Introduction
Advanced Practice Nurses (APNs) play a crucial role in healthcare, offering specialized skills and knowledge across various domains. In Wisconsin, as in many other states, APNs encounter numerous practice barriers that can restrict their ability to provide care independently. These barriers, which vary depending on the specific APN role, can be seen at both the state and national levels. This essay will explore the practice barriers faced by the four APN roles—Nurse Midwife, Nurse Anesthetist, Nurse Practitioner, and Clinical Nurse Specialist—in Wisconsin. It will also discuss the forms of competition that interfere with APNs' ability to practice independently and the influence of interest groups and lawmakers on APN policies.
Practice Barriers for APNs in Wisconsin
1. Nurse Midwife
In Wisconsin, nurse-midwives face several regulatory constraints that limit their practice. According to the Wisconsin State Legislature, nurse-midwives are required to have a formal contract with a physician who has completed postgraduate obstetrics training (Licensure of Nurse-Midwives, 2022). This requirement imposes a dependency on physicians, thereby restricting the autonomy of nurse-midwives. Moreover, nurse-midwives are not permitted to perform certain procedures, such as Caesarean sections and forceps deliveries, except in emergencies where vacuum extractors may be used (Licensure of Nurse-Midwives, 2022). These limitations not only impede the full scope of practice for nurse-midwives but also create potential delays in patient care.
On a national level, the lack of a standardized regulatory framework exacerbates these challenges. States without proper oversight and regulation of midwifery practices often face issues related to the handling of complaints and the availability of accurate workforce data, which is crucial for policy-making (Jefferson et al., 2021). The expansion of the midwifery profession is recognized as a significant strategy to address the worsening maternity care crisis in the United States, yet the current barriers hinder this potential (Jefferson et al., 2021).
2. Nurse Anesthetist
Nurse Anesthetists in Wisconsin, known as Certified Registered Nurse Anesthetists (CRNAs), are exempt from physician supervision under state law, reflecting the high regard for their skills (Wisconsin Association of Nurse Anesthetists, 2021). However, despite this exemption, CRNAs face similar challenges to other APNs due to scope of practice (SOP) constraints. These constraints often dictate how anesthesia is administered, creating barriers to the full utilization of CRNA expertise (Brighita et al., 2016).
Nationally, CRNAs are involved in ongoing debates regarding their role in providing anesthesia care. Although both CRNAs and anesthesiologists can administer the full spectrum of anesthesia-related care, SOP laws vary significantly by state, leading to inconsistencies in practice and potential conflicts with other healthcare providers (Brighita et al., 2016). These barriers are not only a hindrance to CRNAs' practice but also to the delivery of efficient and effective anesthesia care.
3. Nurse Practitioner
In Wisconsin, Nurse Practitioners (NPs) operate under a reduced practice model, meaning that state regulations limit their ability to perform certain aspects of NP practice independently. For instance, NPs must have a controlled collaboration arrangement with another healthcare provider, typically a physician, for the duration of their career (AANP, 2022). While Wisconsin does not require the collaborating physician to be physically present, this requirement still imposes a significant restriction on NPs’ autonomy.
At the national level, the practice environment for NPs varies widely, with some states allowing full practice authority (FPA) and others imposing reduced or restricted practice models. In states like Wisconsin, where reduced practice laws are in place, NPs report barriers such as difficulty obtaining orders for durable medical equipment and supplies, permission for home health services, and hospital admitting privileges (Kleinpell et al., 2022). These barriers hinder the ability of NPs to provide continuous, high-quality care and create unnecessary complications in patient management.
4. Clinical Nurse Specialist
Clinical Nurse Specialists (CNSs) in Wisconsin, as in other states, face significant underutilization despite being one of the most common advanced practice nursing roles. State laws and regulations that limit the scope of practice are the primary obstacles to CNSs fully exercising their capabilities (Thurby-Hay et al., 2020). Additionally, the lack of specific CNS job titles and insufficient support from employers further complicates their practice.
Nationally, the challenges faced by CNSs include a lack of certification exams for certain population levels and poor interprofessional partnerships, which hinder collaborative practice (Thurby-Hay et al., 2020). These barriers prevent CNSs from contributing to healthcare delivery to the extent of their training and expertise, thereby limiting their potential impact on patient outcomes.
State-Level Competition
In Wisconsin, the primary form of competition that interferes with APN practice is the mandatory collaboration agreement with physicians. This requirement creates a hierarchical dynamic, where physicians are positioned as gatekeepers to APNs' practice. This competition is particularly pronounced in rural areas, where the availability of collaborating physicians may be limited, thus restricting APNs' ability to serve underserved populations.
National-Level Competition
On a national scale, competition arises from the varying scope of practice laws across states, which can create inconsistencies in how APNs are utilized. For example, in states with full practice authority, NPs can provide a wide range of services independently, whereas in states with reduced or restricted practice, their abilities are curtailed. This variation not only creates competition among healthcare providers but also affects patient access to care.
Furthermore, the competition between APNs and other healthcare providers, such as physicians and anesthesiologists, is evident in the ongoing debates over scope of practice laws. These debates often center around issues of competency, safety, and the perceived encroachment of APNs into areas traditionally dominated by physicians.
Lawmakers Influencing APN Policy in Wisconsin
At the state level, key lawmakers play a significant role in shaping APN policies. The Wisconsin Governor, Tony Evers, along with the Wisconsin Nursing State Board, which includes Chairperson Robert Weinman, Vice Chairperson Emily Zentz, and Secretary Janice Edelstein, are instrumental in the regulation of nursing practices in the state (Wisconsin State Legislature, n.d.).
The Wisconsin State Legislature also plays a crucial role, with Senate President Chris Kapenga, Majority Leader Devin LeMahieu, and Minority Leader Melissa Agard representing key figures in the legislative branch. In the Assembly, Speaker Robin Vos, Majority Leader Tyler August, and Minority Leader Greta Neubauer are important lawmakers who influence healthcare policies, including those affecting APNs (Wisconsin State Legislature, n.d.).
Interest Groups Influencing APN Policy
Interest groups at both the state and national levels have a significant impact on APN policies. Nationally, organizations such as the American Association of Nurse Practitioners (AANP) and the National Organization of Nurse Practitioner Faculties (NONPF) advocate for the advancement of APN practice, providing resources and support for NPs to enhance access to quality healthcare (AANP, n.d.).
In Wisconsin, state-specific groups like the Wisconsin Nurses Association (WNA) and the Wisconsin Nurse Practitioner Network (WNPN) play an essential role in advocating for APN rights and addressing the barriers that limit their practice. These groups work to influence state legislation and raise awareness about the importance of expanding APN practice authority.
Methods to Influence Policy Change
Influencing policy change in healthcare, particularly regarding APN practice, requires a multifaceted approach. One effective method is active participation in professional organizations and interest groups, which allows APNs to stay informed about current policies and advocate for changes that benefit their practice.
Additionally, lobbying efforts targeted at state lawmakers and policymakers can be instrumental in effecting change. By engaging with legislators and providing evidence-based data on the benefits of expanding APN practice authority, APNs and their supporters can influence the development of more progressive regulations.
Research and public awareness campaigns are also vital in influencing policy change. By conducting studies that demonstrate the positive impact of APNs on patient outcomes and healthcare costs, stakeholders can build a strong case for policy reform. Public awareness campaigns can help garner support from the general population, putting pressure on lawmakers to consider the needs and benefits of APN practice.
Finally, collaboration with other healthcare professionals and organizations can help reduce competition and promote a more integrated approach to healthcare delivery. By working together, APNs, physicians, and other healthcare providers can create a more cohesive and effective healthcare system that prioritizes patient care over professional rivalry.
Conclusion
Advanced Practice Nurses in Wisconsin face a range of practice barriers that limit their ability to provide care independently. These barriers, which vary by APN role, are influenced by state and national regulations, competition with other healthcare providers, and the involvement of interest groups and lawmakers. Overcoming these barriers requires a concerted effort to advocate for policy changes that recognize the value and expertise of APNs. By engaging in professional organizations, lobbying efforts, research, and collaboration, APNs can influence the development of more progressive policies that enhance their ability to practice independently and improve patient outcomes
