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An on-site interview of Ms. Amanda Bergeron was performed to analyze her role as an advanced practice registered nurse (APRN) in her professional practice setting in which consent was first obtained (Appendix A). Ms. Bergeron is an adult-gerontology acute care certified nurse practitioner (AGACNP) and has been practicing in her current and only position as an AGACNP for three years (personal communication, January 25, 2017).
Ms. Bergeron graduated with her MSN from the University of Texas Health Science Center at Houston School of Nursing (UTHSC-SON), which is accredited by the Commission on Collegiate Nursing Education (personal communication, January 25, 2017). During the interview, Ms. Bergeron stated that she felt prepared to practice as an APRN when she graduated because of her ten years of experience working as a registered nurse (RN) in the intensive care (IC) unit at Memorial Hermann Hospital (MMH) (personal communication, January 25, 2017). When she compared starting work as an APRN to starting as new undergraduate RN, she stated that “the transition was easier since I knew the computer system, who to call, and where to get things done” (A. Bergeron, personal communication, January 25, 2017). On the other hand, a way in which she did not feel prepared to practice as an APRN post-graduation was because she thinks “that what they teach you in school is generalized, however the unit I work is a very specialized-it’s very focused on heart failure. You don’t really learn how to manage patients with that in school” (A. Bergeron, personal communication, January 25, 2017).
Ms. Bergeron is board certified (BC) through the American Nurses Credentialing Center (ANCC) and documents her name on electronic medical records as “Amanda Bergeron, MSN, AGACNP-BC” (personal communication, January 25, 2017). Her signature does meet the requirements of the Texas BON (Use of Advanced Practice Titles Rule, 2005).
Ms. Bergeron works solely on Advanced Heart Failure (AHF) unit at MHH-Texas Medical Center (TMC) (personal communication, January 25, 2017). A typical work day for her begins when she receives sign-out from the fellows at 1900 and rounds on all the IC and intermediate care AHF patients (A. Bergeron, personal communication, January 25, 2017). Her role is very autonomous since she works the night shift, only has a cardiology fellow as a back-up, and the attending physician is on-call (A. Bergeron, personal communication, January 25, 2017). She manages patients who are either pre- or post-operational heart or lung transplantation including some patients on extracorporeal membrane oxygenation (A. Bergeron, personal communication, January 25, 2017).
Since her position is so autonomous, Ms. Bergeron “makes a lot of practice decisions regarding patient care on her own” (personal communication, January 25, 2017); however, if needed, she can communicate with the on-call physician via text or phone. Although there is one director of nursing that oversees all NPs and manages the “employee side of things” (A. Bergeron, personal communication, January 25, 2017), she stated that she feels like she works more for the physicians and the hospital since these are the personnel whom she has to report to on a regular basis.
Ms. Bergeron was not able to provide her individualized job description. The purpose of a job description enables applicants to exercise their professional judgment to determine whether this job is a good match for them commensurate with their education, training, competency, skill and the physical and emotional stamina in order to provide safe and comprehensive care in this particular employment setting.
Ms. Bergeron is authorized to medically diagnose and prescribe medications and medical devices as stated on her Practice Agreement/Practice Protocol for Physicians and NPs (Appendix B), which is the correct document required for a facility-based practice (Facility-Based Sites Statute, 2013). According to her facility-based protocol (FBP), she is authorized to order most medications within the AFH unit, including dangerous drugs and controlled substances, such as four dose- and frequency-specific schedule II medications (Appendix B). An exception to this is immunosuppressives, thrombolytics, and chemotherapy (Appendix B).Â She is also authorized to electronically “sign” prescriptions for medications, including controlled substances schedules III-V (Appendix B). Her FBP authorizes her to order the following medical devices: central venous catheters, arterial lines, dialysis catheters, chest tubes, Swan Ganz catheters, and intubation (Appendix B).
During the interview, the only comment on reimbursement Ms. Bergeron made was, “since I am employed by the hospital, I don’t get billed directly; instead, it goes under the hospital billing” (personal communication, January 25, 2017). Therefore, the number of care plans that list her as the provider and whether or not MHH encountered problems related to the credentialing process is unknown.
Ms. Bergeron does not own personal malpractice insurance, although she is insured by her institution’s policy with a limit of $50,000 for an occurrence and a limit of $100,000 for an aggregate (Appendix C). This claims-made malpractice insurance is considered a blanket policy (Appendix C).
Ms. Bergeron remains cognizant of the Texas BON rules & regulations by attending monthly meetings with the director of MMH and by reading emails from the dean of UTHSC-SON which inform her of any applicable law changes (A. Bergeron, personal communication, January 25, 2017). She is subscribed to the Journal of the Critical Care Nurse and is a member of The International Society for Heart & Lung Transplantation (ISHLT) (A. Bergeron, personal communication, January 25, 2017). She actively participates in this organization by attending their yearly conferences (A. Bergeron, personal communication, January 25, 2017).
Ms. Bergeron employs the use of several resources to ensure she incorporates best practice methods. MMH provides access to the evidence-based “Up-to-Date” app on Ms. Bergeron’s phone (personal communication, January 25, 2017). In addition, the ISHLT will send her treatment guidelines that are applicable to her patient population (A. Bergeron, personal communication, January 25, 2017). Furthermore, she still keeps her portfolio from graduate school (A. Bergeron, personal communication, January 25, 2017). She also maintains a new procedure and skills checklist in order to ensure that requirements for the renewal credentialing process are met (A. Bergeron, personal communication, January 25, 2017). Portfolios and the consistent documentation of procedures, training, and continuing education hours (CEH) abide by the BON’s requirements to effectively manage accurate documentation of training and ongoing proof of competency (Responsibilities of Individual Licensee Rule, 2014).
Ms. Bergeron has authorization to practice as an AGACNP (APRN License No. AP125218) until December 31, 2018 (Texas BON, 2013). According to the National Organization of Nurse Practitioner Faculties (NONP) (2016), Ms. Bergeron met the technology and information literacy competency area by efficiently operating MMH’s technological care delivery system (personal communication, January 25, 2017). Even as a newly graduated AGACNP, she was able to effectively utilize “internal and external agencies and resources” (NONP, 2016) and thereby, satisfying the health delivery system competency area (A. Bergeron, personal communication, January 25, 2017). However, since she had expressed having difficulty with both “the translation of new knowledge into practice” (NONP, 2016) and with AHF patient management, she was deficient in the practice inquiry competency area (A. Bergeron, personal communication, January 25, 2017).
An ANCC certification needs to be renewed every five years. Renewal candidates are required to complete 75 CEHs within their certification specialty within the five years prior to the submission of their renewal application (ANCC, 2016). An alternative would be to obtain an adult-gerontology acute care NP certification (ACNPC-AG) through the American Association of Critical-Care Nurses (AACN); however, ACNPC-AG renewal candidates must complete 150 CEHs within the five years preceding their renewal application submission (AACN, 2017). Both the ANCC and the AACN require 25 CEHs to cover the topic of pharmacology and accredit the substitution of CEHs with academic credit hours, presentations, preceptorship, and volunteer hours (AACN, 2017; ANCC, 2016).
The delegating physician, Dr. Biswajit Kar, is the chief of the Medical division for the AHF Center at MHH’s Heart & Vascular Institute-TMC (Memorial Hermann Hospital, 2017) and thereby, meets the qualification requirements of a delegating, facility-based physician, per Facility-Based Sites Statute (2013). Additionally, I confirmed that Dr. Kar has a current, full, and unencumbered Texas Medical License (TML) (License Number L5002) (Texas Medical Board [TMB], 2017). However, their FBP fails to meet the state’s minimal legal requirements by its exclusion of professional license numbers of the involved parties (Prescriptive Authority Agreements Rule, 2013). In addition, their FBP states that this “agreement must be reviewed, updated, signed and dated at least annually” (Appendix B); therefore, this agreement expired a few hours after this interview took place, since it was last signed and dated on January 25, 2016.
I verified that Ms. Bergeron has valid recognition for Prescriptive Authorization (Rx. Auth. Number 15421) (Texas Board of Nursing, 2013). During our interview, she stated that she does not need a Drug Enforcement Agency (DEA) controlled substances registration, since she doesn’t “discharge patients with narcotic prescriptions” (A. Bergeron, personal communication, January 25, 2017). She mentioned that she is covered inpatient under the hospital’s DEA registration (A. Bergeron, personal communication, January 25, 2017), which complies with the DEA’s Practitioner Manual (DEA, 2006). However, Dr. Kar’s TML authorizes the delegation of only dangerous substances, but not controlled substances to Ms. Bergeron (TMB, 2017). Since their FBP states that the physician is liable for the APRN’s actions (Appendix B), this renders him incompliant with the TMB (Physician Liability Rule, 2013).
According to the Benefits and Limitations Rule (2011), if the APRN is employed by a hospital, then the APRN should not bill the Medicaid program for her services and incident to services; instead, payment will be made to the hospital who will then reimburse the APRN.Â By performing a Medicaid and Medicare (MM) provider search, compliance was confirmed since there were no search results listing Ms. Bergeron as a MM provider (CMS, 2017b). Additionally, I verified that MHH-TMC was a MM provider (ID #450068) (CMS, 2017b). By quantifying the cost of care through the value-based purchasing program, the CMS offer financial incentives to hospitals that are able to provide high-quality care at a lower cost to Medicare which promotes compliance with applicable MM rules (CMS, 2017a).
There are two predominant types of malpractice insurance policies-a claims-made policy and an occurrence policy. A claims-made policy covers the insured for only claims that are reported during the active policy term; whereas, an occurrence policy provides coverage for any incident that incurs during the policy term, regardless of the time when the claim is actually filed (Woolbert & Ziegler, 2016). One advantage to a claims-made policy is that the incident date which elicited the claim is irrelevant-only the date in which the claim is divulged matters (Deaden & Burke, 2004; Tahouni & Kahn, 2009). One disadvantage to the claims-made policy is that if a claim is revealed after the policy period has ended, then the APRN is left unprotected if no further coverage is acquired (Tahouni & Kahn, 2009). Therefore, it is highly recommended that if APRNs have a claims-made policy, then they should also obtain supplemental tail coverage (Woolbert & Ziegler, 2016). In contrast, one benefit to occurrence policies is that the insured is protected for the event, regardless of the when the claim is declared and even if the policy is expired; hence, the need to purchase an extended coverage is eliminated (Tahouni & Kahn, 2009). Furthermore, insurance carriers have shifted from providing occurrence policies to supplying claims-made polices making it challenging to acquire an occurrence policy; therefore, it is recommended to choose a claims-made policy (Deaden & Burke, 2004; Smith, 2015).
Ms. Bergeron admitted that she does not have a philosophy of care; however, I believe that she could utilize Pender’s health promotion model to promote psychosocial interventions and coping mechanisms to improve the quality of life for pre- and post-transplant patients and their caregivers. Littlefield et al. (1996) reported that 52% of pre-heart transplantation patients observed in their study had a psychiatric diagnosis, typically involving depression and anxiety. Smeritschnig et al. (2005) reported that a longer transplant wait-list time was correlated with poorer caregivers’ mental health. Ms. Bergeron should maximize teachable moments to discuss lifestyle, determinants that impact health, and coping mechanisms in order to reduce health risks and to improve the health status of her patients and their caregivers (Furlong & Smith, 2005).
At the exact time of the interview, this APNP was practicing in compliance with the Texas BON; however, her FBP would expire at midnight. Furthermore, her FBP failed to meet the state’s minimum requirements since the professional license numbers were missing. Additionally, she runs the risk of being incompliant with the controlled substance laws since her delegating physician is not compliant with the TMB.
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