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New York/New Jersey legislation could test APN 'tether'

Monday June 3, 2013
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New York and New Jersey are among 15 U.S. states weighing legislation aimed at granting advanced practice nurses the ability to provide the full scope of nursing practice without physician oversight.

Nancy F. Muñoz, RN, MSN, New Jersey’s District 21 assemblywoman and the primary sponsor of one such bill, calls restrictions on nurse practitioners and other advanced practice nurses "an unnecessary tether."

While advanced practice nurses already provide primary and specialty care in New York and New Jersey, they remain restricted in a few areas. The restriction to practicing the full scope of nursing practice in New Jersey is called a joint protocol. In New York, it’s referred to as the collaborative practice agreement.

"What we’re working on [in New Jersey] is removal of the joint protocol," said Muñoz, a Republican.

In a joint protocol agreement, a nurse practitioner has to collaborate with a physician, who agrees to do an annual review of the nurse’s patients’ medical records. In New Jersey, that collaborating physician’s name also appears on prescriptions the nurse writes.

In New York, the collaborative practice agreements include, among other things, a peer review by the collaborating physician of patient records at least every three months.

In essence, written practice agreements have empowered one profession to restrict patient access to another profession, limited NPs from practicing to the fullest extent of their training, been an unnecessary cost burden, and may serve as a platform for NP exploitation, according to Audrey P. Hoover, RN, MSN, FNP-BC, WHNP, director of Pace University Health Care units in New York City.

"NPs collaborate with other disciplines in order to provide the best care for their patients and often it is not [collaboration with] physicians — with whom they have written practice agreements," Hoover said. "Still, NPs may feel some form of obligation to refer patients to MDs with whom they have practice agreements. Also, many times the MDs do not know the NPs very well and only provide chart reviews four times per year."

These agreements can stop APNs from being able to practice without notice. How? Muñoz said all it takes is for a physician to move out of state, retire, die suddenly or be forced out of practice. The same goes for New York APNs.

"We’ve had a couple of cases in New Jersey," Muñoz said. "There was a nurse practitioner in the southern part of the state, in one of the poorer counties. She was the primary provider for thousands of patients. Her joint protocol signer, a physician, retired and left the state. As soon as he did so, she could no longer practice. There was another case in northern New Jersey where the joint protocol physician was indicted for Medicare fraud, and it ended up that the nurse who was working under that physician’s protocol could no longer practice."

Another issue haunting APNs in both states is many of the physicians who agree to collaborate with the nurses do so for a fee.

Hoover said while the NPs at Pace University Health Care have mutually respectful relationships with the MDs with whom they have written practice agreements, they too are vulnerable should an MD choose to terminate the agreement, lose his or her licensure, or become incapacitated or die.

"Patient care would be disrupted until a written agreement can be established with another MD, which may take considerable time," Hoover said.

New Jersey nurses also have the issue of often having the collaborating physicians’ names first on prescriptions, which Muñoz argues could compromise patient care. If a pharmacist or provider doing a prescribed medical test has a question, that person tends to call the first name on the prescription. The collaborating physician would not know the patient, which could lead to delays in care, she said.

The move to give APNs full prescriptive authority is not without merit, according to Mary C. Krug, RN, MSN, APN-C, immediate past president, Forum of Nurses in Advanced Practice, New Jersey State Nurses Association.

Krug wrote in the January 2013 New Jersey Nurse, an NJSNA publication: "The recent Institute of Medicine Report on the Future of Nursing recommended that in order to improve access to healthcare in the U.S., APNs and all nurses must practice to the fullest extent of their educational preparation. For that to happen, restrictive regulatory and legislative barriers must be removed. APNs are not new to N.J.; they have been providing safe, cost-effective, and high quality of care to consumers for over 40 years. The IOM report further references studies comparing the care given by APNs and physicians; the research shows when patients have comparable conditions or complaints, there are comparable outcomes in the quality of that care."

In New York, there are two NP bills being considered: S2309-2013, sponsored by Sen. Velmanette Montgomery, D-District 25, allows certified NPs to practice without collaboration of a licensed physician. The other is A4846-2013, sponsored by Assembly member and Health Committee Chairman Richard Gottfried, D-District 75. This bill would establish the Nurse Practitioners Modernization Act, which allows the practice of registered professional nursing by a certified NP to include diagnosis and performance without collaboration of a licensed physician.

While they sound similar, they’re not, said Juliette Blount, RN, MSN, APN, past president of Nurse Practitioners of New York.

"Our lobbying efforts are focused on legislation that will eliminate the requirement for a written collaborative practice agreement with the physician," Blount said. "That will translate into nurse practitioners really being full scope in terms of our practice authority." While Montgomery’s bill is straightforward in eliminating the collaborative practice agreement, Gottfried’s bill comes with some restrictions.

"Gottfried’s bill … contains language requiring collaborating agreements with physicians for NPs with less than 36 months experience," said Bobbie Berkowitz, RN, PhD, dean and Mary O’Neil Mundinger professor, Columbia University School of Nursing, New York City. "Under certain conditions, the collaborating agreement may be with another NP. There is also language that requires NPs with more than three years of practice to have collaborative 'relationships’ with one or more physicians. These relationships would include written guidelines for practice."

In New Jersey, the bill’s assembly designation is A3512, and is called the "Consumer Access to Healthcare Act." The identical bill in the Senate is No. S2354. As written, the New Jersey bill eliminates the need for joint protocol in prescribing medication but delineates conditions under which an APN can perform this service. However, APNs with fewer than 24 months or 2,400 hours of licensed, active APN practice could prescribe only with a formal collaboration with a provider in place.

"They already write prescriptions for tests and medications," Muñoz said. "It’s not going to change [APNs’] scope of practice. They’re not going to be doing hip replacements or interventional cardiology. They are not going to practice beyond the scope of their license. The interprofessional collaboration between nursing and other disciplines does not go away."

Muñoz urged nurses who are not APNs to get involved because what affects their colleagues also affects the profession as a whole. New Jersey will soon have about 600,000 more patients with Medicaid cards as a result of the Affordable Care Act, Muñoz said, which increases the legislation’s importance.

"[Nurses] need to visit their legislators, either by mail, email or in person, and let them know they support this bill," Muñoz said. "My argument to nurses who don’t have the advanced practice degree is if you elevate the profession of nursing, you elevate all nurses."

The fight for optimal APN practice is far from over, according to Berkowitz.

"To assure the ability for NPs to practice to the full extent of their education, scope of practice, licensure and certification, barriers that may exist within practice environments [such as limited admitting privileges or restrictions on practice within a facility] and payment policies also need attention," Berkowitz said.

Lisette Hilton is a freelance writer.

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LEARN MORE by visiting APN-NJ.org, NPNY.net, Assembly.State.NY.US or NJleg.State.NJ.US.


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