In honor of Nurse Practitioner (NP) Week, Simi Joseph DNP, FPA-APRN, NP-C, NEA-BC and a nurse executive/advanced practice provider gave some insights about working as an NP. Joseph, who is also a Harvard Clinical Research Scholar and a past AANP Clinical Excellence Award Winner, was recently awarded a spot in POCN’s Top NPs of 2022. POCN is a peer education and support network for nurse practitioners and physician associates.
Please tell me about your career path as a nurse practitioner and how you arrived at where you are now. Seventeen years ago, while I started my career in the United States, my motivation and vision were to make a lasting impression in the nursing field. My family migrated to this country to have a better life and to continue my education. I started as a registered nurse in the med-surg unit. The turning point of my career was when I switched my specialty to gastroenterology. I immediately fell in love with the gastroenterology specialty. The enthusiasm carried me all these years to work as an advanced practice nurse for gastroenterology patients. For the past 14 years, I have been taking care of acute and chronic GI patients. I had opportunities to implement many clinical programs for gastroenterology specialty practices. In addition, I am an adjunct professor, nurse researcher, speaker, and have mentored many advanced practice providers.
I feel blessed when I look back at my career growth. There were many mentors throughout my career who have guided me to choose the right path in the nursing profession. In addition to that, I believe in having a passion and determination in whatever you do can open many opportunities in the nursing career.
What makes your nursing specialty such a good fit for your interests and skills as a nurse practitioner? I believe nursing specialties always match with the personality of the nurse. I am a person who loves to work in a fast-paced environment and like to face challenges. Gastroenterology specialty is a mix of treating disease conditions using medications as well as different types of procedures. We get to learn many skills through diagnostic technologies and developments in this area.
Please tell me a little about the America’s Top NP award and how it feels to be recognized by your peers for nursing excellence. As a minority nurse, I feel humbled and honored by this recognition. This award is given to nurse practitioners who have made extraordinary contributions to support patient care, their peers, and to the community. POCN’s America’s Top NP award is very special because the awardees are nominated by their peers who recognize the candidate as someone who have excelled in many areas as an advanced practice nurse.
What do you wish more people knew about a career as a nurse practitioner? Advanced practice nurses (APNs) are a vital part of our complex healthcare system. APNs provides primary, acute, and specialty health care across the lifespan through assessment, diagnosis, and treatment of illness and injuries. They are registered nurses educated at masters or doctoral level in a specific role and patient population.
In addition, APNs are certified and licensed to practice in the United States. To correct the shortage of primary care physicians, more health care facilities are utilizing APNs to care for their patients. For almost 50 years of the history of APNs, evidence shows NPs have consistently proven to be cost-effective providers of high-quality care. There are still many areas where an APN can be utilized to give high-quality and timely care to patients. I always advocate for nurses to advance their careers by becoming advanced practice nurses.
What advances are you most excited to see in the nursing industry? In the nursing industry, I am more excited to see how an advanced practice providers can lead many areas of healthcare industry. They can educate other nurses, manage larger nursing departments, develop, and maintain nursing informatics systems, help draft health care policies, and provide executive-level nurse leadership to medical organizations. Another recent advancement is the achievement of full practice authority license in 29 states, where NPs can practice independently without a collaborative agreement.
In the long struggle to gain full practice authority (FPA), nurse practitioners (NPs) can point to notable advances in the last few years. Now, patients in more than half of the states, the District of Columbia, and two U.S. territories have full, direct healthcare access from NPs.
In April 2022, New York and Kansas granted FPA to NPs. That brings to 26 the number of states where NPs can practice to the top of their license without restriction. In this article, we’ll look at how that progress was made, the impact of COVID, and how newly proposed federal legislation would strengthen NP practice. But first, let’s have a look at what FPA means.
“Full practice authority is essentially that the nurse practitioner can practice to the full extent of their education and training,” says April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, president of the American Association of Nurse Practitioners (AANP). “Nurse practitioners are trained to evaluate patients, make diagnoses, order and interpret tests, prescribe medications, coordinate care, and educate. We are educated and trained to do these things,” says Kapu.
In the past few years, the pace has “really picked up as we have seen more and more states move to full practice authority,” according to Kapu. She notes that four states moved to full practice authority through the pandemic: Delaware and Massachusetts in 2021 and New York and Kansas in 2022. “It’s because we demonstrate our commitment to quality and equitable care and ensuring care is provided in all communities.”
In states that have moved to full practice authority, “we’ve seen improved patient care outcomes. We’ve seen an increase in the workforce. We’ve seen an increase in nurse practitioners working in historically underserved urban and rural areas,” Kapu says.
FPA, COVID and Care
While devastating, COVID helped bring to light the high-quality care that NPs provide and boosted efforts to gain FPA. In some states where NPs worked under less than full practice authority, the governors signed executive orders waiving various restrictions, notes Kapu.
“That’s where we saw the opportunity for nurse practitioners to continue providing care. They provided very high-quality care. They were able to provide more accessible care. As you saw throughout the pandemic, they were in communities and churches, going door to door, seeing patients in their homes, and doing everything they did in the hospital and the ICUs. So we demonstrated that continued quality of care. And that is what quickened the momentum during the pandemic; the executive orders provided that opportunity,” Kapu says.
In Ohio, a reduced practice state, an emergency authorization during COVID allowed NPs to deliver care via telehealth, notes Evelyn Duffy, DNP, AGPCNP-BC, APRN-NP. However, she notes that NPs can still practice via telehealth, and that ability is no longer contingent on the emergency authorization. Based in Cleveland, Duffy is an NP in the University Hospitals Geriatric Medical Group and a professor at the Frances Payne Bolton School of Nursing.
An NP since 1981, Duffy notes that “we’ve come a long way in Ohio. We got full prescriptive authority at the end of the 1990s.”
However, like all Ohio NPs, Duffy needs a collaborative agreement with a doctor. “Ohio is in the reduced practice category,” she notes. “Not a lot obstructs me from doing what I want. The only thing that gets in the way is having to make that collaborative arrangement.”
Kapu stresses the need to get out the message that laws limiting NP practice need to be revised. Laws need to be updated to “allow NPs to practice to the extent of their education and training, not beyond that, but to the extent of their education and training, as they are very capable of doing and have decades and decades of evidence demonstrating their quality-of-care outcomes. So it’s getting that message out that all we have to do is update those laws. It’s no cost or delay and can be put into place, and you would see much-increased access.”
Kapu points to Arizona as an example of what may happen for states that grant FPA. Arizona, she notes, moved to FPA in 2001. Five years later, the NP workforce doubled, and rural areas saw a 70% increase in NPs.
FPA Federal Legislation
On the federal level, new legislation, the Improving Care and Access to Nurses (ICAN) Act, was introduced in September in the House of Representatives. Supported by the AANP and other major nursing organizations, the act would update Medicare and Medicaid to enable advanced practice nurses to practice to the top of their education and clinical training, according to a press release from the American Nurses Association.
Although getting FPA in all states has taken a little longer than wanted, “we have momentum,” says Kapu. “I believe we’ll get there, especially with the increasing access to care needs that we’re seeing in the United States today.”
Between the role’s autonomy and the hours’ flexibility, there’s never been a better time to be a Nurse Practitioner (NP).
What are the advantages of becoming an NP? Unfortunately, we don’t have nearly enough space to list them all, but our sources will give you a good idea of some.
Benefits of Becoming an NP
“I believe that nurse practitioners bring a unique perspective to the relationship with our patients. Our educational foundation is rooted in the nursing model, whereas physicians are trained in a more traditional medical model. Nurse practitioners are accustomed to treating the entire patient rather than solely treating a disease or condition,” says Teresa Cyrus, DNP, APRN, FNP-C, co-owner of Integrative Geriatrics, a practice that provides care to underserved adults and seniors in rural Minnesota.
“I believe it is a more holistic approach to patient care. For example, if my patient is being seen for frequent falls, I can visit their home to determine what may be contributing to them. In addition, I will check in with the nursing staff and the patient’s family to get additional perspectives when developing a treatment plan, and then continue to monitor the patient closely after our visit,” she says.
Cyrus, an assistant professor at St. Catherine University in St. Paul, adds that NPs have been filling roles where it’s been more difficult to recruit physicians in geriatrics, family practice, and rural areas. “In the past several years, I have also seen an increase in NPs working as hospitalists, in more nuanced specialty areas, and even as medical directors.”
Role of NP is Changing
In many states, the role of the NP has or is changing.
“NPs’ role and scope of practice have expanded depending on the state where they are licensed to practice. For example, in my state, NPs can practice independently. That means they can own, manage, and operate their clinics without a collaborating physician,” explains Rei Serafica, Ph.D., who is a full-time faculty member at the University of Nevada, Las Vegas School of Nursing and works once a week at an inpatient psychiatric mental health facility in North Las Vegas.
“Some NPs are entrepreneurs, consultants, educators, and even researchers. Some NPs work in academics like me. We are [training] future NPs, and we also manage and balance our careers by devoting a day to practice as NPs to maintain our professional skills and credentials. In other words, it is a dynamic profession that offers flexibility and multiple career opportunities.”
Opportunities for NPs Are Endless
The opportunities seem endless regardless of the type of NP a nurse chooses to become.
“The healthcare system has found relief in employing us in all sectors. NPs are seen everywhere now—from clinics to hospitals and are at the front, cutting-edge of clinical research, faculty, and teaching,” states Isra Hashmi, FNP-BC, who works in private practice. She adds that job security is a big relief because not only are NPs not going anywhere, and their career is only expected to grow.
Nicole Beckmann, Ph.D., APRN, CPNP-PC, embodies the diversity of working as an NP, as she has worked in three different specialties over 15 years of practice.
“[I] find this to be one of the important ways I can continue to grow professionally and challenge my skills. Additional benefits include increased autonomy in decision-making and management of health conditions. Nurses use their holistic approach to patient care to see patients’ health problems in the context of their lifestyles, personal goals, and preferences. In addition, nurses recognize their patients as people, learning each patient’s story, priorities, and unique needs. [We] bring this approach to the patient/provider relationship to diagnose conditions and partner with patients to determine the best treatment options. Patients appreciate this connection and the meaningful relationships they form with their NP providers. This is what makes being a nurse practitioner so satisfying.”
Hours are Long, But Have an Upside
As for hours, NPs may still have to work long hours, but Beckmann explains the upside of it.
“Depending on the work setting of the nurse practitioner, hours may include evening, overnight, or weekend shifts. However, this also means that nurse practitioners can choose a position and work schedule that fits their lifestyle. For example, part-time positions, extended shifts, and block scheduling may allow for long periods off or for the nurse practitioner to have the work/life balance they seek,” she says.
Cyrus says she loves her job, “Being an NP is tremendously rewarding, and I encourage any nurse who expresses interest to pursue that calling.”
Nurse practitioners (NPs) have a great deal of responsibility regarding patient care, and as the healthcare landscape evolves, so do the daily risks NPs face. Despite compassionate work and service to the community, one lawsuit can affect your professional reputation. Nurse practitioner malpractice data can be used to inform and address areas of clinical improvement as well as help to improve the quality of care and patient safety.
Nurses Service Organization (NSO) and CNA have published the new edition of the Nurse Practitioner Professional Liability Exposure Claim Report analyzing 232 closed professional liability claims against NPs, student NPs, and NPs covered through a CNA-insured healthcare business over five years (2017-2021). By equipping NPs with data, resources, and case study examples, our goal is to help them recognize their exposures, reduce their risks, and improve patient outcomes.
Nurse Practitioner Professional Liability Exposure Claim Report, Fifth Edition
Here are the key takeaways.
NP Professional Liability 5-Year Closed Claim Analysis Patterns and Trends
Malpractice claim costs are on the rise.
The average total incurred amount of a nurse practitioner malpractice claim has increased to $332,137 – a jump of more than 10.5% since 2017. In addition, there has been a continued shift towards larger claim settlements. For example, claims resolved for greater than $500,000 represented 21.5% of all claims in the 2022 dataset, compared to 13% in the 2012 dataset.
The most common allegation against NPs is related to diagnosis.
Diagnosis-related allegations represented 37.1% of all allegations against nurse practitioners and continue to be the leading allegation through 2012, 2017, and 2022 datasets. Contributing factors for these diagnosis-related claims included the failure of an NP to order a diagnostic/lab test to establish a diagnosis, failure to obtain a complete history and physical of the patient, and failure to refer a patient to higher level care.
Cancer and infection are the two most common diagnosis-related injuries, representing more than half of the claims. In many diagnosis-related closed claims, a lack of sound documentation supporting the decision-making process of the treating NP or other staff members under the NP’s supervision hindered the case’s legal defense.
Common missing or incomplete documentation noted in the dataset included:
Lack of a complete patient and family history.
Incomplete physical assessment.
Failure to list current medications and/or complaints.
Failure to document patient noncompliance with appointments, ordered diagnostic tests and/or prescribed medications.
Absence of notification of diagnostic test results and recommendations for further treatment or testing.
Nurse Practitioner’s Failure and Outcome
An example of an NP’s failure to order diagnostic/laboratory testing includes:
A 51-year-old diabetic male patient presented to the NP’s office following an emergency department (ED) visit due to a wound on his right foot that appeared to be infected. The NP photographed the wound, documented that it was 0.5 cm in diameter, and confirmed that the patient was still taking the antibiotics as prescribed to him by the ED provider.
Although he was instructed to return in a week for a recheck, he presented two weeks later. The NP documented the wound as 2 cm in diameter with granulation tissue and purulent drainage, and the forefoot was reddened, warm, and swollen. The NP opined that he might need to perform a procedure to evacuate the infected area, but for unknown reasons, the procedure was not performed. Instead, the patient was given a prescription for a different antibiotic, and his wound was cleaned and redressed. One week later, the patient returned, reporting vomiting and feeling weak. His eyes were jaundiced, and his right toe and right leg were more swollen than the prior week. The NP ordered Ceftriaxone 1 gram intramuscularly in the office and then every 24 hours for the next three days via home health. Also ordered were daily dressing changes to the affected foot, vital signs, and bi-weekly (twice-a-week) blood work for the next two weeks.
When home health arrived for the initial visit at the patient’s home, he appeared diaphoretic and pale. His vital signs were indicative of sepsis (high fever, elevated heart, respiratory rate, and low blood pressure). The patient was transferred to the ED and diagnosed with sepsis. He eventually underwent a below-the-knee amputation of his right leg.
Defense experts could not defend the claim, as they indicated that the patient should have been sent to the ED during his last visit with the NP or referred to an infectious specialist or wound care provider after his second visit. The NP testified he had encouraged the patient to go to the ED for treatment on the second and third visits but that the patient refused. There was no documentation in the patient’s healthcare information record to corroborate this testimony. The claim was resolved with a total incurred of greater than $950,000.
Nurse Practitioners: Analysis of License Protection Paid Claims
State Board of Nursing (SBON) investigations are serious matters and a significant investment of time and effort by the NP until they are resolved. Therefore, legal representation in these matters is highly recommended. A complaint against an NP’s license to an SBON differs from a professional liability claim in that it may or may not involve allegations of patient care and treatment provided by an NP. The disciplinary matters in this section represent the cost of providing legal representation to an NP in defending such actions rather than indemnity or settlement payments to a plaintiff.
The cost to defend license matters is increasing. For example, the average cost of defending complaints against nurse practitioners to an SBON is $7,155, a 19.5% increase compared to the 2017 report and a 61.1% increase compared to the 2012 report.
Key findings in the 2022 dataset related to licensing board complaints are:
Professional conduct, medication prescribing, and scope of practice complaints account for more than half of all license protection closed matters (58.4%).
License board complaints related to the professional conduct category were largely driven by matters categorized as professional misconduct defined by the state, such as unprofessional conduct with patients or coworkers, termination from employment due to unspecified performance issues, and professional boundary issues with patients.
Approximately 43% of license board protection matters led to some board action against an NP’s license. Common SBON actions included probation (12%), public reprimand (11.2%), consent order or stipulation (6.4%), and a fine (3.6%). The more severe SBON decisions – such as the surrender of license (2%), revocation (2.4%), and suspension (2.8%) – are less common but can effectively end an NP’s career.
Risk Control Recommendations for Nurse Practitioners
The following risk control recommendations can serve as a starting point for nurse practitioners seeking to evaluate and enhance their patient safety and risk management practices:
Practice within the requirements of your state nurse practice act, in compliance with organizational policies and procedures, and within the national standard of care.
Maintain basic clinical and specialty competencies by proactively obtaining the professional information, education, and training needed to remain current regarding nursing techniques, clinical practice, medications, biologics, and equipment.
Document your patient care assessments, observations, communications, and actions in an objective, timely, accurate, complete, and appropriate manner.
Consider these questions when pursuing a specific diagnosis:
Are factors present that do not align with the diagnosis?
Are there symptoms inconsistent with the current diagnosis?
Are the symptoms indicative of another diagnosis?
Are there elements that can’t be explained?
Is there a condition with similar symptoms to consider?
This analysis of NP professional liability and license protection closed claims reveals that, while there have been advances in clinical practice and patient safety, many claims continue to develop due to a failure to diagnose, treat, or take precautions regarding medication safety. Further, communication missteps, inadequate documentation, and unprofessional conduct made matters challenging to defend.
It is anticipated that the data, analysis, and risk control recommendations shared in the report will inspire nurse practitioners nationwide to examine their practices and focus their risk control efforts on the areas of statistically demonstrated error and loss.
The Nurse Practitioner Professional Liability Exposure Claim Report: 5th Edition is the fifth claim report published by CNA and NSO addressing nurse practitioner liability since 2005 and represents NSO and CNA’s ongoing commitment to educating the nursing community. The general analysis includes 232 anonymized closed claims involving a nurse practitioner, nurse practitioner receiving coverage through a CNA-insured healthcare business, or nurse practitioner student that resulted in paid indemnity greater than or equal to $10,000.
This information is provided for general informational purposes and does not provide individual guidance. This information is not a substitute for any workplace practices and is not establishing a standard of care.
The week of November 8-14 honors nurse practitioners with National Nurse Practitioner Week. Nurses who achieve this professional status have plentiful and rewarding career opportunities to explore. As a nurse practitioner (NP), nurses have the flexibility and options to focus their practice in specialties that are most meaningful to them.
As nursing students consider their career paths, becoming a nurse practitioner is often a goal for nurses who want a degree of autonomy and who might enjoy the challenges of making many decisions in treating patients.
Because becoming an NP requires at least a master’s of science in nursing and a doctorate in nursing is encouraged, becoming an NP takes dedication to earning advanced degrees. If you’re considering becoming an NP, you don’t need to follow a direct educational path but you do need a commitment to earning those degrees.
Working as a registered nurse while you continue your studies to an NP gives you opportunities to find the niche of nursing that most appeals to you. Throughout your different roles, whether those are your early clinicals as a student or your first jobs after you graduate with a bachelor’s degree and assume a registered nurse (RN) role, you’ll explore many different specialties to find a good fit. Planning out your professional path helps you take steps toward each goal.
The American Association of Nurse Practitioners is a national organization that supports NPs ability to practice independently. In some states, NPs are able to practice entirely independently in a solo practice if they choose. Other states require NPs to work under the oversight of a physician. NPs and physicians are able to diagnose patients and treat them as they consider the patient’s health and additional factors that may impact their treatment plans. Like a physician, nurse practitioners’ required education and advanced training allow them to become licensed to prescribe medications to patients, something RNs aren’t licensed to do.
Within a NP path, nurses can choose a specialty that appeals to them. Many NPs become family practitioners and treat all ages and conditions. Others may specialize in the mental health and psychiatric specialties and others may choose to focus more on a specific age group (older adults or pediatrics). As you become more experienced in your career, you’ll develop important relationships with your patients, many of whom you’ll treat over a long time.
This week, celebrate your accomplishments and the changes you have made in the lives of your patients.