NURG 5940 Clinical Quality Improvement Paper Grading Guidelines Purpose: To identify an unmet need or gap in practice in one aspect of clinical services within the primary clinical placement setting....

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Running head: PMHNPS CLOSE QUALITY GAP FOR VETERANS
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PMHNPS CLOSE QUALITY GAP FOR VETERANS
Removing Practice Restrictions on Psychiatric Mental Health Nurse Practitioners: A Solution for
Bridging the Clinical Quality Gap for Veterans
DeAngela K. Francis
McNeese University
NURS 694
Spring 2019
    
Removing Practice Restrictions on Psychiatric Mental Health Nurse Practitioners: A Solution for
Bridging the Clinical Quality Gap for Veterans
Introduction
    The inherited problems within the changing conditions of healthcare were inevitable. However, the problems that reside within the Overton Brooks Outpatient Mental Health Clinic (OBOMHC) are that quickly ameliorated by allowing Psychiatric Mental Health Nurse Practitioners (PMHNPs) to practice to their fullest scopes. There is a juxtaposition that exists between the description of the scope of practice for PMHNPs as delineated by the American Psychiatric Nursing Association (APNA) and the OBOMHC’s job role and description for PMHNPs.
The most significant reason for this contrast is due to the shortage of licensed Psychiatrist. The purpose of this paper is to focus on the existing problems related to the number of Veterans that are in desperate need of treatment for post-traumatic stress disorder (PTSD). This can be achieved through cognitive behavioral therapies (CBT), such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). Both PE and CPT have been duly noted as significant to helping achieve optimal mental health outcomes, but unfortunately, these services are not always readily available to needing Veterans.
Theoretical Concerns, Evidence-based practice considerations, practical considerations and systems issues
    To improve any process, organizations as well as their stakeholders, must become reflective and accept the need for change in order to achieve success. Manchester et al., (2014), describes healthcare providers as individuals that implement interventions and practices that are steeped in evidence and do so along a continuum in a number of diversified clinical settings. With contextual factors varying from institution to institution, these influences are either the barriers that give way to the change’s failure or they become the antecedents that employs its success. The key to creating success within healthcare, as well as in the OBOMHC, relies on models such as, Kurt Lewin’s 1951, 3-step model of change. Lewin espoused that in order for anyone or anything to change, the host must be willing to go through three distinct phases: Unfreezing, Movement, and Refreezing. As beforementioned, a projects’ successes are predicated upon the perspectives and collaborative principles of its stakeholders during the “planning, implementation, and evaluation phases” (Manchester et al., 2014, p. 82). Models such as Lewin’s are paramount in rendering the needed changes within local, state, and federal lawmaking and credentialing bodies, as well as the policy makers within both the private and public sector healthcare organizations.     
    Change is manifested by pursuing new pathways and being capable of seizing opportunities to help improve a process(es). It is apparent that change is needed in healthcare, as well as OBOMHC to repair and remove antiquated laws and policies that continue to impair the function and capabilities of PMHNPs. Let’s take a step back to the year 2012, when Louisiana lawmakers in the “Louisiana House committee voted strongly against House Bill 951 which proposed allowing nurse practitioners to practice free of physician oversight,” but instead, nurse practitioners (NPs) remain under the supervisory umbrella of a medical doctor (MD). The PMHNP and MD’s collaborative relationship remains necessary by the constitutions of the law in Louisiana despite the record being replete with evidence supporting that NPs no longer need this supervision to practice competently or safely as primary care providers (midlevelu.com, 2014, April 08).
    Many states that have submitted and complied to meet the demands of their constituents by giving NPs the autonomous and independent authority to practice to their fullest scopes. At a National Council of State Boards of Nursing (NCSBN) Symposium, Phoenix, Chapman, & Toretsky (2018), elucidate that since the early 1970’s in Oregon, NPs have been allowed to practice independently and with full-prescriptive authority since 1979. These NPs have also received insurance parity in both primary care and behavioral health settings. In North Carolina, NPs are required to have a collaborative practice agreement (CPA) with a medical doctor, however, this CPA isn’t free and can cost NPs anywhere from $1,500-$3,000 per month, with no limitations on how many NPs one MD can supervise. So, as you can see, this level of reimbursement is enticing and is indirectly causing continued constraint on the role and function of PHMNPs. Phoenix et al., (2018), espouses their position that CPAs with MDs is a means to “justify unequal pay for the same work” (NCSBN Scientific Symposium, Slide 14, 2018, October 24). During this same NCSBN Symposium, Phoenix et al., expounds upon the fact that current laws and regulations are antiquated and have been designed to ensure that NPs do not receive equal reimbursement as MDs. Phoenix et al., also touts that once laws change and reflect the removal of the CPA, it is then that NPs will receive the reciprocity they deserve and at that time they will finally be viewed as equals to MDs by the insurance companies and will receive commensurate reimbursements.
    As beforementioned, the VHA and OBOMHC continue to support the narrative that PMHNPs have one purpose and one purpose only and that is for their ability to prescribe and manage psychotropic medications as defined in the outline of posted job listings on USAJOBS.gov. Although, this narrative in negative in context, it is this narrative that seems to be driving the conversation within the VHA and OBOMHC. These archaic and unimodal ways of thinking are repugnant of evidence and truth and can no longer be the standard that drives the discovery, design, or implementation of theoretical and scientific innovations. Multimodal and whole systems change (WSC) must become the standard bearers of thinking and must become inextricably woven into the fabric of discovering and implementing methods, strategies, interventions, and treatments within the OBOMHC, as well as the VHA. Whole systems change and thinking will help certify that Veterans no longer receive subpar care resulting in less than optimal outcomes at OBOMHC or any other VHA facility.
    Theoretical frameworks are critical to the proper governance and success of change within any healthcare system. When change is needed, systems-level diffusion is vital to the livelihood of the concept or process and it helps to embolden the propensity that the change will lead to WSC. Berta, Virani, Bajnok, Edwards, and Rowan (2014), touts Rogers’ Theory of innovation diffusion as a process where innovation diffuses over time, through multiple stages before the process is adopted. Before adoption of the innovation can occur the contextual attributes must be communicated to help enhance its adoption or uptake. It is through communication with influential stakeholders that are intertwined within the social system of the organization that helps to ensure that these influential decision-makers are engaged in systems-level thinking. Through the proponents of these contextual factors, diffusion and innovation “is also a function of the structure of the social system” and together as a whole, “these elements profoundly influence the extent to which an innovation is discussed, trialed, and adopted (Berta et al., 2014, pp. 313-314).
    Before change can ever be considered within the VHA and OBOMHC, theories such as Rogers Theory of innovation diffusion must be considered to involve thinking, collaboration, and support at all levels of the system in hopes of achieving WSC. With this understanding, PMHNPs must always reflect and consider that despite the importance of the change, without careful consideration of the theoretical frameworks that undergird and support the innovation or change, the risks and its antecedents must be considered and understood in order to avoid unnecessary barriers that could ultimately, in a direct and indirect causal relationship, increase the clinical quality gap that results in the detriment to our Veterans.
    Without innovation diffusion, WSC within the organization is impossible and without WSC, OBOMHC as well as all other healthcare organizations, will fail at providing quality care and outcomes. As with any process(es) in life, the risk of succeeding is...