Advanced Practice Nurses Share Their Stories
It is my privilege to serve in the community where I live, raise my children, and engage with friends and neighbors. My clinic setting is considered regional, which means our 4-Provider Family Practice sees patients of all ages for health concerns ranging from well child visits to serious illness and urgent needs. These regional providers frequently care for patients with several comorbidities that often require more complex plans of care.
To provide the best care possible for my patients, I routinely consult with specialists. This collaboration is woven throughout standard daily practice, happening over the phone, in person, or within our electronic health record system. In a regional practice setting, working with colleagues in endocrinology, cardiology, orthopedics, and other departments is an integral part of facilitating and coordinating comprehensive patient care. This is collaboration in practice. This approach to care is not reflected in the current collaboration agreement language as it is written in the law. The formal collaboration agreement is not what guarantees or even facilitates the collaborative behavior I’ve described. It is collaboration as a practice habit that makes for safe and comprehensive patient care, not a piece of paper.
Permanent removal of the collaboration agreement will have an impact on all practice settings because there is not adequate access to primary care with the providers available compared to patient demand, and this only becomes more significant in the most rural areas of the state. Nurse Practitioners (or their organization) must pay collaborating physicians in order to obtain / maintain the formal collaborative relationship. A transfer of money is at the heart of the collaboration agreement language. The habit of collaboration in practice will not change or be diminished with permanent removal of these legal “agreements”. These collaboration agreements are a limiting factor, a barrier, for Nurse Practitioners who would otherwise be able to open their own practice in rural areas that need providers most.
When the pandemic began in 2020, I was working in a traditional Urgent Care clinic. Many processes needed to change in order to safely care for our patients. Unfortunately, many patients were still very hesitant to even come into a clinic for fear of becoming infected with COVID-19. This led to patients waiting too long to be evaluated when they were ill, as well as patients putting off routine healthcare. This often led to chronic conditions such as diabetes and hypertension getting out of control.
During this time, I was presented with an opportunity to provide both Urgent Care and Primary Care in the home. This was a fantastic option for those patients who needed to be seen but did not want to come into a clinic to do so. I was able to test patients for COVID-19 and give them appropriate treatment after assessing if they were safe to stay at home or if they needed further treatment in the hospital. It was also beneficial to be able to monitor chronic conditions and adjust medications and treatment plans. Patients were able to get the care they need without the fear of catching a potentially fatal infection.
I was not required to have a written collaboration with a physician because the state rule was suspended by Governor Evers as part of the Public Health Emergency Pandemic. This has now ended, and I ask, why was I viewed as a safe, qualified advanced practice nurse, who provided accessible care to many, but I am not qualified today?
I serve adult patients and their families in a large, urban academic medical center. My practice focus is the Cardiovascular ICU as well as Ethics & Transitions of Care from a hospitalwide perspective.
My practice goal is to help understand the whole person, including their goals and preferences for care, taking into account their family and community context. This ensures that the care that is being provided is the right approach for them.
I have always practiced in an urban setting within health systems that have many resources, yet I live in a rural area. Removal of the collaborative agreement requirement would enable me to use my skills and experience for members of my own home community, rather than drive an hour away to serve! I have 23 years of nursing experience, with 15 of those as an Advanced Practice RN, as well as education, training, and dual board certifi cation as both an adult health Clinical Nurse Specialist and an Adult-Gerontology Acute Care Nurse Practitioner. I look forward to the passage of this legislation so that I can help expand access to quality health care!
I provide care to people of all ages – from premature babies to individuals over 100 years old.
I believe in a patient-centered care approach that includes patients and families in the decision-making process. I seek to build personalized plans of care for each of my patients (and families) that are consistent with the patient’s values. I also believe in treating each of my patients like they are members of my family.
Passage of the APRN Modernization Act would remove a signifi cant barrier to practice and allow me to reopen the rural health clinic in Laona, Wisconsin. After working at this clinic for over a decade, my organization downsized, closing all single-provider clinics in the area. As the clinic in Goodman had already closed its doors several years prior, this has resulted in a large healthcare desert. Reopening this clinic will increase access to healthcare in this economically depressed rural community in Northeast Wisconsin.
I am a Family Nurse Practitioner with 15 plus years of experience as a nurse practitioner, 20 plus years as a registered nurse, and 23 years in the healthcare field. I treat patients from pediatrics to geriatrics. My patients include many who would not otherwise receive healthcare treatment. I strive to provide my services to a diversified population within my community.
My approach to patient/client care is simple; I put the patient at the center of their care, because without their involvement, there cannot be a positive outcome. Patient involvement and understanding is key. I apply my diversifi ed knowledge and experience to provide quality and cost-effective care to all my patients.
The patient care situations that are beyond my scope of practice result in either physician specialist consultation or referrals. I do not need a documented physician collaboration agreement in order to continue to provide nurse practitioner care and services within the scope of my clinical education, training, and experience. The permanent removal of unnecessary regulations will allow me to increase access to care for more patients.
I provide care and service to survivors of gun violence and trauma-related incidents.
I have developed the only NP run Trauma and Quality of Life follow up clinic that exists to address all of the biopsychosocial needs for patients after gun violence. This clinic is a leading innovator in multidisciplinary care of patients from historically underserved demographics. As care providers, we work to achieve recovery from traumatic events while addressing reintegration to work, school, and family life. Having the ability to practice autonomously has provided me the opportunity to develop this clinic.
Removal of the collaborative practice agreement will allow me to move this clinic closer to where my patient population lives, providing easier access to health care and support during recovery.
I provide care to Wisconsin residents of all ages (from 5-year-olds to 105-year-olds ) with serious mental illness, alcohol and substance use disorders, dual diagnoses, challenging mental, behavioral, and emotional conditions. I work in an inpatient setting with people who are judged to be a danger to themselves or others, and who are in need of the care and safety afforded by Chapter 51 Emergency Detentions in an inpatient setting.
I am currently working with this very difficult population because it takes very specialized education, training, experience, skills, compassion, and respect for each and every patient to do it well. I could not ask for a better career. I place a high value on human dignity, honesty, and integrity. I maintain my own strong moral principles of honesty, fairness, and honor. It is important that I establish trust with my clients by pursuing integrity and unconditional honesty in all situations no matter what.
I am currently restricted to working with patients in large, heavily-populated urban areas that can support the kind of inpatient and correctional facilities that work with the seriously mentally ill. I am restricted to these areas and these settings because of the lack of willing physician/psychiatric collaborative partners in Wisconsin.
If I were not tied to a collaborative relationship, my practice would change dramatically. I would no longer have to spend my efforts trying to lift up and care for the people who have fallen into the deepest wells of mental illness. Instead, I could work proactively, in rural and non-urban settings to help *prevent* people from falling into that darkness. It is so much easier to head off episodes of serious mental and emotional, behavioral and substance use issues than to wait until after people have fallen into crisis.
But the law says that I am not permitted to work anywhere without a collaborative physician. When this requirement is eliminated, I will be able to do what I truly want to do, and that is to be there for people and offer my help *before* the crisis – not pick up the broken pieces afterwards.
I provide care in settings related to hospital based pediatrics, critical care, and acute care. As a Clinical Nurse Specialist, I approach clinical situations with a big picture view point, assessing all aspects of a situation, gathering input from key stakeholders (all members of the Care Team - Physicians, Physician Assistants, Nurse Practitioners, Respiratory Therapists, Dietitians, Social Workers, Case Managers, etc.), and collaborating with all who are integral to the patient’s life on a plan of care that is safe and has greatest potential for success.
The removal of a mandatory documented collaborative agreement with a physician will allow me to practice to the full scope of my license as an Advanced Practice Registered Nurse. It is inherently part of the nursing process to work with all disciplines. A collaborative agreement limits access to care and creates barriers where none need to exist. The public demands access to quality, skilled healthcare professionals who have appropriate preparation - the four Advanced Practice Registered Nurse roles are poised to serve the public with integrity and professionalism.
I have multiple jobs. Prior to returning to Wisconsin, I practiced in rural Alaska. I came back to help perform compensation and pension eligibility examinations for veterans. I was not able to fi nd a formal collaborating physician to perform this work. To meet this need, I have reactivated my Iowa NP license. I now have Wisconsin veterans driving to Dubuque, Iowa to see me.
Regardless of what state I am practicing in, my approach to patient care remains the same. It’s the same commonsense nursing that I was taught in my undergraduate and advanced practice registered nursing education programs.
Our goal is to provide quality health care where a patient is heard and feels their needs have been addressed at each and every visit. We provide full scope family practice to over 12,000 patients of all ages in Central Wisconsin, and have been in practice for ten years. We have worked with several local employers who were searching for affordable quality healthcare for their employees to provide a cost effective, direct pay healthcare option. Initially, we primarily served the uninsured, individuals with high deductibles, and the region’s large Mennonite and Amish populations – groups with unique needs. Recently, we have been seeing more insured patients because they have been unable to obtain appointments at local health care systems due to appointment backlogs. For the past two years, our area has been without a local walk-in clinic or urgent care. We have stepped up to provide patients an option for acute healthcare other than an emergency room.
Patients outside of our scope of practice are referred to one of the surrounding healthcare systems for further care. We collaborate with several healthcare systems and specialties, not just one collaborative physician.
We have been blessed to have collaborative physicians throughout the entire ten years of business. However, if by chance our collaborative physician would die or decide to terminate the agreement, 12,000 patients would need to fi nd new health care and our ten very skilled employees would be out of work. Nurse practitioners are the ones stepping up to the plate and fi lling in the gaps of our current broken healthcare system, and continuing to require the collaborative agreement only holds back nurse practitioners who might consider opening a clinic to serve their community. I see what is happening to healthcare as the same scenario that has happened to retail. Years ago, we had local small town stores and then the big malls were built and everyone wanted the big fancy malls. Now today the malls are being demolished and the small local stores have re-emerged. This is the same with healthcare. People want local provider offices back in their small communities, and nurse practitioners are the ones looking to take on that challenge. Allowing nurse practitioners to have independent practices would help resolve Wisconsin’s health care access issues.
Certified Registered Nurse Anesthetists (CRNAs) proved that we were uniquely qualified to respond to the COVID crisis. All CRNAs begin our careers as nurses caring for critically ill patients in Intensive Care Units (ICUs). After gaining experience and achieving a high level of expertise in the ICU, we begin the application process for admission to anesthesia school in order to complete graduate level education. This background prepares CRNAs to care for critically ill patients undergoing anesthesia. That background was called upon again in urban centers when hospitals were overrun and in rural areas without ICUs.
Across settings, CRNAs are airway experts. CRNAs are responsible for ensuring safety through the operative period; this often requires the placement of an endotracheal breathing tube, a skill we practice regularly. When it became evident that patients requiring intubation to treat COVID needed the most skilled hands to place them, CRNAs were called upon to lead the airway teams.
During normal times, the majority of the work CRNAs perform is done in or around the operating room; this can include easing patients’ anxiety as they wait for surgery or enter recovery. We are called to place invasive lines, manage sedation, and perform advanced airway management. Our skills and experience as former ICU nurses were called upon regularly these past few years during the COVID pandemic. We should be empowered to practice to the full extent of our training.
I practice on a regional level across Wisconsin and Illinois. My patients are mostly hospital-based.
I approach patient care with the same structure, practice standards, and processes built for tens of thousands of nurses. I use evidence-based practice standards that align with state law and regulations to drive the best outcomes for our families, friends, and communities.
Permanently removing the APRN collaborative agreement will help alleviate accessibility issues in communities that suffer because of them. It is already challenging to compete with other states’ advanced approach to the incorporation of APRNs. This is especially evident in the health system I work in as we span two states and can see a clear difference in access and management of patient populations by APRNs between them.
I work at a private psychiatric clinic and provide medication management for individuals with mental health disorders.
My approach is to provide my patients with individual holistic care that combines both mental and physical health. I strive to build a therapeutic, non-judgemental relationship. As a prescriber, I collaborate with patients to develop a medication plan aimed to minimize polypharmacy. Behavioral, cognitive, and interpersonal psychotherapy interventions are integrated into my practice.
Permanent removal of the collaboration agreement would allow our clinic to continue to provide psychiatric services to our 1,500 patients (and growing) should anything happen to my business partner, who is a psychiatrist.
have been providing care to rural, underserved Wisconsinites for over 35 years, most of the time as the solo provider within a clinic. During this time, I have had the honor to be part of so many patients’ lives. In some cases, I’ve cared for four generations of the same family. As a care provider, you become part of their family over the years. The work is so rewarding, and the patients appreciate it so much.
During the COVID epidemic, Wisconsin APNPs worked without practice restrictions; they were removed under emergency orders from the Governor. APNPs answered the call and stepped up to assist where they were needed. NPs that were working in clinics/outpatient setting were quickly transitioned to care for hospitalized patients or care in emergency rooms. Certified registered nurse anesthetists (CRNAs), who normally work in surgery providing anesthesia for surgery, were quickly transitioned to work in ICUs with patients on ventilators. These are some of the quick transitions that occurred to care for the citizens of Wisconsin at the time of medical crisis. Now, however, those handcuffs have been put back on despite the loss of over 1/3 of health care providers within the state. The citizens of the great state of Wisconsin deserve better; they deserve access to quality health care by qualified professionals who are ready to step up to the plate like they have in over 50% of the states across the country.
As a Clinical Nurse Specialist (CNS) who works in the specialty of wound and ostomy care, I provide evidence-based care by assessing the patient, ordering and interpreting diagnostic tests, formulating a plan of care, and prescribing treatment plans using advanced clinical knowledge and skills.
Advance practice registered nurses are vital to addressing gaps in access to quality care. Wound healing is not considered a medical specialty and is not part of the physician’s core curriculum. As a wound care CNS, I am credentialed and privileged to provide care for this underserved population. My educational background and advanced certification have prepared me well to provide high quality, cost-effective care that is patient-centric. I currently have a written collaborative agreement with a physician; however, in reality I have little to no interaction with my collaborating physician. I initiate collaborative discussions with specialty providers when the patient’s needs warrant, just as my physician colleagues would do, and refer as needed. During the COVID-19 pandemic, I applied my advanced skills in assessing, evaluating, and formulating treatment plans for patients who developed wounds as a result of COVID-19. I did this as the sole wound and ostomy provider for a hospital that has more than 700 beds.
I support SB 145 and AB 154, along with my nursing colleagues across care specialties, because it would enable us to practice at the top of our licensure and provide needed care to patients, especially underserved populations and communities.
My area of practice involves working with acutely and critically ill adult (hospitalized) medical cardiology patients. I support nurses and doctors in caring for patients with heart attacks, heart failure, cardiac arrest, and abnormal heart rhythms.
In my role, I support bedside nurses in their care for our cardiac patients by ensuring we follow the latest evidence, supporting patient safety, and preventing infection. I create nursing policies that are critical to the care of the patient and support nursing competencies. I teach nurses and doctors about how to care for patients with cardiac diseases and I teach patients about their diseases, medications, and how to care for themselves.
With an independent and full scope of practice in Wisconsin, I would be able to provide patient care, including use of my prescriptive authority, without a collaborative agreement with a physician. Most collaborative agreements are a piece of paper that are not updated and do not determine who we as APRNs collaborate with. In the inpatient setting, we frequently collaborate and consult other clinicians and medical services when we need their support and knowledge to care for a patient. We do not refer to any type of collaborative agreement to tell us how and when to consult other professionals. The paper collaborative agreement is antiquated and meaningless in our day-today practice. It does not provide any measure of safety in actual clinical practice. Completing a collaborative practice agreement is a mere formality to begin practice. It can be signed by a physician that the APRN never works with in clinical practice. As professionals, we are expected to know our clinical limitations, ask questions and use other clinicians to provide the best care for our patients.
The COVID 19 pandemic impacted my NP practice in the long-term care setting at two skilled nursing facilities and two assisted living facilities by increasing demands on my knowledge, skills, and expertise in caring for this special and vulnerable population.
The pandemic limited physician visits from 1 or 2 days per month to no physician patient visits in the facilities from March 2020 until July 2021. I was required to make all my Medicare visits plus physician required Medicare visits, monitor labs, and treat the chronic and acute health problems of all my patients. I was not required to have a collaborating physician due to the suspension of the state rule, but I did consult with my collaborating physician who was available as needed.
My patients and their families were very pleased with the adult/gerontology primary care I provided that didn’t require the patient to leave their homes in the long-term care setting. I worked with the director of nursing and nursing staff in developing plans to minimize COVID-19 outbreaks. I am pleased to say that we kept the cases of COVID to less than 5% of residents and fewer than 5 deaths related to the pandemic at all my facilities. By being in each facility 1-2 days per week, I managed medications, labs, and many other situations with limited need for ER evaluations for acute condition changes.
It is time to remove the mandated physician collaboration agreement in order to practice as a nurse practitioner.