Category: Nurse Practitioner Hot Topics

"Health happens outside of a medical office."

This is a common saying in healthcare. It means that beyond a standard 15-30 minute clinical appointment, a person's health occurs in their daily lives. This includes where they live, work, and play, as well as what they eat, their transportation, and more. We may think that we understand these factors, but do we truly understand how it all works?

In nursing school (pre-licensure and beyond), simulations provide an insightful experience that helps students prepare for both inpatient and outpatient situations in the clinical setting. Simulations can range from a medical emergency in a primary care office to a pregnant woman with undiagnosed eclampsia. Simulations have personally taught me how to function in a team setting, work under pressure, and learn from my mistakes without harming anyone. These lessons are all highly valuable.

The public health simulation that I participated in during my baccalaureate pre-licensure program was my favorite. This simulation showed me that I didn't understand what Americans struggle with as much as I thought I did. If there is one critical simulation for nurse practitioner (NP) students to experience, it's a public health simulation.

What Is a Public Health Simulation?

A public or community health simulation is a non-threatening activity that nursing students participate in. The activities involved in this simulation vary from school to school. While these simulations are not as popular as a traditional simulation in an acute care setting, they are critical in helping students understand disease prevention, population health, and social determinants of health. In the article "Preparing Today's Nurses: Social Determinants of Health and Nursing Education," Thornton and Persaud discuss how simulations can help students understand the health inequities that exist today. Such simulations offer incredible insight into why health disparities exist, as well as provide reflective and thought-provoking moments for nursing students that can help improve their practice as a nurse or advanced practice provider.

At my baccalaureate program, I participated in an activity with a group of student colleagues where we each played a community member with very limited resources. This particular group was a family unit, and mine included a single parent, a child under 5, a teenager, and a live-in grandparent. Our family had no car and the single parent worked two jobs. Scenarios ranged from needing to visit the county building to renew services to taking the children or grandparent to see a doctor. Our family even had our "money" stolen during one event. The experience was incredibly eye-opening. I experienced stress, despair, anger, and hopelessness throughout the simulation. I also felt frustrated with the system. How can somebody who works two jobs make it to the county office to sign for continued services for food or other resources? While I understood that life was difficult for many families in America, I did not fully grasp the extent of it until participating in this four-hour simulation. It truly humbled me. I recognized where I've placed judgment and identified implicit biases that I hadn't previously noticed. That experience made an impression that lasted all the way through my NP program, in both didactic and clinical settings.

Incorporating Community Simulation Programs for NP Students

As I look back on my time as a graduate student, the one simulation that I believe every NP program should invest in is a community/public health simulation. As NPs, we provide disease prevention and management. Therefore, we must go beyond understanding our patients and see the perspective of patients who may not have access to necessary resources. A community or public health simulation provides students with a realistic example of the challenges that many Americans face today. From learning empathy to understanding humility, this type of simulation is critical for future nurses and nurse practitioners to care for patients to the best of their abilities.

In 2011, the Robert Wood Johnson Foundation Initiative on the Future of Nursing released The Future of Nursing: Leading Change, Advancing Health. This compelling report called for the "transformation" of health care delivery by allowing nurses – especially APRNs – to "practice to the full extent of their education and training" as an opportunity to address the challenges involved in primary care and our healthcare system. Nearly 10 years later and amid a global pandemic, we are seeing some of the fruition of this report come to life. With concerns regarding obtaining access to care in rural populations, creating equitable systems for racial and ethnic minorities, and maintaining care for an aging population, our profession and society is facing a sudden shift to address the drastic impact that COVID-19 has created.

Varying Guidelines on Nurse Practitioner Full Practice Authority

Although there is growing evidence linking nurse practitioners to higher quality of care and safety for patients, shortages of care remains a long-standing discussion in healthcare – particularly for APRNs. Additionally, varying guidelines on nurse practitioner full practice authority continues to be an ongoing conversation. In fact, it's often a "regulatory barrier" for the profession and our ability to deliver care at our highest abilities for the communities we serve. This is primarily due to the fact that our licensure has been heavily regulated on the state level, as opposed to a federal level. This legislative regulation often makes it difficult to consistently ensure that nurse practitioners are able to deliver care without the challenge of legal and geographical boundaries that can leave some states far more restrictive in practice than others. While small advances have occurred over the years, they have been slow-coming up until now.

NP Practice Authority During a State of Emergency

Since the onset of COVID-19, we have seen an immediate shift in the various legislative barriers and regulatory practices that have served as a major obstacle for nurse practitioners. Governing bodies, both within the healthcare industry and on a national level, have also embraced the urgent need to reevaluate the traditional restrictions that have been in place since the profession began in the 1960s. One visible shift in this understanding has been made public in an evolving statement from the American Association of Nurse Practitioners, which details the various ongoing changes occurring on a policy level to temporarily suspend and waive practice agreement requirements. These waivers have been the solution to the growing need for competent health care providers to address the exponential necessity of access to care. This refers to cases that relate to the global pandemic of COVID-19, as well as primary care and population health needs that have been present all along. In the midst of social distancing guidelines and state lockdowns, one major tool that has helped drive this accessibility is telehealth. 

The Rise and Impact of Telehealth on NP Practice

The presence of telehealth, or telemedicine, is not a new topic or concept. However, with the rise of technological innovations and societal changes that have occurred due to the global pandemic, the conversation surrounding telehealth has become the topic of our times. According to a 2018 article, Telehealth and Legal Implications for Nurse Practitioners, the most basic definition of telehealth is the "use of…telecommunication technologies to support and promote long distance…health care." The article further explains that telehealth's original goal was to meet the needs of underserved and rural patients. However, much like what has been seen in traditional primary care practices, there are regulatory barriers to telehealth as well. Requirements have often varied from state to state, which has ultimately led to confusion for NPs involved in the practice. Regardless of these obstacles, we have recently seen a drastic transformation in the extended permission of this valuable and urgently necessary tool for the practice of all healthcare providers. This change has truly represented a shift toward practice transformation, as hoped for in the 2011 Future of Nursing Report.

Approaching NP Practice in a Post-Pandemic Society

The major question on everyone's minds is, what's next? How do we approach NP practice in a post-pandemic society, assuming how quickly our trajectory changes? Even more importantly, how do we adequately equip future and new-to-practice nurse practitioners to be well-prepared to handle shifting policies, requirements, and ongoing credentialing needs? The need to implement unique ways to fulfill clinical requirements is now more important than ever. On a positive note, with the ongoing need for social distancing guidelines, future nurse practitioners are being strategically prepared to thrive in telehealth and technology-heavy health care systems. Nurse practitioner students, faculty, and (most importantly) policy-makers must continue to consider all of the possibilities in this "new normal." So, is full practice authority here to stay? If we truly hope to see a transformation in practice, we must aim to follow the pivotal 2011 report: be the future of nursing by leading change and advancing healthcare.