Advanced-practice nurses seek wider scope in 24 states

Physician leaders fear that expanding the range of services nurses can provide may threaten patient safety.

By Myrle Croasdale — Posted April 21, 2008

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Advanced-practice nurses are the focus of a new wave of scope-of-practice bills that are making their way to state lawmakers.

At least 24 states are already considering bills or are expecting measures to be introduced this year. Measures address issues such as independent practice, doctor supervision of nurses, prescribing authority, or extended prescribing, including of controlled substances.

Advanced-practice nurses -- a group that includes nurse practitioners, nurse anesthetists and nurse midwives -- say they are working within their training and are filling a void that is being left by a growing physician shortage.

Physicians, however, worry patient safety will be compromised.

APNs working outside a physician-led team raise concerns, said AMA Board of Trustees Secretary William A. Hazel Jr., MD. If nonphysicians do not have the proper education for the scope they seek, physicians need to act. He said, "we have to do the right thing by patients."

States ponder prescribing expansions

In Missouri, state legislators are considering a bill to allow advanced-practice nurses to prescribe medications, including narcotics.

That would put patients at risk, said Julie Marx, DO, an internist in North Kansas City, Mo.

"Nurses have limited diagnosing and prescribing skills," said Dr. Marx, a former nurse. "They have physician supervision [under the bill's language], but the physician only looks over what they already prescribed [and only] once or twice a month. But by then the harm is done. The patient took the drugs already."

In Ohio, a similar bill would let APNs prescribe narcotics and other controlled drugs. That measure is opposed by the Ohio State Medical Assn.

"These drugs should be prescribed only by physicians," said Randy Wexler, MD, MPH, legislative task force chair for the OSMA.

In Florida, one bill would require labs to accept specimens sent by advanced-practice nurses. Other legislation would allow APNs to prescribe controlled substances to patients in medically underserved areas or to underserved populations.

"We need less narcotics out in the field, not more," said Cyneetha Strong, MD, president of the Florida Academy of Family Physicians.

But Susan Apold, RN, PhD, past president of the American College of Nurse Practitioners, said that if nurse practitioners safely prescribe controlled substances in one state, they should be allowed to do it in all 50 states.

"In some states, a nurse practitioner can prescribe controlled substances, but not all controlled substances," Dr. Apold said. "Why? What's the evidence for that decision?"

Dr. Apold added, "If the education, experience and skill exist, why have legislation that prevents the provider from giving that care?"

New law raises supervision concerns

Pennsylvania is one state where scope expansion is being closely watched by physicians.

In 2007, Gov. Edward G. Rendell signed into law scope expansions for nurse practitioners, clinical nurse specialists, nurse midwives, physician assistants and dental hygienists.

Nurse practitioners, who had limited prescribing authority, gained the right to order medical equipment and to refer patients directly to physical therapists and similar practitioners. Nurse midwives, who previously could not write prescriptions, were granted prescribing privileges that included controlled substances.

This spring, the Pennsylvania State Board of Nursing is expected to release new regulations based on the law.

Susan Schrand, CRNP, executive director for the Pennsylvania Coalition of Nurse Practitioners, said the law removed antiquated language and allowed NPs to do what most states already permit.

Pennsylvania Medical Society President Peter S. Lund, MD, fears that the regulatory language in the law may loosen physician supervision.

"The problem we're concerned about is retail clinics," Dr. Lund said.

The growing number of retail clinics creates pressure to increase the number of nurse practitioners a physician may oversee. The law allows off-site physicians to collaborate with four nurse practitioners a day and, in some cases, up to eight.

"In the near term, the only way to expand is to have allied professionals work with us," Dr. Lund said. "And that's what we'd like to do -- with the appropriate supervision."

Nurse leaders say scope-expanding legislation will improve access to health care, especially in light of physician shortages. A study by the Pennsylvania Medical Society, for example, estimated that the state will be short 10,000 doctors in 10 years.

"There are manpower issues in medicine, and there is reason to expect there will be more and more pressure for nonphysicians to treat patients," said the American Medical Association's Dr. Hazel.

Push on scope prompted by more programs?

But physician leaders said expansion efforts on scope of practice also are being spurred by an increase in the number of advanced degree programs.

By 2015, the American Assn. of Colleges of Nursing will require its approximately 200 member schools that offer advanced degrees to also offer a doctorate of nursing program.

Nurse-doctorates consider themselves primary care practitioners qualified to diagnose and treat patients.

But James King, MD, president of the American Academy of Family Physicians, said these nurses should still be part of a physician-led team.

"I would never see the nurse as leading that team in a patient-centered medical home," Dr. King said.

Nursing leader Dr. Apold disagrees.

"The head of the team should be the person best able to provide that service at the time," she said.

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Nursing measures in the works

[download pdf]

Advanced-practice nurses, including nurse practitioners, nurse anesthetists and nurse midwives, are likely to push for legislation on a variety of scope-of-practice issues this year.

Independent practice or establishing of an independent licensing board: Alabama, California, Colorado, Maryland, Massachusetts, New York, North Carolina, South Carolina, Tennessee, Utah, Vermont

Prescribing authority, including independent prescribing rights and prescribing of controlled substances: California, Florida, Illinois, Massachusetts, Michigan, Missouri, Ohio, New York, West Virginia

Direct reimbursement from commercial insurers, Medicaid or Medicare: California, Kentucky, Massachusetts, New York, North Dakota, Utah

Other scope areas, such as authority to certify death, supervise fluoroscopic x-ray systems, provide pain management, and make mental health and substance abuse commitments: Alabama, Florida, Iowa, Kansas, Louisiana, Nebraska, Oklahoma

Sources: Scope of Practice Partnership, Federation of State Medical Boards

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