ability of an NP to engage in at least one element of NP practice. State law requires a career-long regulated collaborative agreement with another health provider in order for the NP to provide patient care or limits the setting of one or more elements of NP practice.
Red states are called “restricted practice states,” and they restrict the ability of an NP to engage in at least one element of NP practice. State law requires career-long supervision, delegation, or team-management by another health provider in order for the NP to provide patient care.
There are many reasons why states fail to modernize regulations to enable NPs to practice to the full scope of their education and clinical training, not the least of which is pressure from organized medicine. That’s not to say that there aren’t similarities between yellow and red states’ barriers, but each state requires its own approach, and we actively identify legislation, support state-level NP organizations’ policy initiatives, and develop policy resources that cultivate strong NP leaders and sound health policy in every state.
What states are the best to work in as a nurse practitioner? Why?
Of course, any state colored green on our map will be more favorable to NPs than ones colored yellow or red. As the map demonstrates, western and northeastern states have chosen to enable NPs to practice to the fullest extent of their clinical training and licensure.
Why is it important for NPs to be able to practice fully? What do they bring to the health care table, so to speak, that benefits the health care system as a whole?
As clinicians, NPs blend clinical expertise in diagnosing and treating health conditions with an added emphasis on disease prevention and health management. We bring a comprehensive perspective to health care.