Tuesday October 22nd 2019

Words matter

Lisa Summers

The goal of effective dialogue, collaboration and interprofessional understanding when discussing APRN practice is sometimes hampered by politically and emotionally charged language. Given the widespread use of terms like independent, collaboration, supervision and accountability, it is helpful to think about how they might be interpreted.  The American Nurses Association offers guidance to enhance these conversations, highlighted below.

Independent: Perhaps most prone to misinterpretation, independent practice refers to the ability and responsibility of a provider to utilize the knowledge, skills, judgment and authority to practice to the full extent of their education and licensure. The Joint Commission uses the word in defining licensed independent practitioners, and the Consensus Model for APRN Regulation uses it in the definition of an APRN.

Unfortunately, independent is too often interpreted to mean “in a vacuum” or “alone.”  All health care practitioners – physicians, nurses, physical therapists, pharmacists and others  –  must understand the limits of their scope of practice and know when and how to refer or collaborate to provide truly team-based, patient-centered care.

Also, independent practice is not defined by the place of employment, the business model of the practice or the method of reimbursement.

Collaboration: ANA and its partners are working to limit legislative and regulatory requirements for collaboration. However, APRNs are not opposed to collaboration!  Like our physician colleagues, we collaborate and consult with many other health care providers, often on a daily basis.

Collaboration becomes a barrier to APRN practice when laws, regulations or institutional guidelines spell out requirements for written collaborative agreements.  Such agreements typically come about as a result of compromise in the legislative arena, are rarely rational in day-to-day practice, and are contrary to our efforts to building interprofessional teams.  As well, payment for collaborative agreements (versus payment for consultation and care to a patient who has been referred) raises ethical and legal questions.

Supervision: The notion that physicians should supervise APRNs is outdated. Requirements for physician supervision create an unnecessary barrier to access to care, particularly in rural and underserved areas, and lead to fragmented care and duplication of services, needlessly driving up health care costs.

Requirements for physician supervision are at odds with our attempts to build interprofessional teams.  As Barbara Safriet, JD, LLM, FAANP(H), wrote 15 years ago, “By perpetuating a ‘mine, and therefore not yours’ practice culture, current laws erect, rather than remove barriers to interprofessional collaboration, practice and respect.”

Accountability: It is inappropriate to expect physicians, or any provider, to accept responsibility for care they have not delivered. Physicians are not responsible for supervising care delivered by RNs, APRNs or any other licensed health care professional.

APRNs are personally accountable for their practice, to patients, their respective licensing board, the nursing profession and society. When a pediatric nurse practitioner manages a well-child visit, a nurse-midwife attends a birth, a clinical nurse specialist meets behavioral health or other specialized needs, or a nurse anesthetist administers sedation, those APRNs are legally responsible for the scope and quality of care they provide, using their professional judgment to assess and treat patients within the bounds of their legally authorized scope of practice.

As we work together to create a health care system where providers practice to the full extent of their education and training, let’s remember, “Words matter.”

— Lisa Summers is the senior policy fellow in Health Policy at ANA.

ANA resources

ANA’s toolkit for supporting state-based legislative efforts: “Principles for APRN Full Practice Authority” and “Words Matter:  A Guide to Discussing APRN Practice.” – www.nursingworld.org/AdvocacyResourcesTools

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