In 2010, the Institute of Medicine's (IOM) groundbreaking Future of Nursing report made a core recommendation that nurses should practice to the full extent of their education and training.1 One of the new buzzwords resulting from this recommendation is the term top of license. This has come to mean working to the full extent of the practice act under which a professional nursing license is granted. However, with different nursing licenses (RN versus advanced practice RN [APRN]), different entry levels, and a wide variety of certifications and skills, what does top of license really mean? What are its implications for nurse leaders constantly challenged with productivity, staffing, and morale issues? In today's healthcare environment, nurse managers and administrators need a clear understanding of the opportunities associated with demanding top-of-license practice, as well as the barriers to achieving it at the organization level.
Top-of-license practice means matching the right provider with the right skill set to provide the right level of care at the right time and place. It doesn't mean substituting less expensive healthcare providers for the primary purpose of saving money. Nurses are empowered to operate within the full scope of the practice act; no more, but also no less. When clinicians function in this way, everyone's education and skills are used to their fullest extent, and the result is powerful and synergistic, maximizing team productivity, promoting engagement and satisfaction, and, ultimately, leading to improved outcomes.2
Across a variety of settings, top-of-license programs are demonstrating impressive outcomes with a more efficient and effective use of nursing resources.10 For clinical nurses, practicing at top of license can result in less missed care, increased quality, and better patient outcomes. Additionally, there are financial considerations. For example, the Centers for Medicare and Medicaid Services Value-Based Purchasing policies disallow reimbursement for selected adverse patient outcomes and readmission within 30 days. These consequences can be lessened when nursing staff practice at top of license.
Evidence links advanced practice nursing to higher care quality, increased patient safety, and improvement in care coordination and population health.11-13 The use of NPs can also result in positive financial outcomes. One study demonstrated the advantages of adding NPs to inpatient care teams, including an increase in revenue, reduction in length of stay, and improvement in clinical outcomes.14 In our own practice setting, APRNs are having a positive impact on outcomes in patients with heart failure, stroke, chronic wounds, and other chronic conditions.
Perceptions of healthcare professionals needing to “protect their turf” have historically been a major barrier, both for clinical nurses and NPs. (See Top-of-license practice history.) Top-of-license practice for all healthcare professionals depends on interprofessional cooperation. The endpoint of top-of-license practice is improving patient care, not invading professional turf or solely strengthening the nursing workforce.
For NPs, barriers include state practice and licensure laws and regulations.15 Scope of practice, prescriptive authority, and collaborative practice requirements vary by state.16,17 Since the original IOM report was released, significant progress has been made in these areas, but variations still exist that can negatively impact healthcare redesign. There are also specific physician-related “turf” issues and payer inconsistencies that continue to prevent top-of-license practice for NPs. Admitting privileges at hospitals, inconsistencies in acceptance of NP orders by different providers, perceptions about and understanding of the APRN role, and job satisfaction also pose challenges.
Nurse leaders need to face the challenge of creating environments that foster top-of-license practice throughout the organization. The vital question that needs to be addressed is: “How can we support the right person doing the right job to get the right outcome?” This complicated question can only be answered by collaborative input from all healthcare workers—not just nurses. The answer may require a complete care system design review and potential redesign.
From both the financial and planning perspectives, redesigning a care system that promotes and supports top-of-license practice is a tall order. Breaking it down into incremental tasks may be helpful, such as identifying and removing nonvalue-added items from patient documentation and reformatting the nursing unit secretary role to support care transition work now that computerized provider order entry removes much of the order processing work. In addition, Advisory Board Company members have access to the report Achieving Top-of-License Nursing Practice, which contains examples for consideration.
As redesign occurs, there's also a need to acknowledge that not all tasks can be removed from a role. For example, all healthcare workers play a part in preventing infection when we sanitize our stethoscopes. Another example is that we all have a responsibility to engage our patients in their care for both their satisfaction and safety.
Nurse leaders can capitalize on the potential for APRNs to lead innovative and creative initiatives by empowering and assisting them to remove barriers to top-of-license practice. Actions may include:
- being clear about the state regulatory requirements for advanced practice that can impact the scope of practice.
- becoming actively involved in advocating for the removal of scope-of-practice barriers at the state, national, and organizational levels.
- working with APRNs to mitigate institutional barriers to full scope of practice.
- continuing to educate all members of the healthcare team, as well as the public, about the role and contributions of APRNs.
- supporting innovative models that highlight the contribution of APRNs in care coordination, care transitions, and quality improvement activities.
- promoting collaborative models of care in which every member of the care team works to the top of their education and training, and contributes equally to safe, high-quality care.
Interprofessional cooperation and collaboration need to be continuously fostered for true top-of-license practice. Organizations are increasingly moving to high-reliability concepts outlined in Weick and Sutcliffe's Managing the Unexpected.18 As team members work better together, the work should be accomplished with less rework, decreased duplication, and more care coordination. These factors will mean newfound time for all healthcare team members, which will translate to more time to improve care quality.
Another potential facilitator of top-of-license practice is the harnessing of technology in creative ways. For example, the use of enhanced voice recognition software can increase communication between healthcare workers. Use of secured communication software can bring healthcare teams together for shared care planning without the burden of travel. And advanced patient education technology can bring the team to the patient at home.
Leaders can impact multiple areas to ensure the growth and vitality of top-of-license practice, including:
- supporting ongoing research that examines how to best use the expertise of our healthcare team members, including ways of organizing care and funding growth initiatives.
- developing mechanisms that clinical nurses can use to identify and recommend new technologies that foster top-of-license practice by saving time and/or improving care.
- empowering clinical nurses to identify and report on what's working and what isn't to foster shared decision making.
- expanding nursing shared governance to interprofessional shared governance to ensure that bedside team members fully understand the scope of practice and any current issues within the full interdisciplinary team.
Partnering for transformation
To meet our current healthcare challenges, such as patient care complexity and Value-Based Purchasing, maximizing the value of healthcare human resources has never been more critical. The IOM's 2015 Assessing Progress on the IOM Report Future of Nursing asserts that it's time to let go of the “captain of the ship” mentality and embrace an “all hands on deck” philosophy.18 Nurses working at top of license can be essential partners in the transformation of healthcare.
Top-of-license practice history
- Beginnings of nursing care delivery (mid-1850s). One of the most obvious drivers of today's top-of-license issues for the clinical nurse is that nursing formalized as a profession in the mid-1850s, well before its current peers of physical therapy (1920s), respiratory therapy (1950s), and others.3 Because of the lack of other healthcare professions during its inception, nursing provided all of the care that patients needed, except for direct medical interventions, thus operating without the capability to perform at top of license. Performing a multitude of tasks doesn't allow for time to function at peak role. During this early period of nursing, performing tasks was a primary focus, with functional and team nursing the most common systems of care delivery.
- The shift to primary care nursing (1970s). A shift began about 40 years ago when primary nursing became a prominent concept in the organization of nursing care at the bedside, reducing the “producing the widget” mentality of the original nursing care delivery systems. The article “Primary Nursing: A Return to the Concept of ‘My Nurse’ and ‘My Patient’” emphasized the gains for the nurse-patient relationship inherent in primary nursing.4 Although many nurses found the model professionally rewarding, a cost came from not recognizing the rest of the growing healthcare team who could assist nursing in administering care. In today's complex healthcare environment, this care delivery model doesn't foster top-of-license practice because “being everything to every patient” doesn't allow nurses the time for this to occur.
- Top-of-license challenges (1990s). In the mid-1990s, as the nursing workforce was strengthened, some healthcare professionals felt threatened by the movement to increase nursing resources. Because operating at top of license is dependent on interprofessional cooperation, this was a major deterrent to its realization.
- Beginnings of the NP role (1960s). The NP role was first implemented to fill unmet healthcare needs, primarily for those in underserved rural and inner cities communities.5 Although there were precursors in nursing's history, this represented a successful formal effort to expand the scope of nursing practice. The NP role, as conceptualized by Ford in 1965, was designed to be one of collaboration and collegiality with the physician and not as a substitute for the physician.6 Although the NP role was welcomed by overburdened physicians in rural settings, organized medicine saw the new NP role as presenting major boundary issues. This led to efforts to control the expanded scope of nursing practice by imposing a variety of practice restrictions.5,7,8
- Expansion of the NP role (2000s). Since the first NP certificate program was offered in 1965 in Colorado, there has been rapid growth in the number of NPs, with a reported 205,000 nurses holding NP licenses in 2014. Of these, more than 83% see patients covered by Medicare and Medicaid, 97.2% prescribe medications, and 44.8% have hospital privileges.9 Today, NPs are increasingly delivering primary care in the United States alongside their physician and physician assistant colleagues.1 Advanced nursing practice offers great promise in meeting the growing need for healthcare, as access to care is expanded under the Affordable Care Act.
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