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Nurse Practitioner Role Development

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FNP Role Development
Katy Lehigh
Concordia University Wisconsin

FNP Role Development
For five decades nurse practitioners have been providing safe, effective, quality primary care services to all ages and populations. As a testament to their commitment and excellence nurse practitioners are being chosen as provider of choice by millions of Americans. Becoming a skilled provider is a dynamic process that occurs over time. Effective role development is essential in becoming a dynamic, compassionate, and knowledgeable clinician.
Political Perspective
Not all threats to our nation derive from foreign enemies. Our nation suffers within our own borders due to chronic illnesses, rising medical costs, wasted resources, poor coordination of care, and a lack of nationalized healthcare. “America’s health care system is in crisis: It is a ‘sick care’ system, not a health care system” (Blumenthal, 2012). The current healthcare system is fragmented, mismanaged, and poorly financed. Americans receive healthcare insurance through various means, such as government run programs, like Medicare and Medicaid, privately through their employer, private pay, or the purchase through an open market. Regardless of the many healthcare options the United States has to offer, 14.7% of the population remains uninsured (Shi & Singh, 2015, p. 199). “The existence of multiple payers makes the system cumbersome” and poses a billing and collection nightmare for healthcare providers (Shi & Singh, 2015, p. 9). According to the CDC (2011) our total national health expenditures reached $2.7 trillion. Millions of that estimate are wasted annually on unnecessary tests or treatments. However, healing will hopefully begin with the implementation of President Obama’s Affordable Care Act (ACA).
There are many advertised benefits of the ACA including: improved quality and reduced cost, increased access to health care, new consumer protections, young adult coverage, Medicaid expansion, a focus on primary prevention, and more accountability for insurance companies. These changes significantly impact consumers, employers, and healthcare providers. Consumers benefit from free preventative care, protection from healthcare fraud, increased coverage for children up to age 26, no annual or lifetime limits on healthcare, and no restrictions due to pre-existing conditions. Small businesses, and non-profit organizations, may qualify for tax credits. According to the U.S. Department of Health and Human Services, the Affordable Care Act will reduce insurance company abuse, reduce administrative burdens and increase time spent with patients, improve coordination of care, and improve preventative care services (HHS, n.d.). While the ACA offers many benefits, it’s by no means comprehensive.
After full implementation of the Affordable Care Act an additional 32 million people will have access to primary care. Supply of healthcare providers becomes a critical concern with the mass influx of patients, and not only that “the ACA fails to achieve universal coverage; it may also not successfully achieve access for a large segment of the US population” (Shi & Singh, 2015, p. 31). “Experts estimate the U.S. is already short more than 9,000 primary care physicians, a number expected to rise to 65,800 by 2025” (Aleccia, 2013). Nurse practitioners can help to alleviate the tension created by the ACA. They can perform virtually all of the functions of primary care physicians, and focus on prevention, chronic care management while providing holistic cost-effective quality care.
Historical Development
In the past, “nurses functioned independently and autonomously before the rise of organized medicine”, so the nurse practitioner (NP) role was not an entirely new concept (Lucille, 2009, p. 13). Since the inception of the first NP program in 1964, advanced practice registered nurse education has evolved from four month certificates, to bachelors, masters and even doctoral programs. “Although often still focusing on primary care, from the 1970s forward the NP role evolved to include adult/geriatrics, family, women’s health, neonatal, acute care, and other specialty roles” thus proving the adaptability of a nurse practitioner (Aleshire, Wheeler, & Prevost, 2012, p.15).
A common counterpart to the nurse practitioner is the physicians assistant (PA). According to Lucille (2009), the physicans assistant role, established in 1961, stemmed from a disagreement in the curriculum of advanced practice nurses, the use of physician instructors in lieu of nursing instructors, and an overall non-supportive stance for the advancement of nursing. While both roles share a common goal of providing patient-centered quality health care and require physician supervision, in Michigan, there educational experience and methodology differ greatly. Nurse practitioners build on their skills and education received as a registered nurse, and progress to either a master or doctorate level. Conversely, physician assistants require two years of college work in basic and behavioral sciences in addition to prior healthcare experience before being accepted into a masters level program. Differences in methodology are attributed to caring versus curing. Nurse’s have a strong background in theory and have caring engrained into their practice, whereas PAs garner their education primarily from physicians and are more focused on curative processes. Both roles are invaluable and need to be utilized to their fullest potential to eliminate the bottle neck we are going to experience when the ACA is fully implemented.
“Many issues at the heart of rural health care – an aging, increasingly sicker rural population with a strong need for preventative and chronic disease care – fit well within the skills that NPs offer” (O’Grady, Hanson, Lugo, & Hodnicki, 2012, p. 1). The primary care nurse practitioner is able to “provide care for patients in diverse settings, including community-based settings such as private and public practices, acute, and long-term care settings across the life span” (Hamric, Hanson, Tracy, & O’Grady, 2014, p. 396). Nurse practitioners are also known for their relationships they develop with their patients, their empathetic understanding, respectful treatment of patients and family members, and for the importance they place on patient involvement in the development of the plan of care.
Role Implementation
“The Consensus Model for APRN Regulation provides a framework to increase the APRN’s role and improve health outcomes in the United States” (Stanley, 2012, p. 74). APRN regulations include four essential elements: licensure, accreditation, certification, and education (LACE). The primary purpose of LACE is to “provide a formal mechanism for facilitating transparent and aligned communication among all stakeholders” which include 28 separate nursing organizations, such as American Nurses Association, American Nurses Credentialing Center, and the American Academy of Nurse Practitioners Certification Program (Stanley, 2012, p. 77). Goals of the Consensus Model are to provide clear parameters for APRNs, ensure that all APRNs in circulation after 2015 receive the same core curriculum according to the specific APRN role chosen, and to ensure the APRN is deemed competent through certification. According to Stanley (2012), after full implementation of the Consensus Model APRNs will be allowed “to practice to the full scope of their education and more easily move from on state to another, increasing access to quality health care services for all populations”.
Many patients are faced with uncertainty as we take on Obamacare’s ambitious healthcare reform. While the Affordable Care Act is opening new doors for many individuals, there have been adverse effects on others, and a slew of potential complications. For example, with the expansion of the Medicaid program there will be greater eligibility for services, however, with the demand for providers higher than the supply patients can expect increased difficulty accessing providers, less time spent with the provider, increased co-pays and deductibles, and all around increased frustration. These issues are more than likely going to continue until all healthcare providers are utilized to their fullest extent.
Effective time management and use of evidence-based practice (EBP) research will continue to be critical components of provider practice during the transition to full Affordable Care Act implementation. Providers will eventually struggle with making treatment decisions in an even shorter period of time, therefore it is important to keep apprised on EBP and integrate research findings into the practice setting. Dontje (2007) reports that “the use of evidence-based practice (EBP) and national guidelines improves the quality of patient care and closes the gap between research outcomes and practice”. Research will not only improve the NPs knowledge base, but will improve patient outcomes and help with timely and accurate documentation.
Over the last four decades “research related to the safety and quality of NP-delivered care, across settings, indicates that NP care is at least equivalent to that of physician-delivered care with regard to quality and safety” (O’Grady et al, 2012, p. 2). Studies have shown statistical significance in nurse practitioner patient outcomes in the following areas: reduction in thirty-day hospital readmissions and annual hospitalizations, as well as chronic disease management (Oliver, Pennington, Revelle, & Rantz, 2014). Despite differences in curriculum nurse practitioners meet, and even exceed, physician outcomes, which is a testament to nursing education. Health care provider education, and continuing medical education, varies greatly between clinicians, particularly between the NP and the physician. Nurse practitioners are required to attend four years at an undergraduate level with subsequent certification as a registered nurse, after which they are eligible to attend graduate school at the masters or doctorate level. NPs are able to sit for licensure exam after successful completion of graduate school and begin practice immediately after certification. Physicians are also required to attend four years at an undergraduate level. After which they attend an additional four years at medical school where they earn their doctor of medicine (MD). Newly graduated MDs enter into a residency program, with a duration of three to seven years, where they receive professional training under the supervision of senior physicians. Physicians also have the choice to attend a fellowship if they choose to specialize, which may be another one to three years of highly specialized training. Continuing education also differs between the two roles. Michigan NPs are required to complete 40 hours of continuing education every two years while Michigan physicians are required to have 150 hours of continuing medical education every three years.
Interview
Paula Nichols is a family nurse practitioner at Riverside Medical Associates. Riverside is located in a rural community and is primarily a family practice, but also specializes in obstetrics and pediatrics. They offer an afterhours walk-in clinic, which is often utilized for patients who are unable to get same day appointments, urgent care, and for Department of Transportation physicals. It is associated with the local hospital and has the ability to perform lab draws, ultrasound, and basic radiography. This clinic is highly sought after and is the busiest family practice in two counties.
Paula noted a desire “to learn more” and to understand “why I was doing some of the things I did in the ER” as an RN as her impetus to pursue a masters degree (P. Nichols, personal communication, October 22, 2014). Her patient population includes “newborns to geriatrics”, requires direct and indirect patient care, which she views as equally important aspects of care. Michigan is one of twelve “Restricted Practice” states (AANP, 2014). We don’t have a “stand-alone Nurse Practice Act” instead APRNs are clumped in with 25 other health occupations under the Michigan Public Health Code (Michigan Department of Licensing and Regulatory Affairs, 2014). Paula stated that the area nurse practitioners attend monthly meetings in which they discuss topics, such as restricted practice, and are encouraged to write senators and express their frustrations. It only makes sense to utilize APRNs to their fullest potential with the mass influx of patients who are going to be eligible for care.
Reimbursement is going to continue to be an issue until APRNs are viewed as equals to physicians. Paula expressed frustration with some of the coding and billing for reimbursement, however she is fortunate to have her own biller and is able to rely on her for those purposes. She also reported “for BlueCross BlueShield if we bill $100 for something, say a physical, the doc gets reimbursed $100 the NP gets $62”, which can be a cause of discord, but she doesn’t let it affect her (P. Nichols, personal communication, October 22, 2014).
“With an ever-widening scope of practice and professional responsibility, more and more nurse practitioners are obtaining hospital privileges. There are a number of benefits to this. Hospital privileges improve the continuity of care for patients by allowing you to actively participate in their inpatient care. Hospital privileges also improve the image of nurse practitioners among patients and colleagues” (Wright, n.d.). Paula doesn’t currently have hospital admitting privileges, however when she worked at a community care clinic it was mandatory because the clinic was associated with the hospital.
Nurse practitioner led clinics are becoming increasingly prevalent. “Because of their preparation and model of care, NPs will have a pivotal position in health care, responding to the demographic and epidemiologic demands of an expanding, aging, and chronically ill population” (Aleshire et al, 2012, p. 19). Research supports the safety and quality of APRN care, and with the provider demand significantly higher than the supply NP clinics are an excellent way to absorb the strain. In response to independent practice Paula replied “it’s not an interest of mine to be on my own, or have my own practice. It’s easier to have someone else pay me and have collaboration with the docs” (P. Nichols, personal communication, October 22, 2014).
Personal Reflections
My aspiration to become a nurse originated from my great-grandmother, who proudly wore her white cap. Her dedication and admiration of her career provided me with the incentive to purse nursing. She instilled in me the importance of caring with our profession, as a result, caring has always been an integral part of my life, as well as my practice. Personal misdiagnosis and delayed diagnosis of several life threatening conditions developed my realization that there is a greater need for specialized and advanced nurses in my region.
My experiences, personal and professional, along with my education has helped define the nurse I am and set the foundation for the Nurse Practitioner I strive to become. My short term professional goal is to become the most dynamic, compassionate, and knowledgeable clinician I can be. Ultimately my desire is to become a Dermatology Certified Nurse Practitioner and a nurse educator. Inspiration for this specialty originates from a family history of Epidermolysis Bullosa and a desire to impart knowledge and propel nursing standards to a higher level.
Role transition from RN to FNP is honestly quite intimidating. Research conducted on recently graduated FNPs found that “two phases of role transition occurred and were depicted by the central categories that emerged: extrinsic obstacles, intrinsic obstacles, turbulence, positive extrinsic forces, positive intrinsic forces, and role development” (Heitz, Steiner, & Burman, 2004, p. 416). In terms of extrinsic and intrinsic factors, or stressors, “both can be overcome but not necessarily controlled” (Hetiz et al, 2004). Emotions and perceptions can easily become labile when faced with new experiences, and the need for stability can be achieved by utilizing positive forces, such as family and friends, and personal coping mechanisms. While this journey is sure to be tough at times, it’s also exciting to see my personal growth and to develop new knowledge and skills.
Role development is important for personal and professional growth. With the changes set forth by the Affordable Care Act it is imperative that nurse practitioners embrace their role, be utilize to the fullest extent, and continue to persevere under imposed limitations. Ultimately, these lofty goals can be obtained through the emphasis of “health promotion, health maintenance, prevention, and detection of alterations in health through supportive interventions, counseling, and teaching of families, staff, and other providers” (Aleshire et al, 2012, p. 19).
APN Interview
Name: Paula Nichols, MSN, FNP-C

Education: ADN 1985, BSN 1990, MSN 2000 Grand Valley University

Practice setting: Riverside Medical Associates, P.C. 560 Osborn Blvd. Sault Ste. Marie, MI 49783 (906) 632-1800 http://www.riversidemedicalassociates.net/index.htm

Q: Describe your professional background. Please include your education and experience as a RN.
A: “So when I graduated in 1985 I went to Grayling mercy and worked there on a med/surg floor for 3 years. My dream all through nursing school was to be a traveling nurse, so after I got 3 years of experience in…I did that, and so I was a traveling nurse for another 3 years. Travel nursing was one of the best things I have done and I learned a lot. I even worked on a neuro step down floor, and I found that if you have a med/surg background most employers are willing to hire you. After travel nursing, I moved back to Michigan and went to work in the ER for 10 years, and continued to do that while going for my bachelors and masters. I was offered a job in the ER as an NP, but I didn’t want to do that because I’d worked will all those guys for years and I didn’t know if they could make the transition from being a coworker into being their boss. Instead I started out as a NP first assist in the OR, and that was my worst mistake because I didn’t have any knowledge of surgical tools. After 6 months suffering in the OR I applied for a job opening in a community care clinic in the Upper Peninsula. I came up and interviewed for that, but I wasn’t actually their first choice because I didn’t have any NP experience, but their first choice declined. So they did take me because I did have 10 years of ER experience. So then I worked there for 5 years and then went to Riverside Medical from there, and have been there for 8 years.”
Q: What motivated you to become an Advanced Practice Nurse (APN)? Describe why you choose family nurse practitioner.
A: “I think I got bored in the ER and I wanted to learn more, and I wanted to know why I was doing some of the things I did in the ER. I also had a friend in the ER who was finishing up her bachelors, and she said ‘I really want to be a nurse practitioner and I really want you to do it with me’. So she said ‘I have one more year to finish up my bachelors and you want to have one more baby, so you have your baby this year and I’ll finish up my bachelors’ and so that’s exactly what we did. I also think it was a desire to learn more. I really wanted to be a pediatric nurse practitioner, but everyone I talked to said you can only do pediatric nurse practitioner stuff but if your family you can go in any direction, so that’s what I did.”
Q: Describe how your previous nursing experience prepared you for your new role as an APN. A: “I think all along you are learning everything as you go through, but I know being in the ER really prepared me well. I had another friend who was an RN in the bariatric program, and she really struggled because she saw the same things. My med/surg and traveling (RN) helped as well and it all builds on each other.”
Q: Were there any noted strengths or weaknesses of the graduate school you attended and how did they prepare you for your role as an APN?
A: “I think it was a good education. I attended a distance education program and the instructors were on the TV, and there were maybe 20 of us in the class and watched the instructors on the screen. It was kind of a disadvantage because you weren’t on campus, and I think you have more access to instructors while you’re on campus. Grand Valley did find us nurse practitioner preceptors in our area. I don’t know if that was a weakness of the program, that’s just the way I chose to do it. The clinicals required so many hours of family practice, and I took it upon myself to experience other areas. I went to a midwife for a while and she really made me feel confident with pelvic exams, and just taught me a lot of female issues, which you don’t learn much about in the ER. We typically just sent them to the floor. I spent time with a radiologist reading x-rays, and time with an orthopod and learned how to do muscular exams better. Some people chose to stay with the same family practice, but I just tried to vary it to get the best experience.”

Q: What practice settings have you worked in as an APN?
A: “Community care clinic and a family practice.”
Q: What has been the most rewarding aspect of being an APN? What has given you the most job satisfaction as an APN?
A: “It’s funny, I think the one thing that satisfies me the most is the one reason I didn’t want to go into family care. Being an ER nurse for 10 years all I could think was, I don’t want to get to know these people and have them bring me cookies. I don’t know if it’s because I am older now, or what it is, but I love seeing the same people over again and getting to know them and their families. It’s hard to build a rapport with the ER and community care clinic, and they don’t always trust what you have to say, but they gain more confidence in you the more you see them. It’s rewarding when you figure something out that no one else has figured out. I had a lady who’d developed colon cancer. She’d been going to someone else who’d never done a rectal or fecal occult with her exams, and she was in her 60s. She had positive stools, so I sent her for a scope and then they ended up finding the cancer.”
Q: What was your first day like in your new APN role?
A: “My first days as an APN were technically in the OR and I don’t feel like I was really a NP there. Then when I went to the community care clinic…that was kind of hard because I was the only one there. There was nobody else. I could go across the hallway and go talk to the ER doc if I had a question, but basically it was just me figuring it all out, and you’re thrown right into 20 or more patients a day. And I was working for the Tribe and I didn’t know what meds were on their formulary, but I know what to do with the patients if they had a sore throat or an earache. Being an ER nurse I did a ton of them, even if I didn’t diagnose it I knew what to tell them. I think my first day at Riverside was more stressful than the community care clinic because I hadn’t done family practice. Like when you start someone on a blood pressure pill, oh my god, when do you bring them back? I used to tell them to go see their primary doctor and now I am that person. So that was harder. Although there I was worked into it more slowly. My first day I only saw 3 patients, and I have more physician and other nurse practitioner resources.”
Q: How long before you began to feel confident in your new role? Were there any specific milestones that marked this achievement?
A: “Gosh, I mean it was awhile, and I’m still learning every day, and there’s not a day that goes by that I’m not bugging one of the doctors, what do you think about this, what should I do. I guess it was a few months before I felt like I can handle this day to day, but you know there is always billing questions and you’re just always learning. I don’t think there were milestones per say, but the doctors reaffirming that I knew what I was doing and I have been doing the right thing, and that has continuously made me feel more confident.”
Q: Did you have a mentor to help guide you in your role? If not, do you believe a mentor would have been beneficial to your professional development as a novice APN?
A: “No, I didn’t have a mentor at the community care clinic or at Riverside, but I’ve had the docs there to ask questions, and Malorie, who’s a women’s health nurse practitioner, so she’s a good resource for that. I think it would have been nice to have a mentor (at the community care clinic) because my medical director was so disorganized and never there. Even if I would have had a good medical director it would have been easier. I never really received a good orientation, and was frustrated not knowing how the system works or what was in their formulary.”
Q: What barriers have you encountered in your career as an APN? What did you do to overcome those obstacles?
A: “My medical director could have been a barrier at the community care clinic, but at Riverside all the docs and NPs have been great and they always let me know they have my back. I would say the only barriers I can think of, and it’s not necessarily a barrier, it’s more frustration with Michigan being a restricted practice state. Sometimes patients don’t want to see a nurse practitioner, the want to see their doctor, and I understand that, you know, especially if you haven’t seen their doctor for a while. I’m the first one to say, after they see me, let’s make an appointment with your doctor right now so you can see them next time. But after you see them a few times you build a rapport and they are more willing to come back and see you.”
Q: Has your role as an APN evolved since you received your degree in 2000?
A: “I don’t think so, other than them (the Riverside Medical physicians) being more confident with me and letting me do more things, like removing moles and doing pre-ops, or more skill kind of things. In fact they, (Riverside physicians), have more confidence in me than I do sometimes.”
Q: Do you consider yourself to be an expert at this time?
A: “Probably not. I mean I think if you ask the docs they would say I am, but I’m always learning and always asking questions.”
Q: How did you decide on your current clinical practice setting?
A: “I guess working the in community care clinic I knew those docs (Riverside Medical) were great and it was one of the best practices in town.”
Q: Describe your clinical practice setting, clients served, typical work day, and direct patient care responsibilities.
A: “So newborns to geriatrics. I usually start my day at 8 in the morning, everyone gets noon to one off for lunch and we’re off at 5. Usually my first patient is at 8 and I might get in 10 minutes early and look at labs and tell my nurse who needs to be called and what for, and there are always questions to respond to and medication to be reordered. There is a lot of dealing with insurance, but my biller does most of that. There’s a lot of sitting down and figuring out you what to do…I ordered a MRI of the back and they (insurance) need a prior auth. So what do I tell them to get this covered? We (RN and biller) have to discuss all the symptoms so you can get it covered. It’s a lot of phone coverage to be honest. I also have urgent care appointments during the day from 10-1130, then 4-5 is also open for urgent care.”
Q: What are some examples of indirect patient care that you provide on a daily basis? How do these influence your patient outcomes?
A: “So I think a lot of the phone, following up on lab work and x-rays. You need a really good system to keep everything organized so you know what you’ve done and what you need to do. It’s really easy to get lost with everyone coming and taking your charts. It took me awhile to figure out how I wanted to do things, and it changed again after we got the electronic medical record. The electronic medical record has made our documentation a lot slower. Some of the docs are 50-60 charts behind. We just started a week ago with Dragon its software with a microphone, and you can dictate, and it types it right on to the screen, and that has helped. But you still have to click so many things on the electronic medical record…it takes forever. At least in the HPI I can dictate that out, and then I’ll dictate their plan and come back later and complete all the clicks. I try and do as much as I can right after the person, but it can be hard to keep up. I definitely do the HPI and the plan right after I leave the room. Now in the computer I have to figure out the ICD code and procedure codes and make sure I am billing right. I think the indirect (patient care) is important. I’ve had lot of people say, ‘oh, you’re calling me about my lab work, nobody else has ever called me about my lab work’. I think it’s important that if you poke somebody that they deserve to know the results. That builds a relationship too, when you can call them and let them know what’s going on and answer their questions.”
Q: Michigan is still listed as a “Restricted Practice” state, how does this impact you as a practitioner? Do you see Michigan moving to “Full Practice Authority” in the future?
A: “We have monthly meetings with all the area nurse practitioners, and our leader pushes us to speak up and write senators in hopes that we can get full authority. There are a lot of physicians fighting us, and they don’t want us practicing independently. We don’t see much of this up here (Northern Michigan), but I met a NP from Philadelphia who said, it’s awful, the docs hate NPs because we are taking patients away from them. To me, you know, it’s like why don’t you want us to have a defined role with a nurse practice act. So you don’t want us to prescribe meds…at least look at the whole picture of rural areas. There’s going to be a lot of people who are going to need care and we can help to relieve the pressure. Our docs are accepting a lot of new patients and when I asked why they said they need to keep the NPs busy.”
Q: Describe your relationship to other care providers, particularly physicians, and explain any necessary changes that could assist in enhancing those relationships.
A: “The docs here treat me as a peer which is nice. There are some things I get frustrated with there (Riverside Medical)…like my biller told me that we just became a patient centered medical home, and there is so many criteria that you need to meet for that. Who is doing the best job with it - the nurse practitioners. Who’s getting all the credit and money for it - the physicians. Like OBs, you get a one lump sum for an OB. So I may do a prenatal visit because the docs aren’t in, but I don’t get any payment for that, it just all goes to the doc. You know, so there are little things like that that frustrate me…and I think UPHP, because they are a rural health clinic, they get so many tens of thousands of dollars at the end of the year. The docs get that and the nurse practitioners don’t get any of it…I’m certainly not going to leave, it’s not better anywhere else.”
Q: Does you clinic utilize evidenced based practice material into your treatment plans and what do you use as references?
A: “I try to. I mostly do online stuff. Medscape is really good, I read a lot of Medscape, and I get prescribers letter, which is excellent, and comes once a month to keep up on drugs. Up to Date is really good. The hospital has it. You can buy it yourself, but it’s costly…it really and truly is up to date, if you want to go and look up anything and it will give you all of the evidenced based practice info.”
Q: Do you believe your current position/organization utilizes your full potential as an APN?
A: “Probably beyond actually.”
Q: How are you reimbursed for care delivered? Do you have difficulty with reimbursement from third party payers?
A: “So when I started there, I have a biller, and so she did all the paperwork for getting me numbers. Like billing numbers, NPI number, numbers for Medicare, Medicaid, BlueCross and all these different numbers. So she bills directly under me. She was telling me, and this blew my mind, for BlueCross BlueShield if we bill $100 for something, say a physical, the doc gets reimbursed $100 the NP gets $62. So that’s frustrating, but she said all the others are equal, whatever the doc gets reimburse I get reimbursed. But then the other thing she said for UPHP a well-child exam they bill $106 and we get paid $28. I mean the docs get paid $28 too, it’s the same, but it amazes me how much insurance does or doesn’t pay. No, we don’t have any trouble getting money for everything thing I’ve done. It’s tricky learning how to code correctly. We do use “incident to” every once in a while. Sometimes if I’m stumped Dr. T will come in and look at a patient and we’ll decide on a plan, so then I’ll do up a note and he’ll cosign it, and then we get reimbursed for everything.”
Q: Has the implementation of the ACA affected your patient care? If so please describe.
A: “I don’t think so, not that I’ve seen yet. I don’t know that I’m really that well versed in the affordable care act. I’ve had a few new patients who are now… like I have a really bad diabetic who would never let me check anything but his A1C, because he had no other money, but now because of the affordable care act he has insurance and now I can check his lipids and all this other stuff that I couldn’t do before, so that’s been good. But then I’ve had a lot of other people who’ve lost benefits because of it.”
Q: Under Michigan law, all RNs are required to complete 25 continuing education contact hours with one hour of pain and symptom management. Do APNs fall under the same requirements?
A: “We have to have 40. We still have to keep our Michigan RN license and renew that every 2 years. Then you have to pay another $25 for the NP part of it every two years. Then you’ve got to do your certification CEU’s. So I went through the ANCC to be certified, I took their test, and I think you need 125 credits every 5 years to renew that certification.”
Q: If you don’t mind sharing, can you please reflect on your interview process for your current position?
A: “The 3 docs called me into the office and the office manager was there, and we just met in their office. I had a little bit of an in because Katelyn Mackie was in high school at the time and she came into the community care clinic, in one of those programs to find out if you want to be in a health profession, and we hit it off really good. She was a lot of fun. Well she had told Dr. Mackie all about me and he already had a good opinion of me when I got there, so that helped a lot. They just asked me the typical questions.”
Q: Are you currently satisfied with your salary and benefits, and does your employer typically reimburse continuing education?
A: “They do (pay the continuing education). I took a big hit when I left the community care clinic. I lost $15,000 coming to Riverside and they just last year, after 8 years, bumped me back up to where I was at the clinic. They do pay for my insurance, they pay for continuing ed., they give me $1500 a year for professional stuff to pay for your license, conferences you want to go to, or any of that kind of stuff. And that’s huge, I mean when you have your insurance paid for and the conferences paid for, that really adds up, so I think it’s a good deal. I’m not making $100,000 and I could probably if I was somewhere else. I’m only working 4 days a week and I don’t have any on-call, so to me that’s a good deal.”
Q: What advice or tips do you have for new ANP graduates?
A: “I would say certainly getting all the experience you can while you’re in school. It’s the time you can play dumb and have everybody teach you, so try and learn all you can there. Keep up with all the current stuff. You even have to do things like watch Dr. Oz because everybody comes in with all the Dr. Oz comments, and you know, just being well versed in everything.”
Q: Lastly, do you have any opinions on: 1) Independent practice, 2) hospital admitting privileges, and 3) reimbursement equity with physicians?
A: “I had to have hospital privileges when I worked for the community care clinic because I was part of the hospital, but not now that I’m with Riverside. They’ve never talked to me about seeing patients in the hospital, yet. I think a lot of the reasons doctors don’t want us to be independent is because they are worried we are going to go off and work on our own. It’s not an interest of mine to be on my own, or have my own practice. It’s easier to have someone else pay me and have collaboration with the docs. I’m thankful that I have my own biller to handle all of that, but it would be nice to be paid as much as the docs do.”

References
AANP. (2014). Historical timeline. Retrieved from http://www.aanp.org/about-aanp/historical-timeline.
AANP. (2014). State practice environment. Retrieved from http://www.aanp.org/legislation-regulation/state-legislation-regulation/state-practice-environment
Aleccia, J. (2013). Bracing for Obamacare: Nurse practitioners fill doc shortage gap. Retrieved from http://www.nbcnews.com/health/health-care/bracing-obamacare-nurse-practitioners-fill-doc-shortage-gap-f6C10849957
Aleshire, M.E. Wheeler, K., & Prevost, S.S. (2012). The future of nurse practitioner practice: A world of opportunity. Clinics: Nursing 47(2), 14-24.
Blumenthal, S. (2012, August 03). Healing America’s health care system. Retrieved from http://www.huffingtonpost.com/susan-blumenthal/affordable-care-act_b_1737731.html
CDC. (2011). Health expenditures. Retrieved from http://www.cdc.gov/nchs/fastats/health-expenditures.htm
Dontje, K.J. (2007). Evidence-based practice: Understanding the process. Retrieved from http://www.medscape.com/viewarticle/567786
Hamric, A.B., Hanson, C.M., Tracy, M.F., & O’Grady, E.T. (2014). Advanced practice nursing: An integrative approach (5th ed.). St. Louis, MO: Elsevier.
Heitz, L.J., Steiner, S.H., & Burman, M.E. (2004). RN to FNP: A qualitative study of role transition. Journal of Nursing Education 43(9), 416-420. Retrieved from http://www.sonoma.edu/users/k/koshar/n560/Qual_crtique_article.pdf
HHS. (n.d). Health care providers: The top five things you need to know about the affordable care act. Retrieved from http://www.hhs.gov/iea/acaresources/brochures/health-care-providers-top5.pdf
Lucille, J. (2009). Advanced practice nursing essentials for role development (2nd ed.). Philadelphia, PA: F. A. Davis
Michigan Department of Licensing and Regulatory Affairs. (2014). Is there a nursing practice act in Michigan. Retrieved from http://www.michigan.gov/lara/0,4601,7-154-35299_63294_27529_27542-295888--,00.html
O’Grady, E.T., Hanson, C., Lugo, N.R., & Hodnicki, D. (2012). Unleashing the Nation’s nurse practitioners. The Journal of Rural Health 28, 1-3. doi: 10.1111/j.1748-0361.2010.00349.x
Oliver, G.M., Pennington, L., Revelle, S., & Rantz, M. (2014). Nurse practitioner practice: Full scope, better outcomes. Retrieved from http://www.medscape.com/viewarticle/832738
Sharamitaro, A.P. (2013). The ACA in 2013: What can stakeholders expect. Health Capital Consultants, 6(4). Retrieved from http://www.healthcapital.com/hcc/newsletter/4_13/ACA.pdf
Shi, L. & Singh, D.A. (2015). Delivering health care in America: A systems approach (6th ed.). Burlington, MA: Jones and Bartlett
Stanley, J.M. (2012. Impact of new regulatory standards on advanced practice registered nursing: The APRN Consensus Model and LACE. Clinics: Nursing 47(2), 74-84.
Wright, W.L. (n.d.). Hospital privileges for NPs. Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/article/hospital-privileges-for-nps.aspx

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