Transition to Advanced Practice Registered Nurse
Nurses may consider advancing their careers in the pursuit of personal growth and development, as well as the quest for better care delivery approaches. The advanced practice registered nurse (APRN) role is an important nursing role development that was created as a solution to the shortage of primary care physicians, as well as to meet the primary care needs of the rural and underserved population (Kerr & Macaskill, 2020).
The number of APRNs in the job field has been growing at an exponential rate, which can be attributed to the emerging and anticipated future service needs created by the growing and aging populations. While there is a clear opportunity for personal development and improved care, it requires a greater level of commitment, dedication, hard work, and compassion-fueled efforts. As a result, as I prepare to embark on the journey, I am ready to face the challenges while also using them to shape me into a better future APRN.
The purpose of this paper is to (1) describe the interventions I intend to use in navigating my first year of experience using Brown and Olshanky’s 1997 model and (2) provide a synthesis-level evaluation of how patient-centered medical homes (PCMH) and value-based payment models (VBPM) will impact my practice and transform primary care delivery, and (3) provide my thoughts on the economic benefits of using nurse practitioners in healthcare practices.
Part 1: Theoretical Model of the Transition to the Primary Care Nurse Practitioner Role
The first year of practice presents numerous challenges to new nurse professionals, but it also serves as a crucial foundation upon which they can build professional expertise. Brown and Olshansky (1997) described the “from limbo to legitimacy” model, which nurses can use as they advance in their careers from amateurs to cognoscenti. The model is divided into four stages: laying the foundation, launching, meeting the challenge, and broadening the perspective. The stages highlight the distress and accomplishments of the initial year of advanced practice.
The first phase, laying the foundation, is the time between graduating from school and beginning the initial nurse practitioner position. This stage has been divided into four subcategories: recuperating from school, negotiating the bureaucracy, looking for a job, and worrying (Brown & Olshansky, 1997). During this phase, I intend to take a two-week vacation away from home with my friends.
The years I spent in nursing school were filled with difficulties, and I intend to ease and relax my mind by taking a break from the shackles of nursing school. In addition, after my vacation, I intend to spend more time with my family members—siblings and parents—to bolster my bonds with them.
After one month, I anticipate having pressing financial needs, which will prompt me to apply for jobs at various hospitals. However, due to the uncertainty of finding work, I anticipate that worry will pretzel the situation, which I intend to duck by volunteering at hospitals of my choosing while I wait for a job.
The second phase is launching, which is described as the most painful and difficult period. This is the time it takes to transition from the safe shores of school to the turbulent and tumultuous waters of the first year of practice (Brown & Olshansky, 1997). This stage is distinguished by heightened anxiety, a sense of being an imposter, getting through the day, and battling time.
According to Brown and Olshansky (1997), the lack of experience among novice professionals contributes to feelings of imposter syndrome. I intend to avoid this by identifying and utilizing a mentor, consulting on things I don’t know, and reading to alleviate any anxiety that may arise from not knowing. Brown and Olshansky (1997) also emphasize that there is no harm in saying, “I don’t know what this is, but I’ll look it up before the procedure.”
While I understand that novice nurse professionals are slower than their experienced counterparts and that the pressure to complete tasks may be doubled or tripled, especially at 4:30 p.m. on Fridays, I will make sure that I schedule appropriately, seek help when necessary, and consult in areas that are unclear to me.
In the third phase, meeting the challenge, nurses have made significant progress and are less anxious, more settled, and more legitimate. At this point, they reflect on environmental issues and concerns that may have contributed to their success.
Following an interview with 35 nurses at 1, 6, and 12 months after graduation and entry into the practice field, the majority reported feeling more like a nurse practitioner at 6 months, and even better at 12 months than at 1 month, indicating they have accumulated sufficient knowledge and skills in the practice (Brown & Olshansky, 1997). I intend to boost my confidence and competence by seeing multiple patients and performing a variety of procedures.
Finally, the last stage of the model is broadening the perspective. Nurses become more system savvy at this point, learning how clinics operate, connect with other institutions, and become more involved in politics and advocacy roles (Brown & Olshansky, 1997).
The patients’ positive feedback, praises, gratitude, and numerous thank-you notes for the services they receive are credited for the competency attained at this stage. Such words of affirmation encourage nurses to take more risks in learning more complex systems to improve their competency. At this point, in addition to developing system knowledge and reassuring myself, I will up the ante.
Part 2: Patient-Centered Medical Homes (PCMH) and Value-based Payment Models (VBPM)
Various healthcare delivery systems, including patient PCMH and VBPM, have been developed to achieve the triple objectives: improve patient care delivery, reduce healthcare costs, and improve the patient care experience. The PCMH models ensure the delivery of a comprehensive, accessible, high-quality, cost-effective, patient-centered, culturally appropriate, and team-based approach (Shi et al., 2017).
In contrast, the VBPM advocates for reimbursement methods that are based on the value a care provider adds to the patient (Cuenca, 2017). The emergence of VBHM is attributed to the efforts of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which created new incentives for physicians to transition to value-based, alternative payment models, the US Department of Health and Human Services (HHS), which announced in 2015 a goal of moving 50% of Medicare payments into alternative payment models linked to value by 2018, and the Health Care Transformation Task Force, an alliance of major health systems, insurers, and other industry players, which announced a goal of placing 75% of its business into value-based payment arrangements by 2020 (Cuenca, 2017). The PCMH and the VBPOM have implications for a nurse’s practice and primary patient care in general.
Impact on my Practice as a Nursing Practitioner
To implement the PCMH, a nurse must demonstrate a high level of planning, which will allow for the appropriate scheduling of patient visits. This will help me improve my planning skills as a nurse practitioner and my ability to solve problems by seeing patients and addressing their concerns in the allotted time. Regarding VBHM, due to patient attribution, nurses are individually accountable to specific patients, striving to solve their problems as effectively as possible (Cuenca, 2017).
Furthermore, this approach will allow me to surround myself with a team of dedicated professionals who will check whether quality metric data has been correctly assigned, update any missing metrics, and review patient satisfaction surveys, thereby increasing my productivity.
Impact on Primary Care Delivery in the United States
Both the PCMH and the VBPM are low-cost interventions that aim to improve quality of life. As a result, such models have increased access to healthcare because people are no longer concerned about the exorbitant costs that must be paid, and they are also guaranteed quality care. According to the Centers for Disease Control and Prevention (2021), the PCMH model is associated with effective chronic disease management, increased patient and provider satisfaction, cost savings, improved quality of care, and increased preventive care.
VBHM has been linked to higher patient quality metrics. Cuenca (2017), however, expresses concern that the ease of access to high-quality, cost-effective interventions may lengthen patient wait times. This is ethereal in comparison to the benefits accrued from the care model.
Part 3: Economic Benefits of Using Nurse Practitioners in Healthcare Practices
The expansion of the supply of nurse practitioners has been proposed as one method of addressing the shortage of primary care physicians as well as other issues such as access to care. Poghosyan et al. (2019) conducted a study to determine the economic impact of expanding the scope of practice (SOP) of nurse practitioners for Medicaid.
The findings were as follows: compared to states with reduced SOP, states with full OP had 17% lower outpatient costs (i.e., $160.45 per beneficiary per year) and 10.9% lower prescription drug costs (i.e., $145.44 per beneficiary per year). States with restricted SOP had 11.6% higher outpatient costs (i.e., $107.31 per beneficiary per year) and 5.1% higher prescription drug costs (i.e., $67.89 per beneficiary per year). These findings not only support nurses’ roles in the profession but also the need to broaden their scope of practice.
According to the American Association of Nurse Practitioners (AANP) (2015), the cost-effectiveness of nurse practitioners begins with their academic preparation, which costs 20% to 25% less than that of physicians. Furthermore, nurses are far more cost-effective than physicians in terms of compensation, with statistics demonstrating that while the median total compensation for primary care physicians ranges from $208,658 (family) to $219,500 (internal medicine), the mean full-time nurse practitioner’s total salary was $97,345, across all types of practice (AANP, 2015). As a result, my thoughts, as supported by the literature cited, are that the role of nurse practitioners in lowering healthcare costs is indisputable.
In a job interview, I would cite the median earnings of physicians and compare them to those of nurses, as stated clearly on the AANP’s websites. Furthermore, I will compare the costs of academic preparation for nurses and physicians to demonstrate that nurses are more cost-effective in healthcare delivery. Moreover, unlike physicians, who may leave the hospital to attend to their private clinics, nurses stay in hospitals for longer hours to care for patients. This increases their importance in providing patients with high-quality, cost-effective care.
American Association of Nurse Practitioners. (2015). Nurse practitioner cost-effectiveness. American Association of Nurse Practitioners. https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioner-cost-effectiveness
Brown, M.-A., & Olshansky, E. F. (1997). From limbo to legitimacy: A theoretical model of the transition to the primary care nurse practitioner role. MCN. The American Journal of Maternal Child Nursing, 22(5), 274. https://doi.org/10.1097/00005721-199709000-00016
CDC. (2021, May 14). Patient-centered medical home (PCMH) model. Centers for Disease Control and Prevention. https://www.cdc.gov/dhdsp/policy_resources/pcmh.htm
Cuenca, A. E. (2017). Preparing for value-based payment: Five essential skills for success. Family Practice Management, 24(3), 25–33. https://www.aafp.org/fpm/2017/0500/p25.html
Kerr, L., & Macaskill, A. (2020). The journey from nurse to advanced nurse practitioner: applying concepts of role transitioning. British Journal of Nursing (Mark Allen Publishing), 29(10), 561–565. https://doi.org/10.12968/bjon.2020.29.10.561
Poghosyan, L., Timmons, E. J., Abraham, C. M., & Martsolf, G. R. (2019). The economic impact of the expansion of nurse practitioner scope of practice for medicaid. Journal of Nursing Regulation, 10(1), 15–20. https://doi.org/10.1016/s2155-8256(19)30078-x
Shi, L., Lee, D.-C., Chung, M., Liang, H., Lock, D., & Sripipatana, A. (2017). Patient-centered medical home recognition and clinical performance in U.s. community health centers. Health Services Research, 52(3), 984–1004. https://doi.org/10.1111/1475-6773.12523
Module 1: Advocacy and Healthcare Policy
An ongoing challenge for advanced practice registered nurses (APRNs) has been changing state legislation that allow APRNs to practice to the fullest extent to which they were academically prepared. For this discussion question, contact the Board of Nursing (BON) in your state or access your BON online. Examine laws that govern APRNs in your state. Consider the following: do APRNs in your state have prescriptive authority; is there legislation in place that allows them to practice autonomously; and finally, if a bill has been passed and adopted, which legislator introduced the bill and who were the strongest advocates for the bill? Then post an initial response that addresses the following:
Explain how the lack of autonomy for APRNs impact patients in rural populations? As a health care professional in an advocacy role, what resources could you utilize to guide you in changing policies that impact APRNS in your state? Include in your discussion the type of stakeholders and collaborative partners you would seek to guide or assist you on this cause.
Note: my state is Michigan.