A Significant Change for New York NPs
Faculty Profile: Stephen Ferrara, DNP, associate dean, Clinical Affairs
Stephen Ferrara joined the faculty of Columbia Nursing this year and oversees the school’s attending faculty as well as Columbia Nursing’s Primary and Immediate Care faculty practice in midtown Manhattan. In addition, he guest lectures in health policy. He has more than 14 years of clinical experience working in college, correctional, retail, men's, and occupational health settings. As Executive Director of the Nurse Practitioner Association of New York State, he advocated for the passage of the state’s NP Modernization Act, a law that allows experienced NPs to practice without a written collaborative agreement with a physician. Ferrara received the American Association of Nurse Practitioner's NY State Award for Clinical Excellence in 2012 and was inducted as a fellow of the American Association of Nurse Practitioners in 2013. Ferrara earned master's and DNP degrees from Pace University, and completed a post-graduate fellowship in Health Information Technology for clinician leaders at The George Washington University. Ferrara blogs about issues and policies affecting nurse Practitioners for A Nurse Pracitioner’s View.
Q: The Nurse Practitioners Modernization Act goes into effect January 1, allowing nurse practitioners in New York State to operate more independently of physicians. What’s in the bill and what isn’t?
Once the law goes into effect, nurse practitioners holding 3,600 or more clinical hours will be able to practice without the outdated requirements of a written practice agreement with physicians. The law marks a significant regulatory change in New York and signifies the first step in reducing practice barriers for advanced practice nurses. However, much remains to be done.
Newly minted NPs with less than 3,600 clinical hours still require a signed practice agreement with a physician who reviews their patient charts quarterly, and provides written descriptions of their established health care protocols. In addition, all nurse practitioners still need to maintain a collaborative relationship with a physician which might need to be proven, such as if a case needs review. Ultimately, this enforced physician collaboration should also be removed.
Q: Seventeen other states and Washington, DC have also removed the requirement of a written practice agreement between an experienced nurse practitioner and a doctor as a condition of practice. What remains to be done to remove barriers to NP practice across the country?
Each state has distinct legislation regulating our profession and requires its own legislative fix to improve NP practice. This process is very difficult and slow moving. It took eight years of lobbying legislators and employing grassroots advocacy in New York to get the law passed and we still have a long way to go. Barriers exist even after a state changes its scope of practice laws. For example, federal laws forbid Medicare from reimbursing home health care ordered by nurse practitioners. And only qualifying physicians are allowed to prescribe suboxone, a medication that treats opiate dependence. I’ve heard many NPs express their frustration that they can’t prescribe a drug they feel would greatly help their patients.
Ultimately, additional research demonstrating that nurse practitioners deliver good patient outcomes will create a compelling case to remove barriers. No published studies have shown that NP care provides worse patient outcomes; in fact NP care has always proved to be the same or better than physician delivered care.
Q: What new job opportunities will potentially open up to our graduates considering the expansion of nurse practitioner roles? What skills do they need to succeed in this environment?
Most NP opportunities will exist in primary care, because that’s where the biggest health care provider shortage exists. Federally qualified health centers and community clinics will also provide new opportunities. And now, of course, there is one less barrier for an NP with 3,600 clinical hours to open their own practice in New York State! As care shifts away from the hospital, jobs will open in patient centered medical homes, retail clinics, and telehealth.
In addition to strong clinical acumen, nursing students need a greater understanding of health policy so they can be knowledgeable about the systems in which they will act as decision makers. They also need to master care transitions from the hospital to the home, and what resources are needed to keep patients safe once they arrive at home. And they need good computer skills to manage electronic health records and other sources of data.
Q: You oversee Columbia Nursing’s Primary and Immediate Care faculty practice in midtown Manhattan, one of the premier nurse-run primary care services in the nation. What are the benefits and challenges of working in an NP run setting?
It’s a big plus working with likeminded professionals who integrate health maintenance, disease prevention, and wellness into their practice. Patients who seek out NP care because they want a partnership between themselves and the clinician is another. One of the biggest challenges is working with patients who don’t understand the role of NPs. This misunderstanding of our role sometimes comes from other providers who minimize our value or don’t refer patients to us for whom we could provide care. We have to do a better job in educating the public of what an NP does. The nurse practitioner profession is relatively young —NPs have only been practicing since 1965 and didn’t gain legal scope of practice in New York State until 1988.
Q: The Primary and Immediate Care practice emphasizes teamwork and partnerships between patients and providers. What advice do you have for nurses to improve communication with their patients and to foster greater patient engagement with their care?
We must approach patients as individuals, within the context that of belonging to other cultural, spiritual, and socio-economic systems. If a patient can’t take their daily medication because they can’t afford it, nurses need to factor that into the care. If a patient can’t afford to buy fresh produce to cook healthy meals and is tempted by a dozen fast food restaurants on their way home every day, nurses need to work within those constraints. They could suggest that the patient eat less fast food instead of eating it every day, for example, or seek out resources and support service referrals for them in their community. Nursing has always excelled in getting out into the community to understand a patient’s needs.