All Imaginable Futures Are Not Equally Possible

There is much movement in the world of nurse practitioners (NPs). Some of it is tectonic, bold, and exciting; some promises advances in the future; and some consist of smaller incremental steps in the right direction. The most important element in modernizing the nation’s NP acts is the context of each state’s political environment. While some state legislatures have a culture of making more progressive moves, others are steeped in tradition and more at ease with smaller, slower change. The nature of each state legislature’s political climate must be fully evaluated and linked to strategies that have a high chance of success, however limited the victory achieved. Otherwise, without that high degree of political competence, we may keep ourselves stuck in the past.

We All Have a Stake in Each Other’s Success: Moving Toward Autonomy
Nine state NP organizations submitted legislation seeking complete statutory independence in 2011. This is imperative for a number of reasons. Most important is the rollout of health reform; with or without the Supreme Court upholding the individual mandate later this spring, other elements of reform create subsidies and patient protections from insurance companies. Therefore, the number of people who will be swept into the system will create a surge in demand for health care. Congratulations to NPs in Vermont and North Dakota who succeeded in modernizing their nurse practice acts! This brings the number of states with complete independent practice authority to 16.¹

Fully Modernized
North Dakota (ND) NPs launched a massive public education campaign about the abilities of NPs and then obtained support for a legislative change that would remove the requirement for a physician’s signature on prescriptions. As described by Billie Madler, DNP, FNP, and president of the ND Nurse Practitioner Association, it was “an exciting legislative session for ND NPs, and we are very proud of our accomplishment.” She describes the range of political competencies deployed and says, “success of legislation to remove the collaborative agreements required in North Dakota to prescribe medication was multifactorial. NPs from all parts of the state were mobilized and actively participated in efforts to inform our legislators of reasons this change was needed.” NPs shared true life stories of barriers created by the collaborative agreement, gave examples to illustrate the antiquated nature of the collaborative-agreement requirement, highlighted the quality of care provided by NPs across the state, and emphasized the increased accessibility to care that NPs provide. With physicians from the state, NPs were able to articulate that any healthcare provider who gives high quality care collaborates—or, better yet, consults—with other providers on a regular, often daily, basis. Moreover, as a nursing body, NPs value being governed by our profession; during this process, NPs outlined how the ND Board of Nursing has been effective and will continue to be effective in regulating the practice of NPs. “As a result of this successful legislation, NPs in North Dakota are very pleased that an unfounded requirement has been lifted,” Madler said, “and we are able to provide care to the citizens of North Dakota to the full scope of our education.” The bill passed by an overwhelming margin, and the new law took effect August 1, 2011.

Vermont Presents Alternatives to Graduated Prescribing
Moving east to New England, the Vermont Board of Medical Practice proposed legislation that would have required NPs to be supervised by a physician for 5,000 hours before entering into solo practice. Vermont NPs’ unity and political competency led to passage of alternative legislation that provides full NP autonomy and requires new graduate NPs to be mentored by NPs in prescribing for 2 years or 2,400 hours before earning full statutory authority. While this “mentored prescribing” is not in line with the requirements for advanced-practice registered nurses (APRNs) outlined in the Consensus Model for APRN Regulation,² it does represent a step toward autonomy. The Vermont Nurse Practitioner Association held tight to the principals of “nurses regulating nurses” and “practice autonomy” and refused to concede points that would have compromised their core values. At least a dozen other states are planning to submit legislation seeking full statutory authority in 2012.¹

Legislative victory for North Dakota citizens Front row, from left—Representative Don Vigesaa, Senator Judy Lee, Governor Jack Dalrymple, Senator Bill Bowman, Senator Joan Heckaman. Back row, from left—Representative Bill Devlin; Cheryl Rising, MSN, FNP; Representative Karen Rohr, PhD, FNP; Cal Rolfson, NDNPA lobbyist; Kris Todd-Reisnour, MSN, FNP; Connie Kalanek, PhD, RN, executive director of the North Dakota Board of Nursing; Billie Madler, DNP, FNP

 

Incrementalism vs. No Progress
The Virginia Council of Nurse Practitioners (VCNP) and the Medical Society of Virginia (MSV) have agreed to submit a consensus bill designed to address problems with current access to health care in Virginia, particularly in underserved areas, in the 2012 legislative session. The VCNP reports that their leadership, bound by a mutually agreed upon confidentiality agreement, met regularly with the MSV leadership over the summer with an eye to submitting consensus legislation to expand access to health care in Virginia. Of note, the current NP statutes in Virginia that require physician supervision of NPs are found in the Medical Practice Act, which was written in 1973. Although the Medical Practice Act has not been updated in many years, the VCNP leadership is reporting that they have agreed with the MSV to eliminate the supervisory language but to replace it with a mandate for NPs to work in collaboration and consultation with a physician in a “patient-care team.” The requirement for the physician supervisor to “regularly practice” where the NP prescribes has been removed; however the patient-care-team physician will “actively provide management and leadership.” The Joint Board of Nursing and Medicine will retain regulatory oversight over the physician-NP practice agreement process, with continued but increased required NP to MD ratios of 6:1 (up from 4:1).³

While this may seem a small step in the journey toward a modern nurse practice act, it is important to put it into context. The process in Virginia is highly politicized instead of relying on an evidence-base to make policy decisions. The compelling evidence on APRN safety and nursing standards were not incorporated into the draft bill to the degree that many had hoped. Established in 1619, the Virginia legislature is the oldest legislative body in the western hemisphere, and it clings proudly to tradition and to Thomas Jefferson. Virginia’s legislative environment is heavily influenced by politics in which the ruling forces use their efforts to maintain their dominance in the policy community, thereby introducing an irrational element into the legislative process. Leaders of VCNP considers the proposed legislation to be a small victory because it is the first time in decades that the practice act may be opened to remove the requirement for physicians to practice regularly at the site with the NP. The mandated physician-led patient-care teams in the proposed legislation appear to be more favorable than the previous requirement for “direct physician supervision.” The VCNP is fully supportive of the Institute of Medicine (IOM) recommendations and has taken part in a months-long process engaging their leadership team in how best to approach modernization in Virginia. Previous attempts to open and modernize the practice act have been unsuccessful. Although the proposed legislation in no way meets the recommendations set out by the IOM4 or the APRN Consensus Regulations,² in Virginia, incrementalism is the only way to move forward.  The VCNP expects that this incremental approach will pave the way for more progress in the future, and these NPs see these small steps as a roadmap toward ultimately achieving a modern nurse-practice act. Regardless of what happens in the Virginia Assembly in 2012, NPs have been working tirelessly to move forward and will not stop until the state has a practice act which reflects modern advanced practice nursing.

While we have pockets of visionary innovation and APRNs making huge steps forward, we must face the fact that there are areas in which modernization will have to occur more slowly and steadily. This lack of evidence-based policy-making suggests that the legislature may not be the appropriate place to adjudicate scope-of-practice issues because of the politicalization and highly technical nature of scope-of-practice changes. It seems that the southern states, the original colonies in general, are having a harder time with modernizing. Small incremental changes are the only way forward in states that cling to tradition and the pull of the familiar, ie, the physician as the historical and most familiar type of healthcare provider.

Dr. Loretta C. Ford on Scope-of-Practice Victories
Dr. Loretta C. Ford reminds us to work toward eliminating provisions that 1) maintain physician control of APRNs, which is inappropriate to legislate and limits the “team” to two professions (what about all the other professions?); 2) medicalizes advanced-practice nursing; 3) compromises board of nursing authority; 4) does not allow for real innovation of new nursing models; and 5) does not encourage or even allow for research or evaluation. Moreover, the APRN consensus model, the IOM nursing report, and healthcare-reform legislation all point to full utilization of NPs with statutory autonomy. She reminds NPs to take bold steps, to more courageously take our rightful place in health care in this country. According to Dr. Ford, “nursing has never had a better opportunity than the current environment to make the statutory changes we have sought and fought for over a long period of time. And, if we don’t grab the brass ring NOW, we may never have another chance.” She asks a penetrating question for all policymakers to consider. “How can we expand access, assure quality, and offer more affordable care in the public’s interest?”

The patient safety violations or quality concerns in the 16 states with modernized nurse practice acts are no different than in the states with antiquated nurse practice acts. This state-by-state comparison serves as the strongest evidence possible for the efficacy and safety of autonomous NP practice. The politicization of the nation’s scope-of-practice laws is not serving consumers well. All of the states that have moved forward positively have exhibited a high degree of political competence. They have widened their stakeholder base, including consumer groups and university presidents; they have negotiated on principled ground; and they positioned NPs from a place of power, presenting decades’ worth of strong evidence supporting the safety of APRN practice.

Looking Toward the Horizon
Recently, I was made aware of Duke University’s doctorate-in-nursing-practice (DNP) student projects, now available on You Tube. The student projects are fantastic in every way and will “knock your socks off.” Under the direction of Nancy Short, RN, DrPH, a Robert Wood Johnson Policy Fellow and award-winning educator at Duke University, these roughly 6-minute videos are edgy, direct, and wildly creative. Dr. Short has raised the bar on what is possible with DNPs. The topics include group visits, mental health, and bariatric surgery, among many others. The wide scope of issues addressed and the expertise of these videos created by APRNs really tell the story of how we are present in nearly every sector of health care and making a huge impact. Of note, the videos also shed light on “orphan issues,” ie, problems in our health system that may not have champions, such as preventing sudden death in young athletes and removing supervision requirements for nurse anesthetists. The videos provide strong context for and the background of many varied issues, discuss policy issues, and use expert interviews to include elements of investigative reporting. They offer sharply worded summaries of how we are falling short in either building an evidence base or in implementing the little evidence we do have. Clear and unambiguous policy recommendations are made based on existing evidence and epidemiology. The APRNs include poignant stories to humanize the issues by giving a soul to the data, which adds a powerful punch to their messages. If you feel discouraged by the current times; the quality of presidential candidates; the economic forecast; the persistently fragmented, uneven quality and safety concerns in our health systems; and the profoundly gridlocked political system we have elected, you may want to look to a more positive horizon. Check out the promise of our profession, soon to be fully unleashed onto the public from the Duke University DNP program, at www.youtube.com/user/profshort1?feature=mhee#g/c/D54B80AB82E1F8AE