Scope Of Professional Practice Research Articles

Pharmacist-Prescribed Hormonal Contraception: A Survey of Perceptions of Georgia Community Pharmacists and Non-Community Pharmacists.

Pharmacist-prescribed hormonal contraception (HC) is supported by a majority of pharmacists and pharmacy students; however, few studies have evaluated perceptions of non-community pharmacists, or differences in geographic areas. The primary objective of this study is to assess differences between community and non-community pharmacists in perceptions of pharmacist-prescribing HC in Georgia, a state that does not currently permit this practice. Secondary objectives include assessment of community pharmacist interest in prescribing HC, and differences in perceptions between pharmacists in metropolitan and nonmetropolitan areas. A survey was emailed in early 2022 to 2592 Georgia pharmacists, with Likert questions assessing interest, perceptions, comfort, and perceived barriers regarding pharmacist-prescribed HC. Chi square testing identified differences between groups. The completed survey response rate was 11.8%. Regardless of practice site, a majority agreed that pharmacists are well trained to prescribe HC (community 61.8% vs. non-community 68.1%, p = 0.25) and provision of HC services is within pharmacists' scope (community 73.6% vs. non-community 74.2%, p = 0.90). Overall, metropolitan and nonmetropolitan community pharmacist perceptions were similar; however, more metropolitan pharmacists believed pharmacists are well trained to prescribe HC (66.7% vs. 48.7%, p = 0.049) and that it is within their scope of practice (78.1% vs. 61.5%, p = 0.045). In summary, the majority of pharmacists, regardless of practice type, believe that pharmacists are prepared to prescribe HC and that it is a part of pharmacists' professional scope of practice.

P19 Nurse evaluation of a local antibiotic IV to oral switch (IVOS) prompt tool

Abstract Background Early IVOS has numerous benefits for our patients, our planet, and our nurses.1,2 Importantly, a multisite qualitative study concluded that encouraging the prompt transition from IV to oral antibiotics was perceived favourably by nurses as an antibiotic stewardship nursing role.3 In November 2022, the UK Health Security Agency published the national IVOS criteria;1 these formed the basis of our revised local IVOS prompt tool. The aim of the project was to evaluate nurses’ initial responses to a local IVOS prompt tool. Objectives To evaluate if prompting for IVOS is currently viewed as a nursing role; to evaluate how confident nurses feel using the local IVOS prompt tool and its suitability for nursing clinical practice; to consider the need for trust-wide nurse engagement and training and to make recommendations to inform antimicrobial stewardship (AMS) nursing practice. Methods The local IVOS prompt tool was shown to nurses between November 2022 and March 2023, using a problem-based learning approach to gather nursing views. Nurses were asked to provide anonymous feedback via a short questionnaire, using a five-point Likert scale. Results Ninety-eight nurses participated and completed the questionnaire with the following mean scores obtained. Prompting for IVOS was recognized as a nursing role (4.2/5.0); generally, nurses felt confident to use the IVOS tool during the problem-based learning activity (4.1/5.0) and on the ward to assess their patients (4.2/5.0). Qualitative feedback received included ‘time constraints- another tool [to complete] when there are already many’. It was deemed that the IVOS tool would be best placed in the clinic room (where IV antibiotics are prepared), as reference aid rather than as an assessment tool requiring formal completion. Conclusions Nurses consider IVOS to be within their scope of professional practice and felt confident to use the tool to assess for early switch within an educational and practice setting. Application of the tool in clinical practice is a focus for trust-wide nurse engagement, education and future AMS nursing research.

EMS and Bioterrorism Response

Introduction:Previous studies have found that public health systems within the United States are inadequately prepared for an act of biological terrorism. As the COVID-19 pandemic continues, few studies have evaluated bioterrorism preparedness of Emergency Medical Services (EMS), even in the accelerating environment of biothreats.Method:This study utilized an Internet-based survey to assess the level of preparedness and willingness to respond to a bioterrorism attack and identify factors that predict preparedness and willingness among Nebraska EMS providers. The survey was available for 1 month in 2021 during which 190 EMS providers responded to the survey.Results:Only 56.8% of providers were able to recognize an illness or injury as potentially resulting from exposure to a biological agent. Provider Clinical Competency levels ranged from a low of 13.6% (ability to initiate patient care within his/her professional scope of practice and arrange for prompt referral appropriate to the identified condition(s)) to a high of 74% (the ability to respond to an emergency within the emergency management system of his/her practice, institution, and community). Only 10% of the respondents were both willing and able to effectively function in a bioterror environment.Conclusion:To effectively prepare for and respond to a bioterrorist attack, all levels of the healthcare system need to have the clinical skills, knowledge, and abilities necessary to treat patients exposed to biological agents. Policy changes and increased focus on training and drills are needed to ensure a prepared EMS system, which is crucial to a resilient state. EMS entities need to be aware of the extent of their available workforce so that the country can be prepared for the increasing threat of bioterrorism or other novel emerging infectious disease outbreaks. A resilient nation relies on a prepared set of EMS providers who are willing to respond to biological terrorism events.

Evaluating Nebraska EMS Providers' Ability and Willingness to Respond to Emergencies Resulting from Bioterrorist Attacks.

Previous studies have found that public health systems within the United States are inadequately prepared for an act of biological terrorism. As the coronavirus disease (COVID-19) pandemic continues, few studies have evaluated bioterrorism preparedness of Emergency Medical Services (EMS), even in the accelerating environment of biothreats. This study utilized an Internet-based survey to assess the level of preparedness and willingness to respond to a bioterrorism attack and identify factors that predict preparedness and willingness among Nebraska EMS providers. The survey was available for 1 month in 2021 during which 190 EMS providers responded to the survey. Only 56.8% of providers were able to recognize an illness or injury as potentially resulting from exposure to a biological agent. The provider Clinical Competency levels ranged from a low of 13.6% (ability to initiate patient care within his/her professional scope of practice and arrange for prompt referral appropriate to the identified condition(s)) to a high of 74% (the ability to respond to an emergency within the emergency management system of his/her practice, institution, and community). Only 10% of the respondents were both willing and able to effectively function in a bioterror environment. To effectively prepare for and respond to a bioterrorist attack, all levels of the health care system need to have the clinical skills, knowledge, and abilities necessary to treat patients exposed to biological agents. Policy changes and increased focus on training and drills are needed to ensure a prepared EMS system, which is crucial to a resilient state. EMS entities need to be aware of the extent of their available workforce so that the country can be prepared for the increasing threat of bioterrorism or other novel emerging infectious disease outbreaks. A resilient nation relies on a prepared set of EMS providers who are willing to respond to biological terrorism events.

Working in the time of COVID-19: Rehabilitation clinicians' reflections of working in Gauteng's public healthcare during the pandemic.

BackgroundWhen the coronavirus disease 2019 (COVID-19) pandemic manifested in South Africa, rehabilitation services were seriously affected. The consequences of these were wide-ranging: affecting service users, their families and caregivers, rehabilitation practices and practitioners as well as the integrity and sustainability of rehabilitation systems.ObjectivesThis study aimed to explore the nature and consequences of disruption caused by the pandemic, based on the experience of rehabilitation clinicians who were working in public healthcare facilities in Gauteng.MethodsThis was a phenomenology study that used critical reflection method. Trained and experienced in reflecting on barriers and enablers that affect their practices, a multidisciplinary group of rehabilitation clinicians captured their experience of working during the time of COVID-19. Data construction extended over 6 months during 2020. An inductive thematic analysis was performed using Taguette: an open-source qualitative data analysis tool.ResultsThe main themes captured the disorder and confusion with its resultant impact on rehabilitation services and those offering these services that came about at the beginning of the pandemic. The importance of teamwork and leadership in rehabilitation also emerged as themes. Other themes related to having to approach work differently, working beyond professional scopes of practice and pandemic fatigue.ConclusionThe COVID-19 pandemic disrupted the way rehabilitation was being performed, creating an opportunity to reconceptualise, strengthen and improve rehabilitation services offered at public healthcare. The presence of effective leadership with clear communication, dependable multidisciplinary teams and clinicians with robust personal resources were strategies that supported rehabilitation clinicians whilst working during COVID-19.

Interchangeability in Military Interprofessional Health Care Teams: Lessons Into Collective Self-healing and the Benefits Thereof

Interchangeability-i.e., the capacity to change places with another-is necessary for military interprofessional health care teams (MIHTs) to provide around-the-clock patient care. However, while interchangeability is clearly a necessity for modern health care delivery, it raises uncomfortable questions for civilian health care teams where it is usually labeled as unsafe. This perception surfaces because interchangeability runs counter to some of health care's cultural beliefs including those around patient ownership and professional scopes of practice. It is, therefore, not surprising that little is known about whether and how some level of interchangeability can be harnessed to improve the productivity of health care teams overall. In this article, we explore the notion of interchangeability in the particular context of MIHTs given that these health care teams are familiar with it. This exploration will offer insights into how interchangeability could maximize civilian health care teams' capacity to adapt. We conducted a secondary analysis of interview data as an analytic expansion: "the kind of study in which the researcher makes further use of a primary data set in order to ask new or emerging questions that derive from having conducted the original analysis but were not envisioned within the original scope of the primary study aims". Within our secondary analysis approach, we used thematic analysis as our analytical tool to describe (1) what interchangeability looks like in MIHT teams, (2) how it is fostered in MIHTs, and (3) how it is enacted in MIHTs. Interchangeability was realized in MIHTs when individual team members adapted to take on roles and/or tasks that were not clearly niched in their specific areas of expertise but instead drew on the broad foundation of their clinical skill set. Cross-training and distributed leadership were ways in which MIHT members described how interchangeability was fostered. Furthermore, five features of working within MIHT teams were identified as key conditions to enact interchangeability: knowing your team members; being able to work with what/who you have; actively seeking others' expertise; situating your role within the broader picture of the mission; and maintaining a learning/teaching mindset. Interchangeability can be understood through the theoretical lens of Swarm Intelligence and more specifically, the principle of collective self-healing-which is the ability of collectives to continue to successfully perform despite disruption, challenges, or the loss of a team member. Our findings highlight how MIHTs have adopted interchangeability in a wide array of contexts to realize collective self-healing. Despite the discomfort it provokes, we suggest that interchangeability could be a powerful asset to civilian health care teams.

Pharmacist-Prescribed Hormonal Contraception: Does Didactic Hormonal Contraception Education Affect Student Pharmacist Perceptions of This Professional Activity?

Since 2014, select states have allowed pharmacists to prescribe hormonal contraception (HC). This study describes student pharmacists’ perceptions of a pharmacist’s scope of practice, education, and interest, and identifies differences between students who have completed didactic HC content in their professional curriculum versus those who have not. A voluntary online survey was emailed to all students in three Georgia pharmacy schools. Descriptive statistics were reported. Likert square responses were dichotomized, and Chi square testing identified differences between groups. A total of 1256 students were invited, 35% completed the survey, of those 68% had received HC didactic content in their curriculum. Regardless of HC education, most students “agree” or “strongly agree” that pharmacists are adequately educated to prescribe HC (92% vs. 86%, p = 0.05) and prescribing HC is within the pharmacist’s scope of practice (89% vs. 84%, p = 0.12). Although not currently permitted in Georgia, most are interested in prescribing (97% vs. 96%, p = 0.5). Of the students who have received HC didactic content, 87% felt “moderately”, “well”, or “extremely well-educated” regarding HC prescribing clinical skills. Regardless of didactic training, pharmacy students believe pharmacists are prepared to prescribe HC and support pharmacist-prescribed HC as a part of their future professional scope of practice.

ИНИЦИЈАЛНО ДИДАKТИЧKО-МЕТОДИЧKО ОБРАЗОВАЊЕ БУДУЋИХ ПЕДАГОГА – ПРОЦЕНЕ СТУДЕНАТА ПЕДАГОГИЈЕ

Of the great importance for the building professional identity of a modern pedagogue is initial education. With the necessary quality, it provides a basis that is later upgraded with the professional training and numerous forms of permanent self-education and self-learning. Having in mind that professional identity of pedagogue implies a wide range of didactic and methodic competencies that are acquired during the study, this paper is precisely focused at examining these areas of initial education of pedagogues. The aim of this paper is to determine the estimations of pedagogy students about didactic-methodical education that they acquire during their undergraduate studies, and to point out possible demerits and also make recommendations for improving the established situation. The research was conducted on a sample of 105 final year students of BA, MA, and PhD academic studies of the Department of Pedagogy at the Faculty of Philosophy in Nis. Obtained results show an enviable level of didactic-methodical education and indicate to the need to innovate and improve the quality of study program in the field of representation and the scope of professional practice.

An Ethics-based Approach to Global Health Research Part 2: Strategies for Overcoming Logistic and Implementation Challenges.

With the growth of global pharmacy partnerships and collaborative research, particularly between high-income countries and low- or middle-income countries, it is necessary to establish best practices for fair and ethical collaboration and research. There is a gap in the pharmacy literature in this regard. Through this commentary, authors will present a pathway for future global health researchers including generating ideas based on mutual needs of the partnership and the community; exploring the importance of regulations including the need to conduct research and partnership projects within the confines of each participant's professional scope of practice, expertise, and licensure; describing the need to develop agreements and the components that should be included in such an agreement; discussing ethical guidelines for research planning, obtaining ethical approval, and planning for adverse events; and illustrating ethical considerations for research implementation with considerations around consent, data collection, linking patients to care after the completion of the study, and dissemination. Global examples, with a pharmacy-specific approach where applicable, within each section highlight the importance of discussion and action around ethics and equity when pursuing collaborative research, recognizing that many of these situations involve difficult decisions.

Exploring glocalization in the construction and implementation of global curricula.

11020 Background: Despite proposed advantages of global oncology curricular harmonization including physician mobility and improving the quality of care the challenges and unintended consequences require greater study. The aim of this study was to problematize the concept and implementation of global oncology curricula and their relationship to local contexts of power and culture. Methods: Fourteen international participants involved in the development and implementation of global oncology curricula completed in-depth, one-on-one semi-structured interviews lasting 40-60 minutes. Snowball sampling was employed. The participant sample was representative of different geographic regions, genders and professional scopes of practice to ensure diverse perspectives were sought. Through iterative analyses, using an abductive approach, the study team discussed and reviewed the data and made revisions through collaborative analysis to enhance comprehensiveness and to improve credibility. In the final analysis the meaning and implication of the themes were discussed yielding a conceptual analysis. Results: Our data have articulated 5 key challenges for global curricula including 1) Ambiguous or conflicting perspectives on the purpose and scope of Global Oncology Curricula 2) Insufficient representation of diverse perspectives and realities in the creation of the final curricula 3) A rigid conceptualization of competency requirements 4) A mismatch between the curricular requirements and local context and 5) The influence of power relationships and decision makers. Leveraging the strengths of diversity including fostering representation, addressing power differentials and factoring local contexts may be an approach to mitigating these challenges. Conclusions: Global oncology curricula may serve important advocacy roles within the healthcare system. Leveraging diversity may positively impact the common challenges in the construction and implementation of global oncology curricula.

Conscientious refusal, abortion, and the professional standard of care

Summary While clinicians may legitimately refuse to participate in some abortions, they should not refuse when doing so would likely cause significant harm to a patient's health or endanger her life in order to comply with duties inherent in the ethical core of medicine. The argument that clinicians have an obligation, on patient request, to provide any and all interventions that are not illegal and fall within the scope of professional practice should be rejected. The ethical core of medicine can be thought of as constituted by the Hippocratic injunction to help and not to harm, the primary obligation to ensure patients’ health by employing interventions within the professional standard of care, and the acknowledgment that individuals voluntarily choose to join the profession to which certain fundamental obligations attach. Clinicians should have the ethical right to refuse to participate in ordinary abortion, but lack this right if refusal threatens patients’ lives or poses a significant risk of harm to their health as recognized by the standard of care. Refusal to participate in some abortions has presumptive ethical merit under the principle of evaluative respect and accommodation which grounded in the respect moral agents should have for each other's attributions of moral status. Clinicians are moral agents, not medical vending machines, who have deeply held, self-identifying moral commitments (religious or otherwise) that deserve respect when not in conflict with the ethical core of medicine.

Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and...

Oxygen administration practices during exercise training in Ontario pulmonary rehabilitation programs

RATIONALE: Individuals with moderate to severe lung disease may exhibit exertional hypoxemia that can limit exercise capacity. Oxygen may allow training at higher exercise intensities and durations, however, clinical practice guidelines for oxygen administration during exercise training in pulmonary rehabilitation (PR) are lacking. OBJECTIVE: To explore and describe clinical practices of oxygen administration in PR and facilitators and barriers to oxygen administration. METHODS: A 51-item web-based survey of health care professionals working in Ontario PR programs was conducted. PR programs were identified through an Ontario Lung Association database. MAIN RESULTS: Responses from 44/81 (54%) identified PR sites were obtained and a total of 56 eligible respondents from these sites initiated the survey resulting in 46 completed surveys and 10 partially completed surveys. Seventy-one percent of respondents reported oxygen administration protocols. Common practice was to maintain oxygen saturation above a specified level with exercise, which was managed by either administering oxygen or by stopping exercise. A prevalent perceived facilitator was knowledge regarding the benefits of oxygen during exercise, however half of the respondents reported they would not titrate oxygen in order to increase exercise training intensity or endurance capacity. The most common perceived barrier was oxygen administration outside professional scope of practice. CONCLUSIONS: Heterogeneity in oxygen administration practices exist in Ontario PR programs in regard to availability of oxygen protocols, professional training, authority to administer oxygen and methods for managing hypoxemia during exercise. The development of clinical guidelines around oxygen administration is warranted to facilitate exercise training and optimize functional outcomes during PR.

Exploring Public Health and Nursing Students' Perceptions of Each Other's Professional Roles.

Public health education specialists and nurses often work interprofessionally in the public health setting. Using a mixed-methods design, this exploratory study evaluated the effect of an online interprofessional case study activity on nursing and public health education students' perceptions of each other's professional role. For the public health experimental group only, a statistically significant change (p < .05) was found in their perceptions of the professional roles of nurses including large changes in six specific domains. Recommendations for implementing interprofessional education programs include more emphasis on education about professional scopes of practice and roles/responsibilities of the health professions.

Navigating complexity in team-based clinical settings.

Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio-relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. Constructivist grounded theory informed data collection and analysis; during semi-structured interviews, we used rich pictures to elicit team members' perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. Routine care became complex when the prognosis was unknown, when treatment was either non-existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants' training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non-physician team members in advocacy training.

Disturbing Behaviours: Ole Ivar Lovaas and the Queer History of Autism Science

This paper “queers” the history of autism science through an examination of the overlap between the regulation of autism with that of gender and sexuality in the work of Ole Ivar Lovaas. Lovaas is the founder of Applied Behaviour Analysis (ABA), the most commonly used and funded autism intervention today that seeks to extinguish autistic behaviors, primarily among children. Less commonly recognized is Lovaas’ involvement in the Feminine Boy Project, where he developed interventions into the gender identities and behaviors of young people. Turning to Lovaas’ published works, we perform a “history of the present” and argue that a queer disability studies lens opens up the richness of autism as a cultural nexus, and deepens understandings of intersecting and contested histories of science, professional scopes of practice, and dominant futurities. The article makes a significant and timely contribution to understanding the disabling material effects of autism science in the lives of autistic persons. In particular, this case study highlights the need for feminist science studies to further investigate the historical and contemporary links between dominant scientific constructions of disability, gender, and sexuality.

The impact of blame culture on paramedic practice

PurposeThe purpose of this paper is to explore English and Finnish paramedic perceptions of the healthcare blame culture, its relationship to complaints, the use of defensive practice and if this impacts on paramedic practice and clinical care.Design/methodology/approachParticipants were recruited from English and Finnish ambulance services that have similar organisational and professional scopes of practice. The aim was to gain insight into the similarities and differences between the countries regarding the existence of a blame culture in paramedic practice. Semi-structured focus groups and interviews involving 20 English and Finnish paramedics were undertaken. Qualitative perceptions concerning the reality of a blame culture in paramedic practice and its impact on professional roles were sought.FindingsThree major themes that were identified in the thematic analysis included: blame culture and its influences; the impact of complaints against paramedics; and the use of defensive practice within their roles. These data themes were similar for both groups of participants. The majority of participants thought the healthcare blame culture to be widespread and believed that this was likely to directly influence paramedics’ working practices.Originality/valueWhilst the impact of blame culture and complaints on the medical profession has previously been examined, this study makes an important contribution by exploring the factors that impact on paramedics’ lives and their practice, within two European countries. The inappropriate use of social media by some members of the public in both countries was a disturbing issue for many participants and was identified as an area for further research.

Assistive Technology in Pre-Service Rehabilitation Counselor Education: A New Approach to Team Collaboration

Purpose: Recognizing a perceived lack of assistive technology/adaptive equipment (AT/AE) competence on the part of counselors and educators (Kuo, 2013), this article provides an overview of assistive technology concepts and accreditation standards, and introduces a training model intended to improve rehabilitation counselor readiness to address client AT/AE needs.Method: Drawing on the extant literature, professional scopes of practice, and interdisciplinary clinical experience, the authors conceptualize AT/AE service delivery along a biopsychosocial continuum.Results: The resultant model of AT/AE team collaboration can be taught by counselor educators and understood by students without specialty certification or preexisting knowledge of AT. The model spans the continuum of care from medical to psychosocial, details the roles of rehabilitation disciplines, and offers a pedagogical tool for infusing AT concepts across the curriculum.Conclusion: Ultimately, this article advocates for increased rehabilitation counselor engagement and entry-level competence in addressing the psychosocial aspects of AT/AE. Future research should be conducted to validate the constructs of this model.

CPD needs of opioid nurse prescribers: A survey

Background: The Misuse of Drugs Act non-medical prescribing legislation permits nurse independent prescribers (NIPs) to prescribe any controlled drug that is within their scope of professional practice. Continuing professional development (CPD) is essential for safe effective prescribing and is required for professional revalidation. This study was conducted to explore the educational requirements of non-medical opioid prescribers. Methods: Informed by a critical realism position, an electronic survey was distributed to 147 NIPs working in a Scottish NHS Health Board. The aim was to identify how many NIPs were prescribing opioids and to explore their CPD requirements regardless of whether they prescribed opioids or not, including preferred method of delivery of education and to explore whether the single competency framework was sufficient to facilitate safe and effective prescribing. Results: The response rate was 46% (n=68). The majority of respondents (69%, n=37) prescribed opioids. Ninety-four percent of respondents (n=64) stated they felt that ongoing education was necessary to ensure safe opioid prescribing practice. Face-to-face methods of learning in small group discussions were the preferred option. Two thirds of the respondents (66%, n=45) felt that there should be protected time for prescribing CPD and 64% (n=27) felt the single competency framework provided a good standard for prescribing CPD. Conclusions: The results from this study suggest that nurses are prescribing opioids in acute and community hospitals. Group opioid education is recommended and using a structured competency framework to inform clinical practice may ensure safe, effective prescribing practice.

Registered Nurses as Caregivers: Influencing the System as Patient Advocates

Registered Nurses (RNs) influence the health of individual patients and populations. RNs provide the most value for the healthcare system when they work collaboratively with other healthcare team members, work to their full scope of practice, and when they are engaged and accountable. In 2011, the Institute of Medicine report on the future of nursing made the call to achieve the full value of nursing care. Creation of this future state requires both a vision of the “to be” as well as removal of existing barriers. In this article, we present a description of this future state in the context of a team based culture that utilizes collaboration to achieve the full scope of practice, accountability to deliver healthcare based on a discrete body of knowledge, and accountability to provide value and measure effectiveness of nursing care. This proposed future vision focuses on patient advocacy for nurses working in healthcare systems. Barriers that currently exist, such as overlaps in professional scopes of practice, organizational policy and structure, and a lack of the ability to grant privileges to nurses based upon their education and skills are discussed. We offer recommendations to remove barriers and contribute to creation of a new future state of nursing, and conclude that the removal of barriers to inhibit the fullest scope of nursing practice will continue to require focus in purpose and persistence in action.