Читать книгу The Advanced Practice Registered Nurse as a Prescriber - Группа авторов - Страница 17

One of the greatest responsibilities for an APRN is that of prescription medication management. Prescribing is not typically a part of the registered nurse (RN) role in most countries including the US, and often requires a major paradigm shift to transition from administering drugs to selecting and prescribing medications. Consequently, the individual APRN’s transition to the prescriber role involves a union between knowledge of pharmacotherapeutics and socialization to the role. APRNs begin gaining knowledge and competencies throughout their graduate education and continue this process through practice. Role socialization to become a prescriber is initiated during APRN education and likewise is part of continuing professional development.

Transition to the prescriber role is part of the larger role transition that the APRN experiences first as a student, then as a novice practitioner, and when scope of practice changes. Schumacher and Meleis (1994) identified five factors that influence role transition. These continue to be relevant for APRNs in today’s practice arena. They are:

1 Personal meaning of the transition

2 Degree of planning for the transition

3 Environmental barriers and supports

4 Level of knowledge and skill

5 Expectations.

Identification of these factors may allow the APRN to prepare ways for a smooth transition, although there are other dimensions of transition that also need to be considered.

Students in APRN programs typically experience a role transition process that involves role confusion and role strain, including tension, frustration, and anxiety (Brykcznski, 2019). Role acquisition extends to the practicing APRN. The first year of practice is an especially challenging one. A study by Brown and Olshansky (1998) identified four stages in the transition to the primary care NP role. These are laying the foundation, launching, meeting the challenge, and broadening the perspective. Table 2.1 describes these stages. The study findings revealed the importance of skillful mentors who serve as a compass to guide the NP and serve as a source of information and support. Access to a mentor can be especially important in respect to adoption of the role of a prescriber, which brings a special set of challenges.

Table 2.1 Nurse practitioners’ experience during the first year of primary care practice

Source: From Brown and Olshansky (1998), reprinted with permission from Wolters Kluwer Health.

Stage 1: Laying the Foundation

Recuperating from school

Negotiating the bureaucracy

Looking for a job

Worrying

Stage 2: Launching

Feeling real

Getting through the day

Battling time

Confronting anxiety

Stage 3: Meeting the challenge

Increasing competence

Gaining confidence

Acknowledging system problems

Stage 4: Broadening the perspective

Developing system savvy

Affirming oneself

Upping the ante

Grappling with general questions about prescribing contributes to professional development and strengthens prescribing expertise during an APRN’s career.

 What is the APRN’s role in a particular healthcare setting?

 What is the APRN’s relationship to a collaborating or supervising physician when this relationship is required by state law?

 What if I disagree with a physician about the choice of the most appropriate medication?

 How does one adapt when relocating to a state with a different scope of practice?

General questions are often followed by more specific patient‐centered questions. For example:

 Am I making the right medication choice?

 Is medication the most appropriate treatment option or should non‐pharmacologic approaches be used at this point in the treatment trajectory?

 What type of antibiotic should be prescribed to treat a methicillin‐resistant Staphylococcus aureus infection?

 When should a person with type 2 diabetes consider beginning insulin therapy?

 What is the appropriate medication to manage acute, subacute, or chronic pain?

When faced with the reality of determining specific practice decisions, particularly those about prescribing, the novice APRN may experience a sense of uncertainty. Novice APRNs enter advanced practice step‐by‐step, decision‐by‐decision. Experience is a remarkable teacher, and, gradually, APRNs develop their professional practice and role identity which includes competence in prescribing. APRNs need time to transition into their new role. It is key, however, to emphasize that a novice APRN receiving the wisdom of a trusted colleague is different than the “requirement” for physician supervision. All novice prescribers, including physicians, benefit from this type of support.

Another aspect of adopting the APRN role is to contend with constraints imposed on all prescribers by health plans and healthcare delivery systems. For example, insurers promote the use of generic medications by requiring higher co‐payments or refusing to pay for some brand‐name drugs. Healthcare systems such as the Veterans Health Administration (VA) and health maintenance organizations such as Kaiser Permanente increasingly use formularies. These limit the medications that are paid for by the health plan, which promotes the use of generic drugs. For the most part, use of generic drugs is an important approach to address skyrocketing US healthcare costs, especially if they produce the same outcomes as branded medication. There are situations, however, in which the patient responds differently to generic vs. branded drugs. The APRN can be limited to only the generic, which compromises patient care. When a branded or non‐covered medication is necessary, a particularly time‐consuming, infuriating, and complex challenge is the prior authorization process. Providers must obtain permission from the health plan to make an exception to the policy (Jones et al., 2019).

In the practice setting, the APRN may be confronted with challenges to adopting the role of prescriber. In states with considerable limitations on autonomous prescribing, restrictions may be stipulated in practice agreements. Furthermore, specific clinical practice settings or individual characteristics of the collaborating physicians may limit the APRNs’ decision making, especially when an APRN choses a medication that differs from his or her preference. Collaborative practice agreements may specify that the physician has the ability to override an APRN’s prescribing decision.

The shift from professional preference and tradition to evidence‐based practice has been shown to be a key strategy for achieving quality patient care. Improved models for prescribing that increase the effectiveness of care and reduce error and cost are emerging from the rational prescribing and evidence‐based care movements. These models use clinical practice guidelines and electronic health records, exert more control over pharmaceutical marketing, and promote standards for formularies.

Commitment to these evidence‐informed models is essential for APRNs to improve quality and safety. Recently educated APRNs, steeped in careful attention to rational and evidence‐based prescribing, are likely to encounter situations with colleagues who may be unaware of current medication information. These situations often require assertiveness and communication skills that facilitate collegial sharing about continuously changing knowledge.