Introduction to California Nurse Practitioner (NP) practice
According to the Department of Consumer Affairs (n.d), a nurse practitioner is a registered nurse with more education and skills to manage health-illness needs at the primary care level, psycho-social assessment, and physical diagnosis. They undergo training in a program that aligns with the Board standards outlined in the California Code of Regulations CCR, Standards of Education. The NP in California shares similar scope of practice with the RN and require authorization to perform overlapping medical procedures as stated in CCR section 1485 (Department of Consumer Affairs, n.d.). However, they have full authority to perform nursing functions that contribute to primary healthcare, such as physical and mental assessment, skin test performance, immunization, blood withdrawal, and initiation of emergency procedures. Supervision for overlapping medical functions varies from one procedure to another. Depending on the procedure, there are different forms of supervision, depending on the procedure- some require a physician to be present in the facility and available via phone in case of any emergency (Department of Consumer Affairs, n.d). Therefore, the supervision mainly involves NP’s collaboration with physicians, physician’s approval of the overlapping function, and their availability on the phone to address any emergency.
How the NP practice laws in California affect patient care
The restriction on nurses’ authority to perform certain overlapping procedures presents a significant challenge in patient healthcare, especially in primary health care settings. Several systematic analyses conclude that NPs equal healthcare quality with physicians, even without a physician’s oversight. After delving into specific care aspects such as chronic disease management, prescription, and ordering diagnostic tests, these studies came to this finding (Spetz, 2019). According to Spetz (2019), patients under the care of NPs experienced lower rates of preventable hospital admissions, readmission, and emergency room visits compared to those under physician’s care. The rates were even lower where NPs had full practice authority. Thus, restricting NPs practice authority affects patient outcomes by increasing the rate of preventable hospital admissions, readmissions, and frequent ER visits.
The NP practice laws in California significantly impact access to patient care. A survey revealed that NPs in California are more probable to grant primary care compared to physicians. 58.8% NPs provided primary care, while 51.2% NPs spent almost half their time administering primary care (Spetz, 2019). However, only 16.7% of physicians were in primary care facilities (Spetz, 2019). The survey also revealed that NPs are more likely to attend to a new Medi-Cal and uninsured patients than physicians. Also, NPs have higher chances of working in community health centers than physicians- 17% NPs were employed in community health centers compared to 6% of physicians (Spetz, 2019). Trends suggest a rapid growth of NPs in states with full practice authority, which implies increased access to primary health care, the foundation of quality healthcare and life. Therefore, restriction on authority to practice significantly reduces patients’ access to care.
Restricting NPs full authority to practice affects healthcare delivery in rural areas. Surveys indicate that NPs working in states that grant full practice and prescriptive authority are more likely to work in rural settings. National statistics suggest that NPs are more likely to work in small cities and rural locations than physicians (Spetz, 2019). The shortage of physicians in rural settings, compounded by mandatory supervision and collaboration, significantly prevents NPs from working in rural areas, thus limiting the availability of health care services in these settings (Winter et al., 2021). In particular, on-site physician supervision and collaboration requirements impede NPs efforts to provide prompt quality healthcare, for instance, in assessment and prescribing drugs.
Specific case and how it is affected by California state’s practice act
The case study of a 35-year-old African-American male presents with features of anxiety, insomnia, and mental health issues. From the history, the patient needs mental health assessment and diagnosis to ascertain his illness and initiate prompt treatment. A psychiatric mental health nurse practitioner (PMHNP) would perform a psychiatric health assessment since the state grants full authority for this function. However, the NP would require supervision and physician collaboration when ordering lab tests, prescribing medications, and recommending further care. They would then establish a nursing diagnosis. However, a physician is responsible for establishing a medical diagnosis and prescribing the appropriate treatment. This is due to restrictions on prescriptive authority on PMHNP in California state. The physician would also be responsible for ordering any relevant diagnostic tests and making recommendations for rehabilitative treatments for this patient. Due to a shortage of mental health physicians, the requirement for NPs to collaborate with physicians and remain under their supervision when performing overlapping functions such as drug prescription presents a significant delay in the delivery of healthcare services.
California is the only western state that restricts NPs authority and practice by demanding them to have physician’s supervision. Several studies have associated these restrictions with a shortage of NPs, limited access o healthcare services by the residents, particularly in rural areas, higher hospital admission and readmission rates, more ER visits, and lack of utilization of primary care services. Despite solid evidence suggesting the comparable quality of care under an NP and a physician, proponents of these restrictions argue that oversight is crucial for the quality of care.
Department of Consumer Affairs (n.d). General Information: Nurse Practitioner Practice. Board of Registered Nursing. Retrieved from https://www.rn.ca.gov/pdfs/regulations/npr-b-23.pdf
Spetz Joanne. (2019). California’s nurse Practitioners: How Scope Of Practice Laws Impact Care. Healthforce Center At UCSF. Retrieved from https://www.chcf.org/publication/californias-nurse-practitioners/
Winter, S., Chapman, S. A., Chan, G. K., Duderstadt, K., & Spetz, J. (2021). Nurse Practitioner Role and Practice Environment in Primary and in Nonprimary Care in California. Medical Care Research and Review, 78(6), 780-788. https://doi.org/10.1177/1077558720942706
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