Category Archives: Scope of practice
Linda H. Aiken, PhD, FAAN, FRCN, RN, is the Claire M. Fagin Leadership Professor in Nursing, a professor of sociology, and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. Aiken is a research manager supporting the Future of Nursing: Campaign for Action and a National Advisory Committee member for the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative. This is cross-posted on the Leonard Davis Institute Voices blog.
All too often, the debate about expanding the role of nurse practitioners (NPs) and physician’s assistants (PAs) takes place in a vacuum, as though these practitioners do not already deliver significant amounts of primary care. But they do, and existing evidence indicates that quality of care and patient satisfaction are good as a result.
Even before the passage of the Affordable Care Act, the nation had a shortage of primary care providers. The shortage is likely to intensify when the demand for primary care increases as millions become insured. The numbers of and roles assumed by NPs and PAs have been growing steadily, and allowing these providers to take on an even greater role could address the increased demand for primary care.
Susan B. Hassmiller, PhD, RN, FAAN, is senior adviser for nursing at the Robert Wood Johnson Foundation, and director of the Future of Nursing: Campaign for Action.
On Thursday, New York Times blogger Pauline Chen, MD, took a fresh look at the disagreements over the services that advanced practice registered nurses should be authorized to provide, reporting on a primary care meeting at which a doctor dared to raise “the unmentionable” topic with his colleagues. The room, she reports, erupted into discord and chaos.
The same divide was documented in a survey reported by the New England Journal of Medicine in May. It is a terrible shame. What we need, now more than ever, is open and reasoned conversation within and between health care fields about the best way to provide high quality care and improve our population’s health.
These are challenging times for our health care system. Millions of Americans are about to gain insurance through the Affordable Care Act. Our population is getting older and living with more chronic illnesses. And we have an urgent need to promote prevention, improve quality, and contain costs.
There is no question that we need more physicians and more primary care physicians in particular. There is no question that physicians should treat the sickest patients and those with the most complex health problems. But there also is no question that we need nurse practitioners to be able to practice to the full extent of their education and training.
The Iowa Supreme Court ruled last week that advanced registered nurse practitioners (ARNPs) can supervise fluoroscopy, a high-tech X-ray and imaging procedure. The high court ruling was in response to a challenge by three nursing organizations to an earlier decision from a district court.
“We believe the district court erred in second-guessing the department of public health and nursing board on the adequacy of ARNP training to supervise fluoroscopy,” the Iowa Supreme Court wrote. “The record affirmatively shows ARNPs have been safely supervising fluoroscopy and are adequately trained to do so… Allowing ARNP supervision of fluoroscopy improves access to healthcare for rural Iowans and helps lower costs.”
Experts say the ruling has implications for patients, especially those living in rural areas with limited access to doctors, who will be able to get test results more quickly. That can alleviate fears if the fluoroscopy shows that a patient does not have a serious health problem or, conversely, it can facilitate quicker treatment if a patient needs it.
Julie A. Fairman, PhD, RN, FAAN, is Nightingale Professor of Nursing at the University of Pennsylvania School of Nursing, and director of the Barbara Bates Center for the Study of the History of Nursing. She is a predoctoral fellow at the Penn Nursing Center for Health Outcomes and Policy Research and recipient of an RWJF Investigator Award in Health Policy Research. Safiyyah Okoye, BSN, RN, and Jill Vanek, BSN, MSN, are students at the University of Pennsylvania School of Nursing.
The 2011 Institute of Medicine (IOM) report “Future of Nursing: Leading Change, Advancing Health” pointed out that because nursing scope of practice regulations vary across states, and because there is little rationale for these variations, the federal government, through the Federal Trade Commission (FTC) and the Antitrust Division of the Department of Justice, “is well situated to promote effective reforms [related to regulation of APRN scope of practice] by collecting and disseminating best practices from across the country and incentivizing their adoption.”
The IOM recommended that the FTC and the Department of Justice review existing and proposed state regulations related to advanced practice registered nurses (APRNs) to identify those that limit competition without contributing to the health and safety of the public, and urge such states to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.
Created in 1914 to promote consumer protection by eliminating and preventing anticompetitive, unsafe, or deceptive business practices, the FTC is the logical agency to address scope of practice laws. The FTC’s responsibility is to promote competition, inform consumer choice, and protect consumer safety. All are directly related to APRN scope of practice regulations, including those mandating physician supervision and oversight of APRNs when there is not “a compelling consumer protection rationale” for doing so. That includes evidence justifying restrictions on APRNs’ ability to provide health care services that could override the public interests with regard to choice, cost or competition.
Judith Hansen, MS, BSN, RN, is the executive director of the Wisconsin Center of Nursing and co-lead of the Wisconsin Action Coalition.
Since the release of the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, leaders in Wisconsin have made concerted efforts to plan well and engage nurses and key stakeholders. Our goal is to empower them with a firm foundation so they will be ready to implement the report’s recommendations.
Our first task was to create awareness and knowledge of the IOM Report, so initial efforts began even before we were designated as a state Action Coalition. In September 2010, the University of Wisconsin-Madison (UW) School of Nursing launched the report by bringing ‘home’ Donna Shalala, PhD, FAAN, former chancellor at UW.
Shalala, also a former head of the U.S. Department of Health and Human Services, chaired the Committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, at the IOM, and provided a powerful keynote address to engage the nurses of Wisconsin. To continue this process, the Wisconsin Center for Nursing (WCN), utilizing its partnership and grant funding through the Wisconsin Department of Workforce Development, sponsored a summit in May, 2011.
As the state’s nursing workforce center, WCN has existing partnerships with a vast array of partners including the Wisconsin Nurses’ Association, the Wisconsin Nurses’ Coalition, the Administrators of Nursing Education in Wisconsin, the Wisconsin Organization of Nurse Executives, the Wisconsin Department of Health Services, the Wisconsin Healthcare Workforce Data Collaborative, and baccalaureate and technical school education programs.
By Lisa Wright Eichelberger, DSN, RN, dean, College of Health, Clayton State University and co-lead, Georgia Action Coalition
I know I am not in Oz but, I must tell you, Georgia does seem like a different place since the release of the Institute of Medicine’s (IOM) report on the future of nursing. I have worked as a nurse in Georgia for the past 16 years, but in the past 18 months I have seen things happen that I never thought would. As I told this year’s graduating class at Clayton State University, I truly believe this is the most exciting time to be a nurse. One of the reasons is the release of the IOM’s nursing report and the support for nursing from the Robert Wood Johnson Foundation (RWJF) and AARP.
Make no mistake, when the IOM and RWJF speak, people listen.
In the past few months, I have had the honor and privilege to use the “Future” report to initiate conversations with former Surgeon General David Satcher, MD, PhD, and Louis Sullivan, MD, former secretary of the U. S. Department of Health and Human Services. I also had the opportunity to talk to former Ambassador Andrew Young, BS, BDiv, about the report during a recent lunch. All three of these leaders were familiar with the IOM and RWJF.
Expanded Advanced Practice Registered Nurse Scope of Practice Laws: Can We Ignore Economic Motives and Effects?
By Mark V. Pauly, PhD, Bendheim Professor of Health Care Management, Wharton School, University of Pennsylvania and co-director, Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI)
The recent and useful article by Patricia Pittman and Benjamin Williams, “Physician Wages in States with Expanded APRN Scope of Practice,” examined annual earnings of salaried physicians in states with and without expanded Scope of Practice (SOP) laws. It found that there is no smoking gun to support the hypothesis that laws which permit registered nurses to do more result in lower primary care physician salaries. While there may still be reasons why physicians and others may be skeptical of such laws, and whatever suspicions people may harbor, proven financial harm to physician salaries would not appear to be one of them; primary care physician salary levels were not different, either absolutely or relative to surgeon salaries, in states with expansion laws.
In my view, these results definitely help in the debate about expanded SOP rules, potentially moving it to a different (and probably more appropriate) level where it is about quality and access, not about economics. However, the results are, as the authors note, far from definitive as proof that no causal impact exists. In addition, they raise more questions than they answer about how primary care workforce markets actually function. Paradoxically, if there are no financial impacts, there may be no cost savings either. Here I first lay out the questions which these results raise for understanding how markets are working, and then specify some empirical issues that would need to be addressed for more definitive empirical conclusions.
By Kristine M. Gebbie, DrPH, RN, Adjunct Professor, Flinders University School of Nursing and Midwifery, Adelaide, South Australia
The term, "scope of practice," is primarily linked to the legal definition of a profession in the statutes or regulations that define the profession and the niche it fills in the array of health practitioners. As such, the limits (or opportunities) presented by legal language is of primary importance to individuals and organizations considering exactly what a nurse, a physician, a dentist, a veterinarian, a naturopath or a physical therapist can be expected or allowed to do generally. However, the many decisions made by institutions in designing credentialing standards, position descriptions or practice policies may be of even greater importance on a day to day basis.
The research brief on nurse-managed health centers published on the Future of Nursing website1 puts the issue of credentialing into perspective. The authors identify the reluctance of managed care organizations to credential nurse practitioners as providers of primary care, despite the research literature supporting such decisions. Nearly half of responding organizations (47%) do not allow employed nurse practitioners the full legal scope of primary care practice that could benefit both patients and the organization. That credentialing is strongly influenced by geography and history is also evident, for example, in the number of U.S. institutions that limit the role of nurse midwives, while in many other parts of the globe they are readily credentialed and provide an enormous amount of obstetric care.
A further limitation may be imposed by employing organizations in the specifics of position descriptions (PDs) setting out what the employees in a given class or range are being hired to do.