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State of the scope of practice

Healthcare reform brings the focus back to nurses as primary care providers

Monday August 26, 2013
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After a detailed analysis of research showing how advanced practice registered nurses provide safe, quality care, the Institute of Medicine recommended rewriting federal and state laws to allow APRNs to practice to the full extent of their education and training — a position opposed by many physician groups.

Nearly three years later, though physician opposition continues, a projected primary care provider shortage and the expected demands of healthcare reform are increasing the pressure on state and federal governments, insurance payers and healthcare administrators to do what growing numbers of people believe is simply good evidence-based practice.

"As a physician, itís a little embarrassing to see these medical guys who make a big deal of evidence-based medicine, and theyíre against this," said John W. Rowe, MD, a professor in the Department of Health Policy and Management at the Columbia University Mailman School of Public Health in New York City, former CEO of Aetna, Inc. and a member of the Institute of Medicine committee that published "The Future of Nursing: Leading Change, Advancing Health" in 2010. "The evidence is all in favor of having advanced practice nurses provide for basic primary care services."

Since the report came out, Rowe and others, including nursing organizations, consumer groups, businesses, state governors and public health organizations, have been working to reframe the scope-of-practice issue, taking it beyond turf battles between physicians and nurses. In addition to the IOM report, they point to evidence-based studies, reports and existing practice models showing how eliminating barriers to practice best serves patients at a time when primary care is desperately needed. (See sidebar for a list of some of these studies.)

"This is not a competition or about nurses having more power," said Susan C. Reinhard, RN, PhD, FAAN, senior vice president for public policy at AARP, which has come out strongly in favor of expanding scope of practice for APRNs. "This is about nurses and other professionals being able to do what they are trained and educated to do. We need more primary care providers across the board. This is not a nursing campaign, it is an American campaign."

As healthcare delivery changes and demand increases, all groups — including nurses — will have to let go of their territorial impulses, Reinhard said. Projections from the Association of American Medical Colleges predict the country will face a shortage of 45,000 primary care physicians by 2020. A nursing shortage also is predicted, as demand for care by aging baby boomers increases and more nurses retire. Nurses must be willing to allow other providers, including certified nursing assistants, health educators, home health aides, and, in some cases, family members to give whatever care they can safely provide, according to evidence and standards of practice, she said.

Barriers to practice

Seventeen states and Washington, D.C., do not require any physician supervision for advanced practice nurses. The rest require some sort of physician involvement in diagnosis, treatment or prescribing, and many states are considering legislation to change those laws, said Jan Towers, PhD, NP-C, CRNP, FAANP, FAAN, senior policy advisor for the American Association of Nurse Practitioners.

Besides legislative restrictions, other barriers to APRN practice include difficulty getting reimbursement from insurance companies; federal regulations preventing non-physicians from ordering home care services, hospice or medical equipment; and institutional barriers, such as not having admitting privileges at a hospital or not being allowed to perform certain procedures. Even in states where they are allowed to practice without physician supervision, APRNs still may struggle with restrictive hospital or compensation policies, Towers said. But she and others believe such restrictions are more likely to loosen in states that allow APRNs full scope of practice.

The barriers to scope-of-practice hurt patients in a number of ways, nurse practitioners said. Many times the laws make practice more cumbersome, forcing nurse practitioners and families to work around them, said Susan Apold, PhD, RN, ANP-BC, FAAN, dean of the division of health and human services at Concordia College-New York.

For instance, in New York nurse practitioners must sign a collaborative agreement with a physician, but if the physician dies, retires or is arrested, the nurse practitioner can no longer see patients, Apold said. To resume practice the NP must find another physician collaborator. In Florida, nurse practitioners cannot prescribe certain drugs for patients, even with physician oversight, Towers said. They must get a physician to officially prescribe the drugs. Federal regulations prohibit nurse practitioners from ordering home care or medical equipment for Medicare patients. The nurse or family must find — and pay — a physician to do this, Apold said.

In Colorado, hospitals and nursing groups last year successfully battled a lawsuit brought by anesthesiologists and medical societies that would have required physician supervision of nurse anesthetists, something small rural hospitals said they could not always provide. In North Carolina, which is considering a law to require physician oversight of nurse anesthetists, Sharon Pearce, CRNA, MSN, fears a similar situation, especially if the state requires the physician to have anesthesiology training. The practice where she works, run by two nurse anesthetists, could not afford to pay an anesthesiologistís salary, said Pearce, president-elect of the American Association of Nurse Anesthetists. Nursing groups in North Carolina are fighting the law, Pearce said, but they face formidable opposition from physician groups who are outspending them.

Physician resistance

Physician groups, led by the American Medical Association and the American Academy of Family Physicians, actively oppose state legislation to remove physician supervision of APRNs, citing concerns for patient safety. An AAFP white paper stated physicians have an average of 11 years of education and training compared with 5 to 7 years for a nurse practitioner.

But such training doesnít mean physicians are the only ones able to provide safe, quality basic primary care — or even the best ones to do so, Rowe contended. He noted that as an experienced physician, he has more training, medical knowledge and experience than a new graduate nurse practitioner. "But it doesnít mean I know more about providing core primary care."

The AMA declined to provide someone to expand on its view for this article. Instead an AMA spokeswoman provided a quote from the organizationís president, Ardis D. Hoven, MD, saying the group supports the use of "physician-led teams, comprised of a variety of healthcare professionals." The AAFP has published a similar statement on its website.

Nurse practitioners agree the best patient care is delivered by a team of providers with the patient at the center, Towers said. "Weíre very team-oriented. But that doesnít mean the physician has to be the leader of the team." The team works best, she said, when all members are allowed to practice according to the standards of care for their professions.

Apold said she believes many physicians who work directly with nurse practitioners do not necessarily agree with their own associationsí positions. When the Robert Wood Johnson Foundation brought representatives from nursing and physician associations together to discuss the issue, they generally agreed that doing away with hierarchies best served patients and that non-physicians could lead provider teams. But when they returned to their professional organizations, "the process fell apart because the associations were not able to divorce themselves from a guild mentality," said Susan B. Hassmiller, RN, PhD, FAAN, senior adviser for nursing at RWJF.

APRNs are not the only providers dealing with scope of practice barriers. Physician assistants, optometrists and pharmacists are battling regulations they say keep them from practicing to the full extent of their education and training. RNs also encounter legal and institutional limits that can hinder patient care. Hassmiller gives the example of a home health nurse who was unable to order Styrofoam boots for a patient to prevent foot-drop. The patientís husband was forced to wrap her in a blanket, carry her to a car, and drive her to the parking lot of the physicianís office so the physician could examine her and order boots.

Moving forward

As the demand for healthcare increases, nurse leaders and policy experts said, nurses must continue to use the latest evidence to show physicians, payers and employers what the public already knows: that nurse practitioners, nurse midwives and nurse anesthetists provide safe, excellent care,

Nurses can work with their organizations and other groups to pass state laws allowing APRNs to prescribe and practice without physician supervision, fight proposed legislation that would be restrictive, and lobby for changes in federal regulations. They can educate hospital administrators about what nursesí education and training allows them to do, and press insurers to officially include APRNs on their lists of providers. The American Nurses Association recently proposed that insurers participating in the new state and federal health exchanges have a certain number of APRNs as recognized primary care providers.

Though progress seems slow, it is happening.

More states than ever are considering laws to expand scope of practice for APRNs, Towers said. Hassmiller is optimistic that within the next five years, consumer and marketplace demand will fuel the push to lift scope-of-practice barriers. As people become more familiar with the nationís 155,000 nurse practitioners in settings such as retail clinics, community centers and medical groups, they are more likely to want to see them again, Rowe said, citing a recent study from the American Association of Medical Colleges. An increasing number of insurance companies are willing to directly reimburse APRNs, Apold said.

Fighting over who gets to be in charge, and who gets paid extra to be in charge, is ridiculous, given the impending need, Pearce said. "Thereís going to be enough work for everybody. We should be walking arm-in-arm and seeing how we can collaborate together to do whatís best for our patients."

Cathryn Domrose is a staff writer.


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The evidence

Some of the most recent studies and reports supporting the removal of scope-of-practice barriers include the following.

• A position paper from the Robert Wood Johnson Foundation released in July, outlining several successful models for taking full advantage of the skills of advance practice registered nurses, including expanding APRN practice through the U.S. Department of Veterans Affairs, using APRNs for transitional care, and using teams of healthcare professionals in which everyone collaborates according to their strengths, as opposed to a having a physician delegate tasks: www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf405378

• A July study from the University of Texas Medical Branch at Galveston showing states with the fewest restrictions on nurse practitionersí scope of practice had 2 times more patients receiving primary care from nurse practitioners than did the most restrictive states: http://content.healthaffairs.org/content/32/7/1236.short

• A paper released by the National Governorís Association in 2012 urging states to consider easing scope-of-practice restrictions to encourage nurse practitioner involvement in primary care services and to provide more access to healthcare: www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.html

• A systematic review of evidence showing that care provided by nurse practitioners and nurse midwives was as good as or superior to that provided by physicians, published in 2011 in the journal Nursing Economic$: www.NursingEconomics.net/CE/2013/Article3001021.pdf

• A UCLA-led study, published in June, showing geriatric patients who were co-managed by a physician and a nurse practitioner received better quality care than those seen only by a physician: http://OnlineLibrary.Wiley.com/doi/10.1111/jgs.12268/abstract

• A June survey from the American Association of Medical Colleges showing that although half the respondents initially preferred a physician as their primary care provider, when they were told they could see a nurse practitioner or physician assistant sooner, most chose that option: www.ClinicalAdvisor.com/Consumers-Receptive-to-NP-PA-Care-Models/Article/297335/

• Research from George Washington University published in June showing fewer than 25% of students graduating from medical residency programs go into primary care, and fewer than 5% go into practice in rural areas. In contrast, about 65% of nurse practitioners practiced in at least one primary care site in 2010-11, and nearly 20% practiced in rural settings, according to the American Academy of Nurse Practitioners: http://Journals.LWW.com/AcademicMedicine/Abstract/PublishAhead/Toward_Graduate_Medical_Education__GME_.99378.aspx