NR 510 Week 1: Barriers to Practice Discussion

NR 510 Week 1: Barriers to Practice Discussion

NR 510 Week 1: Barriers to Practice Discussion

Read the assigned Hain & Fleck article, and discuss the following: 

  • What are the barriers to APN practice identified in the article? Describe these barriers in your own words. 
  • What are your impression of the barriers to APN Practice? (Are you surprised by these barriers? Is this new information to you? Have you ever been involved at the legislative level in nursing? Do these barriers concern you or motivate you toward becoming an APN?) 
  • Do these barriers represent Restraint of Trade? Why, or why not? 
  • Your thoughts on how nurses can influence these barriers. 

The barriers to APN practice that were identified in the article are state practice and licensure, physician related issues, job satisfaction, payer policies and not being allowed to follow patients who are admitted to acute care facilities (Hain &Fleck, 2014). 

These barriers to me mean that APN are restricted in their practice. They do not get to practice to the best of their education. I do feel that in the beginning there does need to be some guidance from a physician. The barriers can cause dissatisfaction with the job because of the amount of control taken from the APN regarding their decisions with their patients. This should be done in the first five years or so of practice. This would give the ANP the guidance needed while caring for patients. These barriers also mean the ANP does not get the same compensation as does a physician and payers will not pay at the same rate as they would for a patient being seen by a physician. 

These barriers are not new to me nor do they come as a surprise. I have spoken with a few FNPs who have mentioned the fact that they are restricted to a certain extent. When working in the emergency room a lot of times the APNs would only be allowed to work on the lower acuity patients. In the event that there was someone who ended up being a higher acuity the APN would have to go to the physician for their opinion. This I did not see as a bad thing. It is always good to have the extra resource which can provide an additional set of eyes and knowledge for a situation. These restrictions do not concern me currently. I feel my motivation is seeing how certain physicians welcome the APN and are willing to work with them. Many I have seen give the APN more room to do their thing once they gain confidence in the APN. 

These barriers do represent restraint of trade. They do not allow the APN to see patients and prescribe medications without restrictions. They have rules and regulations that restrict them and only allow them to practice in certain ways.

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Nurses can influence these barriers by forming organizati0ons to appeal to their states about the way they are allowed to practice. To do this they will need to research and provide data stating the care they give, and the care given by physicians. They will need evidence about practices to be able to change the minds and get regulations changed. This will not be an overnight process, so they will also need to be willing to commit to making a change over years. 


Hain, D., & Fleck, L. (2014, May). Barriers to Nurse Practitioner Practice that Impact Healthcare Redesign. OJIN: The Online Journal of Issues in Nursing, Vol. 19, No. 2, Manuscript 2, doi: 10.3912/OJIN.Vol19No02Man02 

I also work in the emergency department and we have both nurse practitioners and physician assistants working.  I do see that many of the more critical patients are picked up by the doctors and not the PA or NP.  This is not always the case as we have one NP who is without question a rock star.  She has the ability to handle any situation and is involved in trauma cases when certain doctors are there.  I was very impressed by her as I watched the confident manner in which she conducted her business.  I think that there are definite times where opportunities are limited for the NP but I also feel that these obstacles can be overcome by displaying competence and gaining the reputation of being able to handle any and all cases.  I see that the doctors have differing levels of confidence in the PAs and NPs based on how they view their abilities.  I suppose this is just human nature and helps to protect the organization. NR 510 Week 1: Barriers to Practice Discussion

Also work in the ED and we also have PA’s and NP’s that work from 12p-12a.  Until a few years ago they only hired PA’s.  We typically run 3 pods with a Dr in each and the PA or NP in the central pod (with a doctor).  During those hours our pediatric ED is also open and is run with a Dr and NP.  A majority of the patients seen by our PA/NP are lower acuity ESI 4’s and some 3’s.  But much like your ED it depends on who is working.  Monday is typically our busiest days and we run what we call the pit and it’s an area in triage that has 4 rooms that a PA/NP and a nurse run with low acuity patients that can be turned over quickly (like a fast track). We have some PA’s and NP’s that see higher acuity and complex patients and others who rarely do.  I agree with your statement about the NP needing to display more competence to gain respect and take on more difficult cases.  When we have new ED doctors they are expected to see patients independently at every level of acuity.  When PA’s and NP’s abilities aren’t consistent  it makes it hard for the professions to be respected as a whole.  

Payer policies are an interesting barrier for NPs as well, not only because of lower reimbursement rates but also because patients can voice concerns as well. Recently, I had a patient who no longer wished to see mid-levels because they didn’t feel it was right that the same amount was billed for seeing a mid-level as was an MD. How do you feel about this and what would your response to the patient be? 

When I go to see my PCP I see the NP. She is great. I do not now what is billed when I go to the doctor. The only way I would request to see the MD is if the NP and I could no0t see eye to eye on a treatment. She is actually great about listening to me and dealing with my concerns. As for the patient I would ask if that is their only concern. I would inquire about the care they are receiving. My thought is if the care is good care then why would you switch to someone else? However I have had patient’s that did not like the prescription they got or the meds they were given and they would insist on seeing a “real doctor”. Not once when this happened did the doctor undo anything the NP had done. The outcome was still the same and the prescriptions did not change. This was explained as a professional courtesy between the MD and the NP. I do not now how this works in other areas besides the emergency room but it shows respect. 
I agree that guidance from a physician at first would be helpful. The transition from bedside nursing to being the one diagnosing and prescribing is intimidating, and a complete change from what we are used to doing. 

See Also: NR 510 Week 8: Reflection on Achievement of Outcomes