Nurse practitioners (NPs) are a growing source of health care providers in the United States. In pediatric acute care settings, the NP role has its origin in pediatric critical care in which the role has developed over the past 20 years (Allen, Fennie, & Jalkut, 2008; Freed, Dunham, Lamarand, Loveland-Cherry, & Martyn, 2010; Pitts & Seimer, 1998; Reuter-Rice, 2013; Teicher, Crawford, Williams, Nelson, & Andrews, 2001). In response to critical care physician shortages (Health Resources and Services Administration [HRSA], 2006), training physician work hour restrictions (Accreditation Council for Graduate Medical Education, 2011), and increased recognition of NPs as safe, high-quality health care providers (Dill, Pankow, Erikson, & Shipman, 2013; Institute of Medicine [IOM], 2010; Newhouse et al., 2011), pediatric intensivists have reported that they intend to increase employment of and expand the roles for NP providers in the pediatric intensive care unit (PICU) (Freed, Dunham, Loveland-Cherry, Martyn, & Moote, 2011). However, the intent to expand PICU NP employment and roles must be considered within the context of regulation of PICU NP practice.
Regulations unnecessarily limit NP contributions to care at a time when, according to the Institute of Medicine, every provider's role on the health care team should be developed to its fullest extent (IOM, 2010). Pediatric ICU NP practice is subject to legally defined state scope-of-practice (SSOP) regulations. Organizational-level regulations can also impose barriers to NP practice through the processes of credentialing, privileging of NPs to provide patient care, prescribe medications, and bill, and by creating complex management structures (Jalloh et al., 2016; Kleinpell, Hravnak, Hinch, & Llewellyn, 2008; Kleinpell, Hudspeth, Scordo & Magdic, 2012; Lowe, Plumber, O'Brien & Boyd, 2012; Munro, 2013; Verger, Marcoux, Madden, Bojko, & Barnsteiner, 2005). States with restrictions on NP SSOP have smaller NP populations per capita (10 per 100,000 population less) and 25% slower rates of growth in the NP population compared with states that have full SSOP regulation (Reagan & Salsberry, 2013). Differences in SSOP and organizational-level regulations such as inability to practice to the full extent of one's education, inability to identify NP care in medical and billing records, lack of centralized organizational NP leadership structure, and physician concerns about integrating NPs into an interdisciplinary team have been shown to create barriers to NP practice (Bahouth et al., 2013; Poghosyan, Nannini, Stone, & Smaldone, 2013; Reagan & Salsberry, 2013; Verger et al., 2005). These differences result in variations in NP practice and may have implications for patient care outcomes. The SSOP and organizational-level regulations that shape the NP practice environment in the PICU have not been reported in the literature.
The purposes of this article are to 1) describe the extent to which organizational regulations of PICU NP practice, including prescribing medications, align with SSOP regulations, 2) describe the differences, if any, between PICU medical directors' and lead PICU NPs' reports of the alignment of the organizational regulations of PICU NP practice and prescribing with SSOP regulations, and 3) describe organizational-level restrictions on PICU NP practice.
Frameworks for nurse practitioner practice and the regulation of practice
Frameworks describing NP practice focus on the patient care roles and suggest that formal and informal regulations of NP practice result in different practice environments (APRN Consensus Work Group, 2008; Elliott & Walden, 2014; Kilpatrick, Lavoie-Tremblay, Lamothe, Ritchie, & Doran, 2013; Safriet, 2002; van Offenbeek & Knip, 2004). Multiple sources of NP practice regulation from SSOP regulations, organizational-level policies, and those introduced informally as NPs' attempt to integrate into a team of providers have a cumulative effect and create barriers to NP practice. This results in a variety of practice norms and diverse PICU practice environments. These factors can affect patient care delivery and outcomes. A synthesis of nursing, economic, and policy frameworks that consider NP roles and the regulation of NP practice were used to guide this study; the purpose of this study was not to test the frameworks.
State scope-of-practice regulations
The justification of SSOP regulations are to protect the public and give state regulatory boards power to ensure that practitioners are safe and competent (National Council of State Boards of Nursing, 2017). Each state's legal SSOP regulation of NP practice is governed by a practice act that differs by state. Three levels of SSOP regulations have been used to categorize the different NP practice environments. According to the American Association of Nurse Practitioners (AANP), states are classified as 1) full practice authority; i.e., NPs may evaluate, diagnose, and manage treatment of patients—including prescribing medications under the authority of the board of nursing, 2) reduced practice authority; i.e., a collaborative agreement with a physician is required for at least one of the practice elements: evaluation, diagnosis, or treatment—including prescribing medications, and 3) restricted practice; i.e., there must be physician supervision, delegation, or team management to prescribe, diagnose, and/or manage patient treatment (AANP, 2017). Requirements for NPs to collaborate with physicians to obtain prescriptive authority are particularly pervasive across the spectrum of state regulations enacted to limit NP practice (Cassidy, 2012). As a result, the regulation of prescribing is examined separately in this study from the more general regulation of NP practice—evaluation, diagnosis, and treatment.
Health care organizations also regulate NP practice through credentialing and privileging of NPs and a variety of other policies. Credentialing is the process institutions use to verify providers' qualifications, for example, education, professional certifications, and licensure (The Joint Commission, n.d.). Privileging grants NPs the right to perform specific clinical activities and procedures within the scope-of-patient care based on their qualifications/credentials (The Joint Commission, n.d.). Through the processes of credentialing and privileging, institutions determine the degree to which a physician is required to supervise NPs when performing various aspects of their clinical practice including prescribing medications. This process of credentialing and privileging is also where various sources of public and private regulations of NP practice may or may not align. Organizational-level regulations can be consistent with or more restrictive than SSOP regulations with regard to practice or prescribing (Jalloh et al., 2016; Kleinpell et al., 2008; Kleinpell et al., 2012; Poghosyan et al., 2013). In studies of primary care settings, organizational-level regulations that support NPs have been attributed to improved patient care delivery, NPs' ability to practice to the full extent of their licensure, and decreased work-related stress (Poghosyan et al., 2013). The alignment between organizational regulation of NP practice and prescriptive authority through credentialing and privileging with SSOP regulations has not been examined. Consequently, little is known about the extent to which organizations place limits on PICU NPs' practice and prescriptive authority. In addition, comparisons between PICU physician and NP reports of NP regulation at the organizational or state level have not been assessed.
Organizational-level policies that govern billing practices and reporting structures can restrict NP practice (Jalloh et al., 2016; Moote, Krsek, Kleinpell, & Todd, 2011; Munro, 2013; Verger et al., 2005). Some institutions enable PICU NPs to submit bills for services or procedures as part of their role (Kleinpell et al., 2008). Billing can enable measurement of NP productivity and contributions to patient care. Billing is being reported with increasing frequency in inpatient adult NP care (Kapu, Kleinpell, & Pilon, 2014; Munro, 2013). This novel study gathers data regarding the prevalence of PICU NP billing that will, in part, aid future studies using billing data.
Hospital reporting structures also vary. In some institutions, NPs report to multiple supervisors, often a physician and a nurse or another advanced practice registered nurse (APRN) (Bryant-Lukosius & DiCenso, 2004; Lowe et al., 2012; Verger et al., 2005). When an NP reports to multiple supervisors, competing or conflicting expectations and increased regulation of the NP's practice have been reported (Bryant-Lukosius & DiCenso, 2004; Kilpatrick et al., 2013). The occurrence of PICU NPs reporting to multiple supervisors is not known and may have consequences for practice.
A national, quantitative, cross-sectional descriptive survey of PICU medical directors and lead PICU NPs was conducted to evaluate 1) PICU provider team composition and provider supply, 2) NP roles in PICU care, and 3) regulatory influence on PICU NP practice environments. A modified Dillman approach was used to develop a 34-item survey instrument for this study, which was based on concepts derived from a synthesis of nursing, economic, and policy frameworks for NP participation in care delivery and practice regulations (APRN Consensus Work Group, 2008; Dillman, Smyth, & Christian, 2014; Elliott & Walden, 2014; Kilpatrick et al., 2013; Safriet, 2002; van Offenbeek & Knip, 2004). The survey included four sections: demographic characteristics, institutional characteristics, PICU NP regulation, and PICU NP role–related questions. The influence of regulation on PICU NP practice is the focus of this article.
Guided by study aims and previous research on NP regulation, the survey included seven variables related to PICU NP regulation. Questions asked about NP practice authority, prescriptive authority, and organizational-level regulations (Irvine et al., 2000; Kilpatrick et al., 2013; Kleinpell et al., 2008; Kuo, Loresto, Rounds, & Goodwin, 2013; Moote et al., 2011; Verger et al., 2005). Each respondent's state was identified and categorized using the AANP State Practice Environment classification at the time of data collection (AANP, 2017). Two survey questions asked about the alignment of SSOP and organizational-level regulations and whether institutional policies regarding 1) practice and 2) prescriptive authority were consistent with or more restrictive that SSOP regulations. Multiple-choice questions were asked to determine 1) what organizational entities credentialed NPs within the institution, 2) who employs and supervises PICU NPs, and 3) what are the billing practices for procedures and services performed by the PICU NP.
Institutions identified as operating a PICU in the 2015 American Hospital Association Annual Survey were contacted to confirm the continued operation of a PICU (American Hospital Association, 2015). Surveys were sent to a medical director at each operational PICU (n = 326). Telephone calls were made to each PICU to determine whether a PICU NP was employed. If an NP was employed, an additional survey was sent to the lead (most senior or NP serving in a supervisory role among a group of PICU NPs) PICU NP (n = 140).
An introductory postcard and three separate survey mailings were conducted between October 2016 and January 2017. Survey mailings included a cover letter; a definition of key concepts; a hard-copy paper survey, which included an electronic participation option; and a self-addressed, stamped return envelope. Returning a survey indicated participant consent. Participants (one medical director and one lead PICU NP) who returned a completed survey were eligible for a drawing for a $250 visa gift card. A secure web-based platform, Research Electronic Data Capture (REDCap), hosted at Vanderbilt University was used to capture data (Harris et al., 2009). Surveys were returned electronically through REDCap (n = 29, 19%) by participants or by postal mail (n = 123, 81%). Participants recorded their own responses electronically, or mailed survey responses were double entered by a study team member into the REDCap system. The Vanderbilt University Medical Center's Institutional Review Board approved this study before recruitment and distribution of any study materials.
Data analyses were performed using IBM SPSS Statistics 23.0 (IBM Corporation, 2015). Frequency distributions summarized the nominal and ordinal study data; median and interquartile range were used for summarizing continuous data. Cross-tabulations and chi-square tests of independence were used to assess differences among the distributions of nominal and ordinal distributions. An alpha level of 0.05 (P < .05) was considered statistically significant.
Survey respondents and response rates
Responses were received from 97 (30%) PICU medical directors and 60 (45%) lead PICU NPs. For the purposes of this article, gauging the knowledge of the regulatory environment by providers familiar with PICU NP practice, only respondents from institutions that currently employ PICU NPs were used in the analysis (n = 93, 66% of the US institutions with an operational PICU identified as having employed PICU NPs). The sample included 61 physicians (63% of respondent medical directors) and all respondent NPs (n = 60). For institutional-level data, institutions were included in the analysis if either a medical director or NP responded; if both providers responded from the same institution, the physician response was included in the analyses of institutional-level responses for a consistent institutional-level respondent. Paired responses from both the medical director and the lead NP were received from 26 institutions.
Respondent characteristics are summarized in Table 1. Medical director and lead PICU NPs were employed at their current institution for similar durations of time (11 vs. 10 years, respectively, P > .05). Compared with medical directors, PICU NPs were more likely to be female (88% vs. 36%), younger (40 vs. 54 years old), and board-certified PICU providers for a shorter period (9 vs. 18.5 years) (all P < .01) (Table 1).
Alignment of state scope-of-practice regulations and organizational policies
Summaries of the organizational regulation of NP practice and prescribing authority alignment with SSOP regulations are presented in Table 2. Nearly one third of respondents (30%) reported that organizational policy imposes more restrictions on PICU NP practice than required by SSOP regulations. Of respondents located in full practice authority states, more than 60% reported having full practice authority and no organizational-level restrictions to practice in their institution. With regard to prescriptive authority, nearly three fourths of respondents (74%) reported that organizational regulation of PICU NP prescriptive authority was consistent with SSOP regulation. Differences in reported alignment of organizational regulation of NP practice and prescriptive authority with SSOP regulations were not statistically significant by SSOP environments (P > .05).
Report of state scope-of-practice and organizational regulation alignment by role
Summaries of the alignment of organizational regulation of NP practice and prescribing with SSOP regulations of NP practice reported by a medical director and lead PICU NP are shown in Tables 2 and 3. Although reports of the alignment of organizational regulation of PICU NP practice with SSOP regulations were not statically significantly different, a greater percentage of medical directors described that organizational policies pertaining to practice authority were more restrictive than state laws (33% vs. 26%). At the same time, medical directors were more likely than the lead PICU NPs (25% vs. 5%, P = .009, Table 3) to report not knowing how organizational regulation of NP prescriptive authority aligned with SSOP prescribing regulations.
Responses from the lead PICU NP and the medical directors were analyzed separately (Tables 4 and 5). There were no statistically significant differences in PICU NP or medical director reports of the alignment of organizational regulation of NP practice or prescriptive authority among the varying SSOP regulation categories (P > .05).
Among pairs of medical directors and lead PICU NPs working in the same institution (n = 26), alignment of organizational regulation of practice with SSOP regulation was not statistically significantly different (P = .49), and neither were perceptions of the alignment of organizational regulation of prescribing and SSOP regulation (P = .096). Overall, 52% (n = 26) of the physician and NP pairs indicated that the organizational regulation of PICU NP practice was aligned with SSOP regulations, and 84% (n = 42) indicated that the organizational regulation of PICU NP prescribing was in alignment with SSOP regulations.
Descriptive summaries of organizational-level restrictions to PICU NP practice are presented in Table 6. Most respondents reported that PICU NPs are credentialed and received practice privileges through the institution's medical staffing committee (90%). However, nearly one quarter of PICU NPs are also credentialed by an allied health staffing (25%) and/or nursing staffing (24%) committees. Only 40% (n = 33 of 84) of respondents indicated that PICU NPs bill for services or procedures, whereas just over a quarter (27%) of PICU NPs bill using a personal National Provider Identification.
Nearly 80% of respondents (n = 74 of 93 institutions) indicated that the PICU NPs are employed by the hospital; four institutions have both hospital- and nonhospital-employed PICU NPs working in the PICU. One third of respondents (38%) describe that PICU NPs report to multiple supervisors. Pediatric intensive care unit NPs most frequently reported to a PICU medical director (72%), with half (51%) reporting to an advanced practice provider.
The key findings of this study include the following: 1) most respondents reported that organizational regulation of PICU NP practice and prescribing is in alignment with SSOP regulations; 2) PICU medical directors and lead PICU NPs are generally in agreement with regard to the alignment of organizational regulations of NP practice and prescribing with SSOP regulations; and 3) organizational-level restrictions on PICU NPs can introduce redundant oversight and limit visibility of PICU NPs' practice with billing policies. These findings have implications for clinical practice and should be the focus of future research on regulation of the PICU NP.
Alignment of organizational policies and state scope-of-practice regulations
Pediatric intensive care unit nurse practitioner practice and prescribing
In this initial study of the regulation of NPs in PICUs, a minority, nearly a third of respondents (30%), reported that organizational regulation of PICU NP practice authority is more stringent than required by SSOP regulations. In studies of the primary care workforce, increased regulation of NP practice was associated with reduced patient access to care (Kuo et al., 2013) and a smaller NP workforce (Reagan & Salsberry, 2013). Given the current demand for PICU care and the PICU provider shortage (HRSA, 2006), overregulation should be minimized, and NPs should be allowed to practice to the full extent of their education and certification (IOM, 2010). In addition, given a desire to increase the role of PICU NPs in patient care (Freed et al., 2011), alignment of the organizational regulation of NP practice and prescribing with the SSOP regulations should provide a framework for organizations.
One approach would be implementation of the Consensus Model for APRN Regulation (the Consensus Model). The Consensus Model supports alignment of the NPs' education, certification, and licensure and can guide policy change that may result in more standard national PICU NP practice environments (APRN Consensus Work Group, 2008). However, as long as variations in the PICU practice environment persist, future research is needed to determine how PICU practice environments influence patient, family, and organizational outcomes (Bahouth et al., 2013; Kleinpell et al., 2008; Lowe et al., 2012).
Previous studies have demonstrated safe prescribing, with low error rates among NPs in adult ICUs (Carberry, Connelly, & Murphy, 2013) and higher rates of NP prescribing when physicians are present at a practice site (Kaplan & Brown, 2004). In the PICU, nearly three fourths (73%) of respondents reported prescribing regulation inline with SSOP regulations, whereas 11% of respondents reported more organizational restrictions on prescribing than required by SSOP regulations. In a previous study, the presence of physicians resulted in more provider consultation and fewer barriers to prescribing for NPs (Kaplan & Brown, 2004); this affects the context with which PICU NP prescribing should be evaluated. With the physician's presence in the PICU increasingly around the clock (Pronovost, 2011), changes in NP prescribing patterns should be monitored and evaluated in future studies, particularly comparisons among multidisciplinary provider roles in medication prescribing, patient safety outcomes, and NPs' perception of role actualization (Lowe et al., 2012).
Physician and pediatric intensive care unit nurse practitioner report
Differences in reports of the alignment of organizational regulation of NP practice and prescribing with SSOP regulations were not statistically significantly different among PICU medical directors and lead PICU NPs. The finding of a shared perspective among respondents is encouraging to those who seek to develop the role of NPs in PICU care delivery. Nevertheless, provider collaboration, teamwork, NP autonomy, and role actualization should be examined in studies of organizational regulation of NP practice and PICU climate (Kilpatrick et al., 2013; Lowery, Scott, & Swanson, 2016; Peterson & Way, 2017; Poghosyan et al., 2013). Future research that focuses on providers who report similar and contradictory perspectives of NP practice regulation may highlight how regulations influence clinical practice and NP role actualization.
Overall, PICU medical directors were more likely to report uncertainty about how regulations influenced NP prescribing than were PICU NPs (25% vs. 5%, P = .009). This finding reinforces the importance of NPs' educating physician colleagues and hospital administration on NP SSOP regulations (Kleinpell et al., 2008) and assisting medical directors' in envisioning expanded roles for PICU NPs. Well-informed physicians may become partners with NPs in advocating for organizational-level and SSOP regulations that support full NP practice and prescriptive authority.
Within organizations, credentialing and reporting through multiple organizations and supervisors, as described by respondents in this study, represent unnecessary duplication and competing expectations reported in previous studies (Bryant-Lukosius & DiCenso, 2004; Kilpatrick et al., 2013). Streamlining credentialing and reporting structures can optimize the use of organizational resources. Studies to understand how credentialing bodies perceive their role and to what extent they intervene to restrict NP practice can help foster approaches to limit organizational regulations that have been identified as being more restrictive than SSOP regulations (Kleinpell & Hudspeth, 2013). In addition, APRN-led reporting structures have been associated with improved NP satisfaction, retention, and accountability (Elliott & Walden, 2014; Metzger & Rivers, 2014). The significance of the provider type (nurse, NP, or physician) and number of supervisors should be considered because PICU NP programs desire to grow in size.
Billing is often used to assess NP productivity and their contributions to patient care. However, with 60% of respondents reporting that PICU NPs do not bill, and with the development of value-based and bundled payment systems, the use of billing as a marker of productivity and involvement in patient care will have limited utility in future studies of PICU NP practice. In addition, in a fee-for-service environment, limits on PICU billing restrict NPs' ability to contribute to their organizations' financial health and have implications for evaluating the cost of providing PICU care. As trends in inpatient NP billing change (Kapu et al., 2014; Munro, 2013), continued assessment of practices in and the prevalence of PICU NP billing will be important to understand. In the meantime, with only 25% of PICU NP billing using a personal NPI, additional measures of NP utilization and productivity are needed to allow for a more comprehensive assessment of their contributions to patient and financial outcomes (Moote et al., 2011; Riley, Poss, & Wheeler, 2013).
This study may be limited by respondents' knowledge of NP practice and prescribing regulations. Further work to elucidate physicians' and NPs' dearth of knowledge of these regulations can guide future evaluation of their perspective on the regulation of NP practice.
Questions regarding organizational-level regulation of PICU NP practice were limited in the scope of the question. Practices related to billing for services and procedures were addressed as a single item, and more detailed knowledge surrounding practices would have been generated with separate questions. The addition of a question about parties responsible for a PICU NP's salary would increase the understanding of NP-reporting structures in situations where there are multiple supervisors.
In addition, this sample examined reports of PICU medical directors and lead NPs on the alignment of organizational regulations on practice and prescribing with SSOP and in the PICU. These findings are not generalizable to all ICUs that employ NPs.
The regulation of NP practice results in barriers to and variations in practice that have been shown to decrease access to care and have no association with quality of care (Bahouth et al., 2013; Loresto, Jupiter, & Kuo, 2017; Poghosyan et al., 2013; Reagan & Salsberry, 2013; Timmons, 2017). Respondents report that PICU NPs generally have practice and prescriptive authority that align with SSOP regulations, which varies in the degree of restriction by state. As more states move to full SSOP regulatory environments, the assessment of organizational-level restrictions on practice will become important to evaluate attainment of full practice for NPs in their PICU clinical practice environment (Kleinpell et al., 2008; Lowe et al., 2012). Studies examining how various degrees of PICU NP practice regulation, up to and including full practice, influence patient outcomes are important for understanding the clinical implications (intended and unintended) for regulating NPs in general and PICU NPs specifically.
Within institutions, organizational-level regulations also shape clinical practice environments. Organizational regulations related to granting clinical privileges of PICU NPs should align with SSOP regulations. If the organizational regulations are redundant or more stringent than SSOP regulations, institutions should undertake efforts to eliminate undue regulation (Kleinpell et al., 2012; Kleinpell & Hudspeth, 2013) and facilitate the development of each health care provider's role to its fullest to allow for optimal health care human resource utilization (IOM, 2010; Silver, Ford, & Stearly, 1967).
Although PICU NPs have been integrated into multidisciplinary health care teams, regulation of their practice is inconsistent. Findings from this study indicate that most institutions allow PICU NPs to practice and prescribe at the level of their SSOP without additional restrictions from the institution. The PICU medical directors and lead PICU NPs are also generally in agreement with regard to the extent to which organizational regulation of PICU NP practice and prescriptive authority align with SSOP regulations. However, organizational-level restrictions to practice can introduce redundant oversight with multiple credentialing and supervisory pathways. In addition, billing policies limit the visibility of PICU NPs' practice; additional measures of utilization and productivity are needed. Ongoing evaluation of variations in SSOP and organizational-level regulations should continue to ensure that the regulations on practice are enacted in a way that optimizes PICU NPs' contribution to patient care and result in desired patient, family, and organizational outcomes.
Acknowledgements:The authors acknowledge Dr. Ruth M. Kleinpell, PhD, RN, FAAN, FCCM, for thoughtful review of the manuscript.
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Keywords:© 2018 American Association of Nurse Practitioners
Advanced practice nurse; credentialing; critical care; nurse practitioners; pediatric; policy; privileging; regulation; research