Running head: NEED FOR AUTHORITY AND AUTONOMY FOR NURSES

The Need for an Increased Level of Authority and Autonomy

for Advanced Practice Nurses

Alexander Warren, R.N.

Scholarly Report
Dr. Zelda Peters D.N.P
Albany State University
10/08/2014

NEED FOR AUTHORITY AND AUTONOMY FOR NURSES

The Need for an Increased Level of Authority and Autonomy for Advanced Practice Nurses
Nurse practitioners are an integral part of health care here in the United States and have
been for decades. It is hard to understand not only the discrepancies in their ability to practice
across state lines but also their limitations as health care providers. What could be the benefits of
the barriers to practice? The role of Advanced Practice Nurses (APNs) is confused by these
restrictions and can cause communication difficulties between APNs and other providers and
APNs. Ultimately this can be detrimental to the patient and hinder his or her ability to receive
quality health care. If APNs cannot gain full autonomy a set standard regarding their ability to
provide care nationwide is needed.
When discussing the autonomy of APNs, patients become concerned about the level of
care they are provided when they are treated by non-physicians. This is a valid concern, and
several studies have attempted to determine if non-physicians provide comparable quality of care
relative to doctors. One such study attempted to determine not only how the overall care of nonphysicians compared to that of physicians but how their care concerning a particular disease
process compared. In blood pressure control, length of hospital stay, mortality, duration of
ventilation, hospitalization/rehospitalization rates, and care provided in the emergency
department, non-physicians provided comparable care and comparable outcomes (Newhouse et
al., 2011). In the same study, lipid control was better achieved under the care of non-physicians
than physicians (Newhouse et al., 2011). The need for lawmakers to understand the capability of
APNs to provide care is paramount. With the growing population, the need for expanded
provider roles for APNs is crucial.
The elderly population is growing and is in need health care providers. With the baby
boomers achieving retirement age, the need for healthcare, especially providers, will be at a

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premium. By 2030, 20% of the population in the United States will be aged 65 years or older.
That is a staggering 72.1 million people who will be in need of health care (McGill, 2013). How
can we possibly provide care to another 72.1 million patients using our current health care
system? Mid-level providers must be granted increased autonomy and authority to help control
the flood of new patients.
Mid-level providers were instituted to fill the gap in health care. We already know that
there are more senior citizens than can be adequately provided for by the current ranks of family
practice physicians. This does not include the specialties that also need covering by medical
doctors. Nurse practitioners and physicians assistants, the mid-levels, are the family practice
providers of the future. This is especially true in more rural areas where hospitals and large
practices already have a difficult time recruiting and retaining physicians. The Federal Office of
Rural Health Policy states that 77% of rural counties are facing a physician shortage and 8% do
not have any primary care providers at all (Kutscher, 2013). The number of primary care
providers in rural areas will only continue to decline. APNs will have to be the providers to fill
that gap. We cannot have a larger deficit than we currently have, with current patients having to
drive long distances to see a provider.
The cost of health care is climbing, and patients are having a difficult time affording their
copays, not to mention subsequent bills and medications. The majority of Medicare patients
struggle to pay their bills since most live on a fixed income. Working in home health, I have
come across several patients that had to choose between buying groceries and buying their
medications. Even on Medicare, these patients have a responsibility to pay for a portion of their
health care, and the combination of a few comorbidities raises the amount they will have to pay.
We, as a country, have to make changes to help decrease the cost of providing health care, not

NEED FOR AUTHORITY AND AUTONOMY FOR NURSES

only to Medicare patients but to everyone. APNs can help regulate the high costs of health care.
Currently, APNs are being reimbursed at a rate of 85% of what a physician would be paid
(American Association of Nurse Practitioners, 2013). This 15% reduction in cost may seem
small, but if half of the primary care visits in the nation were performed by APNs, this would
represent a substantial cost savings. There is one reported instance where a single nurse
practitioner ran a worksite clinic. This resulted in direct medical savings of $2.18 million dollars
over the course of two years (Iowa Nurses Association, 2012). The total of $2.18 million dollars
did not include the savings the company made by not having to pay for lost productivity or
absences. This shows the flexibility provided when nurse practitioners practice under their own
license. APNs have the potential to work independently for corporations, run on-site clinics, do
yearly physicals, and potentially save companies millions of dollars. It is also shown that nurse
practitioners are more thoughtful when it comes to the price of medications they are prescribing.
Nurse practitioners prescribe more generic medications in lieu of the more costly brand name
medications, resulting in saved medical costs for the patient (Iowa Nurses Association, 2012).
The burden of health care costs is far-reaching. Granting full autonomy in practice to nurse
practitioners is one possible method of decreasing those costs.
Across the country, the level of practice that APNs can provide varies dramatically.
Every state has different laws concerning the practice of APNs and what is required of them to
practice under physicians. This creates confusion between the APN and his or her physician.
Not only do laws that affect ones ability to practice vary from state to state but ones title also
changes. Some states do not designate a difference between titles such as Psychiatric Nurse
Practitioner and Psychiatric Clinical Nurse Specialist. In some states, both of these titles get
lumped into the all-encompassing and confusing title of Advanced Practice Nurse. This can

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happen with any nurse specialist and obscures the nurses abilities and scope of practice. How
can we expect physicians to understand the subtleties of our abilities to practice if the states
cannot decide on a standard form of title? The need for national standards in scope of practice
and title designation is important for the advancement of all APNs.
Advanced Practice Nurses are trying to change this situation. Currently, they are
proposing the Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation.
This model attempts to set standards for titles and defines a set of guidelines that must be met
prior to the nurse functioning as an Advanced Practice Nurse. The model also sets standards on
accreditation, education, and certification. In doing so, it attempts to create a uniform model for
APRNs throughout the United States. It is essential that nurses themselves endorse a uniform set
of standards for practice. If we cannot agree on what our abilities and titles should be, how can
we expect the government to make laws regulating set standards?
Job satisfaction is something everyone strives for, and APRNs are no different. With
restrictions placed on their scopes of practice and feelings of constantly being monitored by
physicians, their job effectiveness diminishes. All practitioners feel they have the education and
ability to diagnose and prescribe; APRNs are specifically trained to do so. Yet with all the
education, APNs are still limited in their abilities. This limitation causes a decrease in job
satisfaction. An APN at a nurse managed health center (NMHC) has an increased level of
autonomy in comparison to an APN who works at a physician's office. One study revealed that
98% of APNs who work in a NMHC would recommend this type of work to new APNs (Pron,
2013). Their perceived autonomy was also high. Even in states that disallowed full prescriptive
authority, the APNs who worked in NMHCs felt as if their autonomy was greater. The feeling of

NEED FOR AUTHORITY AND AUTONOMY FOR NURSES

being able to practice at your full potential is an important goal of many APNs and leads to much
higher job satisfaction.
With more than 47 million people in the United States without health insurance, we are
seeing more convenient care clinics (CCC) providing care for non-chronic health issues (Evans,
2010). Patients need care for their acute illnesses like sore throats, upper respiratory tract
infections, rashes, and fevers. These patients do not have medical insurance, so these CCCs fill a
gap of care. There are now over 1000 CCCs nationwide, and they are expanding quickly (Evans,
2010). Advanced Practice Nurses are the primary care providers in these clinics, and they are
providing an invaluable resource. These patients without health insurance need no less health
care than patients who are covered. APN led care clinics are the primary care provider system of
the future, and the need for increased autonomy/authority is integral for appropriate delivery of
this care.
With the increasing need for primary care providers, the advanced practice nurse is
becoming ever more important in our health care system. Current laws vary significantly across
states regarding the APNs ability to practice and prescribe medications autonomously. This
discrepancy from state to state causes confusion with physicians and patients which inhibits the
APNs ability to provide care. The cost of healthcare is ballooning, and the number of people
without insurance in the United States continues to grow. Mid-levels, like APNs, are the future
of providing family practice medicine, and nurse led CCCs are helping to provide care to
underprivileged and uninsured patients. We need increased autonomy for APNs and a standard
level of practice nationwide to help provide quality care to the masses.

NEED FOR AUTHORITY AND AUTONOMY FOR NURSES

References
American Association of Nurse Practitioners. (2013). Fact sheet: Medicare reimbursement.
Retrieved from http://www.aanp.org/practice/reimbursement/68-articles/325-medicarereimbursement
Evans, S. W. (2010). Convenient care clinics: Making a positive change in health care. Journal
of the American Academy Of Nurse Practitioners, 22, 23-26. doi:10.1111/j.17457599.2009.00466.x
Iowa Nurses Association. (2012, December). The cost effectiveness of nurse practitioner care.
Iowa Nurse Reporter, 25(3), 10-12.
Kutscher, B. (2013). The rural route. Hospitals in underserved areas taking different roads to
recruit, retain physicians. Modern Healthcare, 43(18), 30-31.
McGill, N. (2013). As senior population grows, aging in place gains popularity: Communities
conducting outreach. The Nation's Health, 43(8), 1-16. Retrieved from
http://thenationshealth.aphapublications.org/content/43/8/1.2.full
Newhouse, R. P., Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., & ...
Weiner, J. P. (2011). Advanced practice nurse outcomes 1990-2008: A systematic
review. Nursing Economic$, 29(5), 1-22.
Pron, A. L. (2013). Job satisfaction and perceived autonomy for nurse practitioners working in
nurse-managed health centers. Journal of The American Association Of Nurse
Practitioners, 25(4), 213-221. doi:10.1111/j.1745-7599.2012.00776.x