Stressful Work Environment 2. The movement of APRN licensure trends toward Full Practice Authority before and during the pandemic is a positive step for the profession. However, the stressful work environment exacerbated by the COVID-19 pandemic has taken its toll on APRNs in much the same way as it has on nurses with other credentials. APRNs, whether they work in acute care settings, primary care, long-term care facilities or other outpatient facilities, have cared for patients with COVID. They have dealt with inadequate staffing, patient death, long work hours, and risk to their own health. Strategies to support all nurses within the work environment are needed. One stressful component of the APRN practice which seems to be different from RNs in other roles is the non- regulatory barriers to their practice exacerbated by the COVID-19 pandemic. Kleinpell and colleagues (2022) implemented a national survey in July 2022 to describe the effects of the suspension of practice restrictions or waivers in states with reduced or restricted practices and the general effect on the APRN practice. A total of 7,467 APRNs participated, most of whom had 5 or more years of practice in both inpatient and outpatient facilities in urban, suburban, and rural settings. Table A provides a comprehensive list of ways in which APRN practice is restricted in states with all three types of state regulation. After reviewing the list of areas in which APRNs are limited in their practice, not because of state licensing regulations, but because of a variety of rules made by numerous organizations, it is easy to see how stressful accommodating these seemingly illogical prohibitions can be. These limitations can be frustrating and time consuming for the APRN, resulting in increased stress in a chaotic environment, while increasing the cost of care and reducing the quality of care patients receive.
Table A: Institutional Barriers to APRN Practice in States with ALL Forms of Licensure
BARRIER
RESTRICTED REDUCED
FPA
Unable to sign an emergency psychiatric hold
x x
Social Security disability forms not honored without physician signature. Can pronounce death but unable to sign death certificate Unable to clear child for hearing aids without physician signature. Unable to order imaging for patients with abnormal mammogram.
x
x
x
Patients have higher copay to see APRN. Home Health approval restricted Hospital bylaws restrictions on practice Insurance requires physician to be PCP. 85% reimbursement compared for physician
x x x x x
x x
x x
x
Laboratory or imaging results given only to collaborative/supervising physician (not to APRN)
x
Ordering blood products requires physician signature.
x
x
Pharmaceutical companies require physician signature for samples.
x x x x x
Pronouncing death prohibited (including fetal death).
x x x
x x x
Restricted health insurance credentialing
Admissions and orders for long-term care require physician signature. All new hire physician and work compensation injuries must be co-signed by physician. Collaborating /supervising physician practice/population restriction
x
x
x
3
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