The Voices Grow Louder

It is my hope that we nurse practitioners (NPs) don’t suffer from “protest fatigue” as a result of our continually fighting for what is important to us, causing us to become immobile, worn out from struggling for what is so rightly our place in health care. The unfolding federal health reform has numerous provisions and language that validate our belonging in a reformed health system. Since many of these measures will be implemented at the state level, we must concentrate hard on avoiding apathy, or lack of will, interest, or concern in addressing restrictive state scope-of-practice acts. We cannot yield to indifference as the challenges for NPs are coming into laser focus. Unless and until the 23 states with restrictive scope-of-practice rules and regulations are “modernized,” much of the promise of reform may be thwarted.

We are fortunate in that two independent sources have made the case for us, releasing us from misplaced accusations of being self-serving or worse, putting patient safety at risk, in our quest to modernize the nation’s nurse practice acts. These documents from two separate, neutral, third parties are saying loudly and clearly that we need to change the way we regulate all health professionals. That is, the highly politicized way that scope of practice is determined is largely not in the interest of consumers and is not in the spirit of the health reform legislation, which is designed to promote innovative ways to improve access, quality, and cost-effectiveness.

The voices demanding modernization of the nation’s remaining nurse-practice acts are growing louder and more diverse—yet, we all know that loud choir members do not make good music. Rather, what matters in choirs is quality, not quantity, and that a singer’s whole body rings out with the sound so it can travel as far as possible. What’s important in a beautiful  chorus is to sing in tune and to have a voice with power and focus. If everyone just roars, it isn’t very pleasant. To this end, we now have some serious talent and heft added to our chorus—adding many voices to our single message. What we have before us is the addition of different voices because when everybody sings the same note, there is no harmony.

These two superb reports were released this summer by outside, independent groups that are calling for a rational approach to scope-of-practice expansions for health professions. Both reports recognize that the way the states look at and manage disputes about scope-of-practice expansion is not serving the public well, does not protect consumers, lacks an evidence base, is too political, and is far too technical for most state lawmakers to fully grasp. The strength of these reports comes from their neutrality in that they have no direct political interest in any specific discipline but rather look at scope-of-practice expansion from a consumer or a health reform planning angle. Another excellent paper from 2009 by our Kentucky NP and certified nurse-midwife (CNM) colleagues is also mentioned here since they have brilliantly linked scope-of-practice restrictions to the grim health status of Kentuckians. (All three reports can be found on the sidebar of this page.  If you don't see it available, please contact NP Communications at 609-371-5085.)

Citizen Advisory Center

Changes in scope of practice are inherent in our healthcare system.

Collaboration between the health professions should become the professional norm. 

Overlap among health professions is necessary.

Practice acts should require licensees to demonstrate that they have the requisite training and competence to provide a service.

Interestingly, the paper is referring to all health professions and uses an example of dental hygienists who are unable to go into  long-term care facilities to clean residents’ teeth without a dentist on site. These laws unnecessarily restrict professionals from being able to use their full range of skills and limit consumer access to care. The White Paper suggests moving away from narrow turf battles. Instead, the authors strongly urge that scope-of-practice expansions be used as a tool to promote the goals of healthcare reform, ie, improved access to and quality of care and lower healthcare costs. The current piece-meal approach to state scope of practice has far-reaching and harmful consequences.

The White Paper cites Pennsylvania as the only state that made scope-of-practice reform central to healthcare reform. Pennsylvania Governor Rendell’s administration concluded that many scope-of-practice restrictions have no basis in clinical evidence but are based on profit motives of those individuals in a position to impose the limitations. When the authors looked at other states with unrestricted scopes of practice for physician assistants (PAs), advanced-practice nurses (APNs), and dental hygienists, they found no evidence of a decline in the quality of care in those states. Pennsylvania was able to expand its scope of practice, with one troubling caveat—collaborative practice agreements with physicians. Politically, they could not appease the physicians, so the requirement for an NP-MD collaborative agreement remained in place to inoculate physician concerns about APNs. Tethering APN practice to a collaborative practice agreement is a policy that lacks any evidence base whatsoever. While Pennsylvania still does not meet our national standards (See consensus document on PWN website), the state has made strides towards an improved healthcare delivery system by borrowing from other states’ successful models.

Strong statements are made in the White Paper about some medical societies that insist on research to prove the safety and quality of expanded scope of practice. The authors of the White Paper agree that to demand research to justify the safety of scope-of-practice expansions is a red herring and an impenetrable barrier. In their experience, the only way to know about the safety and efficacy of an expanded scope of practice is to make the leap and expand the scope. Pennsylvania had no intention of investing in research to determine the impact on safety with expanded scope of practice; rather, the lawmakers proclaimed that the absence of problems in other states that had already liberalized scopes of practice of many professions is sufficient evidence.

In addition to the White Paper, the CAC developed a discussion paper and tool kit entitled “Building a Better Mousetrap to Address Scope of Practice Issues.” In this discussion paper, the notion of a National Scope of Practice Advisory Board is fleshed out. It provides a very interesting and highly relevant resource for any state needing to modernize its practice act.

National Health Policy Forum

The National Health Policy Forum at the George Washington University published a background paper entitled “Tapping the Potential of the Health Care Workforce: Scope-of-Practice and Payment Policies for Advanced Practice Nurses and Physician Assistants.” The author makes the assumption that healthcare reform will force the APN and PA professions to continue to grow at a rapid rate while their demand surges.

The paper warns that the highly variable and inconsistent scope-of-practice laws across the nation will complicate the education, credentialing, and employment of APNs and PAs. The author asserts that scope-of-practice inconsistencies will thwart delivery-system innovation and promising team-based care models and waste investments in education by not allowing APNs to practice “to the top of their license.” The paper states that the glacial pace of expanded scope-of-practice laws, especially concerning prescriptive authority, and sketchily written protocols are illogical and wasteful. The paper describes the American Medical Association’s opposition to autonomous practice for APNs as being unfounded and counter to published research.

This ad hoc, piecemeal approach to existing scope-of-practice statues is often inappropriately political and subject to conflicts of interest, especially when state boards of medicine are regulating nurses. Year after year, state lawmakers are required to legislate highly technical and narrow scope of practice for nurses that many may not be qualified to assess.

Some states have developed a mechanism for policy expertise in this area to insulate legislators from this intense politicization of scope-of-practice expansion. The author recommends a model state nurse-practice act and a process for evaluating scope-of-practice legislation.

One thing is clear—the demand for NPs will swell in coming years, and our capacity to redress access concerns will depend on resolution of the current tensions surrounding NP scope of practice.

The Kentucky Coalition of Nurse Practitioners and Nurse Midwives

The Kentucky Coalition of Nurse Practitioners and Nurse Midwives has published an exceptional White Paper entitled “Nurse Practitioners and Nurse Midwives Provide Quality, Cost Effective Care but Barriers to their Practice Decrease Patient Access to Care.” This paper builds a strong case for NP/CNM care based on four decades of research that, to date, has not produced negative results about the care provided by NPs and CNMs. Despite the dismal health quality indicators in Kentucky, the state has a restrictive statute for NP/CNM practice in place. A well-founded rationale is made in this paper that positive results with NP/CNM care have been found in the United States and in the United Kingdom; the rationale is based on strength of evidence from a wide range of sources over decades. The paper describes specific facts about cost-effectiveness, disease management, and improved access associated with NP/CNM providers. The case is impressively made that, based on national quality indicators, Kentuckians need improved access to prenatal care and chronic disease management and restrictive barriers to practice for NP/CNMs need to be lifted.

Conclusions

Passage of the Affordable Care Act in March 2010 is a significant step toward the goal of access to quality health care for every American. Still, among many reform-driven issues that will need to be worked out at the state level, there is at least one impediment to access to care that resides in the states’ legal authority to define scopes of practice for health professionals. In order for APNs to fully and meaningfully respond to the growing demand for health services, changes need to be made in scope-of-practice laws that limit access to care, thereby affecting the quality and cost of services for millions of consumers. As 32 million newly-insured people are swept into the delivery system by 2014, the questions of who will be caring for all of the newly insured and how the care will be structured become very real. So let’s turn up the volume of this choir and use these new voices to ramp up the power of our message.