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Making a Difference Beyond the Exam Room: The APP Role in Health Care Advocacy

June 26, 2024

July 2024

Lara C. Pullen, PhD

Lara C. Pullen, PhD, is a freelance medical writer in Chicago, Illinois.

Victoria Trott, MMS, PA-C, AQH Naila Russell, DNP, FNP-BC

Victoria Trott,                        Naila Russell,
MMS, PA-C, AQH                 DNP, FNP-BC

When patients go to a hospital, physician assistants (PAs) and other advanced practice providers (APPs) are often the first providers they see. APPs perform the initial patient evaluation and then consult with physicians on the treatment plan, providing early patient care. Once a patient is admitted, physicians and surgeons often provide the initial care, while APPs may round and provide continuity of care.

“Physician assistants fill the gaps of the health care shortage,” said Victoria Trott, MMS, PA-C, AQH, director of advocacy, leadership, and organizational development for the Physician Assistant Leadership and Learning Academy (PALLA) at the University of Maryland in Baltimore.

The APP role can also include specialty care. If, for example, a hospital’s primary medical team is not comfortable handling a patient with anemia, Ms. Trott said, it may call in the APP with expertise in hematology who provided the initial patient consultation. In such a case, the APP, while receiving guidance from a hematologist, will likely be the provider who is most frequently at the patient’s bedside. The APP will also advocate for that patient within the team setting.

Advocacy at the Heart of the Job

Naila Russell, DNP, FNP-BC, a nurse practitioner (NP) in rural Maryland and faculty member at Simmons University in Boston, explained that “advocacy is something that is essentially ingrained in nurses.” Ms. Trott agreed and added that, broadly speaking, APP advocacy happens at three levels: advocating directly for the patient, advocating for the patient within a team, and advocating for the patient within society.1 One way that APPs advocate directly for patients is by ensuring that they understand their treatment plan. APPs also provide resources to patients and help them navigate the health care system, as well as help them develop the skills needed to consult with specialists.

While patients who meet with specialists may receive direct follow-up care from APPs, these providers also play an important role in the transition between care settings. According to Ms. Trott, as patients transition from hospital to specialist care, from primary care to specialist care, or from specialist to specialist, APPs continuously ask, “How can we collectively make greater continuity of care for that patient?” In answering this question, APPs naturally transition to the second level of advocacy, becoming a bridge between the patient and the care team. The role of an APP relies on not only having the ability and time to communicate with patients and physicians but also the knowledge and wherewithal to obtain supplies that patients may need for their care, as well as provide training needed to perform any self-care.

“When I left school, I very much came out with the attitude that I was part of the patient care team,” Ms. Trott said.

Policy Advocacy

The third arm of APP advocacy occurs when these providers step out into the community to ensure that all patients, not just those they treat, receive fair and equitable care. In 2015, the Journal for Nurse Practitioners dedicated an entire issue to the health policy topics that were front of mind for APPs that year.2 The issue opened with an editorial discussing how APPs are essential advocates for health care policy and included articles on perinatal depression, the requirement of supervision for early-career NPs, and the elimination of lateral violence (workplace bullying). The editorial explained that such involvement in health policy is perhaps the most important role an APP plays in patient care, making the argument that such advocacy has the potential to improve the care of multiple generations of patients across institutions and states.

In 2024, APPs often find themselves advocating for social justice, a need that has, perhaps, never been more obvious than it was during the COVID-19 pandemic when the death of George Floyd reinvigorated calls for reform of the health care system. In an opinion piece published in 2020 in the Journal for Nurse Practitioners, Ms. Russell called for NPs to serve as social justice advocates.3 Many professional organizations agreed, and as they began issuing statements on implicit bias and health, many APPs felt galvanized by provision 8 of the American Nurses Association Code of Ethics, which calls for nurses to take the lead on public health issues and collaborate in working to change unjust structures. That tumultuous year saw APPs joining with other health care professionals in calling for an end to racism.

According to Ms. Trott, APPs can help with equitable health delivery because they are often in a position to not only identify the most vulnerable populations but also to aid in determining how best to provide these populations with critical resources, including preventive health, disease progression monitoring, disease intervention counseling, and healthy food options. APPs may also be in a position to advocate for systems of accountability to ensure equitable and fair health care for racially disadvantaged, rural, and other underserved communities.

Joining Forces Through Organizations

“Any time you’re passing legislation or advocating for policy, it’s about coalitions,” Ms. Russell said. She has been on the board of the Nurse Practitioner Association of Maryland (NPAM) for many years and said the organization works closely with the physician group in Maryland. “We see the importance of the association in setting the tone for the profession in the state and nationally,” she said.

Professional organizations facilitate the formation of coalitions and develop and process policy advocacy initiatives. APPs interested in policy advocacy are thus encouraged to join an organization or group that will amplify their impact on policy, practice, and society.

The American Academy of Physician Associates (AAPA) and the American Association of Nurse Practitioners (AANP) both facilitate policy advocacy at the national level. AAPA advocates for all PAs and provides tools to improve practice and patient care. The organization also works to advance the profession and promote quality, accessibility, and cost-effectiveness in patient-centered health care. Their current policy priorities include fighting the opioid epidemic and advancing the PA profession.

AANP empowers all NPs to advance accessible, person-centered, equitable, high-quality health care for diverse communities through practice, education, research, and leadership. They support such advocacy by championing the NP’s role and amplifying the NP’s voice. AANP’s legislative team represents NPs and their patients on critical issues related to licensure, access to care, patient safety, health care reform, and reimbursement.

APPs interested in state issues can also join local organizations. Ms. Russell explained that both NPAM and the Maryland Academy of Physician Assistants advocate for the profession and address issues that impact patients. The organizations track hundreds of bills and “keep a pulse on what’s happening legislatively,” she said. In some cases, they may choose to just monitor bills, while at other times they may oppose or support them. If the organizations choose to support legislation, Ms. Russell explained, they must decide at what level and in what ways they intend to back that legislation.

 Health care providers at Northwestern University stage a peaceful protest against racial injustice in June 2020.  Image courtesy of Northwestern Medicine
Health care providers at Northwestern University stage a peaceful
protest against racial injustice in June 2020. Image courtesy of
Northwestern Medicine

Amplifying the APP Voice

While APP organizations engage in a variety of policy issues and employ multiple advocacy strategies and tactics to influence and shape policy, a recent scoping review suggests that the influence and impact of APPs can be amplified by objective analysis of the efficacy of advocacy work.4 According to the article, this is because the relationship between internal processes, structures, leadership, and climate at the level of organizational visibility, effectiveness, and influence has not yet been widely studied in the nursing context.

The literature review found that most of the available data are in the context of national nursing organizations, with very little known about the effectiveness of efforts at the provincial or state level. Moreover, most of the published literature has focused on descriptions of organizations’ policy advocacy work rather than quantitative research. It is therefore difficult to know how current policy advocacy work can be strengthened to achieve optimal outcomes.

According to the authors of the review, several specific areas of policy advocacy deserve more objective analysis, one of which is the concept of alliances. While alliances appear key to advancing legislation, research has yet to detail the effect of joint- versus single-mandated organizations, stand-alone organizations versus nationally federated models, and unions versus professional associations.

A second gap in the literature is a lack of information on the external perspective of the effect of nursing organizations on policy. Such an analysis would involve surveying elected officials, bureaucrats, advocacy group leaders, and members of other organizations to determine which policy advocacy efforts they believe are most effective. An extension of this approach would involve an analysis of which specific advocacy strategies have been most effective in changing public awareness and perception, legislation, policy, and practice.

Growing into Advocacy

While most APPs comfortably advocate for the patient in front of them and quickly grow into the role of patient advocate in a health care team, policy advocacy may seem more daunting. “Not all nurses feel comfortable in the role,” Ms. Russell acknowledged. Ms. Trott explained that such comfort can be cultivated through leadership development and a clear trajectory for advancement within health organizations. While acknowledging that many health care systems have yet to formalize APP leadership development, Ms. Trott nevertheless encourages APPs to volunteer to sit on committees, which she believes will help health care organizations realize that the APP perspective offers an important “boots-on-the-ground” view of many health care themes.

As identified in the policy advocacy review, APPs lack robust literature describing effective advocacy strategies. Ms. Russell, who splits her time between academia and practicing as an NP, encouraged fellow APPs to contribute to this important policy work. “Even if I wasn’t in academia, I would do it,” she said. For many practicing APPs who have few academic connections, the path to such publications may be found through joining professional organizations.

Policy Issues in 2024

APPs who join professional organizations will likely find themselves advocating for an expansion of the APP scope of practice. “The goal is to be able to practice at the level of your own education and experience,” said Ms. Trott. Because different state legislation dictates to what extent an APP must act collaboratively or independently, the role of these providers varies state by state, she said. In many states, APPs advocate for such legislation in combination with licensure compacts that would reduce administrative burden and allow providers to practice in multiple states with the same license. Included with these efforts is advocacy focused on improving reimbursement rates and ensuring that Medicare includes reimbursement for APPs. Ms. Russell said in most cases this involves updating language that was written in the 1970s so it is provider neutral. This change is important not just for APPs but also for patients. “The ripple effect is that the outdated language limits patients’ access to care,” she said.

Ms. Russell’s words bring the three arms of APP advocacy full circle: make policy changes that expand patient access to APPs, facilitate APP advocacy for patients within the health care system, and expand the ability of APPs to treat and advocate for more individual patients. “Advocacy is something that’s a passion, so you find the time,” Ms. Russell said.

References

  1. Hanks RG, Eloi H, Stafford L. Understanding how advanced practice registered nurses function as patient advocates. Nurs Forum. 2019;54(2):213-219.
  2. Chilton L. Nurse practitioners have an essential role in health policy. J Nurse Pract. 2015;11(2):A19.
  3. Russell N. America needs nurse practitioners to advocate for social justice. J Nurse Pract. 2020;16:710-711.
  4. Chiu P, Cummings GG, Thorne S, et al. Policy advocacy and nursing organizations: a scoping review. Policy Polit Nurs Pract. 2021;22(4):271-291.

 

 

 

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