The following white paper promotes the concept of nurses practicing without any physician supervision, medical direction or oversight of any kind.  The South Carolina Society of Anesthesiologists, The S.C. Board of Medical Examiners, the South Carolina Medical Association, the S.C. Academy of Family Medicine, the S.C. Society of Obstetrics and Gynecology and every other medical organization in the state opposes the goals outlined in the following white paper.  The independent practice of nurses is contrary to the highest standards of patient safety.

 

 

Advanced Practice Committee

David Andrews, MSNA, APRN, CRNA

Carole Bennett, PhD, APRN, BC, Psychiatric CNS

Stephanie Burgess, PhD, APRN, BC, FAANP, FNP

Amanda Geddings, MSN, APRN, BC, FNP

Debby Greenlaw, MSN, APRN, BC, ACNP

Faye Leboeuf, MSN, APRN, BC, CNM

Sam McNutt, MHSA, APRN, BC, CRNA

Angela Reeves, MSN, APRN, BC, FNP

Sheryl Russell, PhD, APRN, BC, ANP

Terry Sims, MSN, APRN, BC, BC, FNP, PNP

Patti Smith, CNM, APRN, BC, CNM

Glyne Sommer, MSN, BC, CNS

Sylvia M. Whiting, PhD, APRN, BC, Psychiatric CNS

Cynthia Williams, MSN, APRN, BC

 

Executive Summary

White Paper on Advanced Practice Registered Nurses

Advanced Practice Committee

SC Board of Nursing

Cost, affordability, and access to quality care are complicated issues that have been linked to a myriad of concerns including impediments to scope of practice, a lack of available health care providers, inability of consumers to pay for health care/insurance, geographic locations, and transportation issues. The United States faces many health financial challenges with one of the largest being how to provide its citizens with access to affordable healthcare while maintaining high quality care.  In response to this challenge, states are revamping delivery models, re-designing insurance pools, recruiting students to select healthcare professions, developing health insurance exchanges, and expanding scopes of practice for health professionals.     

 

In October 2010, the Institute of Medicine issued a report titled, The Future of Nursing: Leading Change, Advancing Health (IOM Report).   The report concluded that healthcare professionals with a history of providing excellent quality of care, like Advanced Practice Registered Nurses (APRNs), should not be limited or prohibited from practicing to the full extent of their education, training, and competencies.  As the IOM report indicates, “No studies suggest that care is better in states that have more restrictive scope-of-practice regulations for APRNs than in those states that do not.”  The report recommends that states, federal agencies, and healthcare organizations should remove scope of practice barriers to improve access to care.  Such barriers, for example, hinder APRNs from practicing to the full extent of their education and training in order to provide access to care.

 

In spite of the abundance of data which documents that APRNs deliver safe, effective, and high quality care, South Carolina laws and polices prevent APRNs from practicing to the fullest extent of their education, training, and experience to increase access to care.  Because of this, South Carolinians are faced with road blocks concerning their healthcare, which prevents many from accessing quality affordable healthcare from APRNs.  These road blocks are found not only in statutes and regulations, but also in institutional policies that mandate physician involvement or oversight.   Moving to independent/autonomous licensure will remove barriers to care that have been created because of the dependent role.   However, recognition as an autonomous provider underscores the need for all professionals to collaborate interdependently while recognizing the similarities and differences of each professional role and the unique contributions of each professional to the healthcare team.

 

The purposes of the White Paper on Advanced Practice Registered Nursing (APRN) are to give a brief snapshot of the State-of-the-State Health Status of SC, define the roles of the APRN, synthesize the literature review on the quality of care, effectiveness, safety, and credentials of the APRN to practice at the highest level, and highlight impediments to APRN practice and the patient’s access to care.   Solutions are offered within the White Paper to remove practice and access barriers.  These solutions will involve changes to the Nurse Practice Act.

White Paper on Advanced Practice Registered Nurses

Advanced Practice Committee

SC Board of Nursing

August 2011

 

Introduction

Cost, affordability, and access to quality care are complicated issues that have been linked to a myriad of concerns including impediments to scope of practice, a lack of available health care providers, inability of consumers to pay for health care/insurance, geographic locations, and transportation issues.^{133, 134}  Challenges for the United States are to provide citizens quality health care in affordable and accessible terms but control costs.  According to government data, health care spending in 2006 exceeded $2 trillion, an amount that triples the amount spent in 1990 ($714 billion).¹³²  National organizations such as the Institute of Medicine, the Kellogg Foundation, and the US Department of Public Health are urging policy makers to revamp the healthcare system for improved access to affordable quality care, while controlling costs.⁴¹  

 

Additionally, professional organizations are stressing the need for changes in the healthcare delivery system for improved access to affordable quality care.  Of particular interest is the area of expanding scope of practice for health care providers in order to increase access to affordable quality care.^{41, 134}  Advanced practice registered nurses (APRNs) have had a keen interest in expanding scope of practice in order to provide affordable, timely, and more efficient access to quality care for their consumers.  

 

In South Carolina, there are four categories of APRNs.  These are Certified Nurse Practitioners (NP), Certified Registered Nurse Anesthetists (CRNA), Certified Nurse Midwives (CNM), and Clinical Nurse Specialists (CNS).  Currently, there are 2253 APRNs practicing in SC.  Of these, there are 841 CRNAs, 1282 NPs, 55 CNS, and 75 CNMs.¹³⁰ 

 

 

State-of-the-State: Snapshot of the Health Status of South Carolina

            In SC, 42 out of 46 counties or parts of all SC counties are designated by the federal government as medically underserved and/or underserved for health manpower.^123-127  The rate of uninsured individuals in South Carolina exceeds that of the rest of the nation with 16% uninsured in SC as compared to 13.5% to the US.^123-127

 

Despite efforts both nationally and regionally emphasizing primary care health care access, the population’s health care status remains very poor.  In fact, the health status of South Carolina counties ranks among the worst in the nation.^123-127  Findings indicate, for example, increased South Carolina death rates for heart disease, diabetes, Alzheimer’s, and infant mortality.^{100-113, 123-127}  According to the data, 34% of children ages 10-17 in South Carolina are considered overweight or obese as compared to 32% of children nationally.

 

More specifically, SC had nearly 17 AIDS cases per 100,000 people as compared to 12.5 cases per 100,000 nationally.  In 2007, 6.2% of deaths in South Carolina were due to cerebral vascular events, whereas nationally less than 6% of deaths were due to strokes.  In 2007 the leading cause of death in South Carolina was heart disease.  Six percent of rural South Carolinians have heart disease with 192.7 deaths per 100,000.  Other statistics show that 10.1% of South Carolinians have diabetes mellitus.^101-113 

 

 

Definitions and Types of APRNs, including Education and Roles

Certified Nurse Practitioners (NPs) are high quality primary and acute care health care providers who practice in primary care, ambulatory, acute care, specialty care, and long term care settings.  As of 1995, these registered nurses are required to complete graduate degrees (masters or doctorate) in advanced practice nursing and have specialized clinical training and education in physical assessment, diagnosing, and prescribing therapeutic interventions including medication, therapies, and patient education for patients across the lifespan.  They conduct research, develop health policy, translate evidence based clinical guidelines into practice, and serve as leaders in health care settings for quality improvement in patient outcomes.

 

Certified Registered Nurse Anesthetists (CRNAs) are high quality anesthesia providers who practice in hospitals caring for surgical and obstetrical patients, ambulatory surgery centers, and office based settings.  As of 1995, these registered nurses are required to complete graduate degrees (masters or doctorate) in advanced practice nursing and have specialized clinical training and education in anesthesia care during the pre, peri, and post-operative periods.  They conduct research, develop health policy, translate evidence based clinical guidelines into practice, and serve as leaders in health care settings for quality improvement in anesthesia patient outcomes. 

 

Certified Nurse Midwives (CNMs) are high quality women’s health providers who practice in primary care, ambulatory, and acute care settings for comprehensive gynecological and obstetrical care, including deliveries.  As of 1995, these registered nurses are required to complete graduate degrees (masters or doctorate) in advanced practice nursing and have specialized clinical training and education in physical assessment, diagnosing, and prescribing therapeutic interventions including medication, therapies, and counseling for women across the lifespan.  They conduct research, develop health policy, translate evidence based clinical guidelines into practice, and serve as leaders in health care settings for quality improvement in women’s health outcomes.

 

Clinical Nurse Specialists (CNS), recognized in the advanced practice role, are high quality care health providers who practice in primary care, ambulatory, and acute care settings in a variety of roles, including mental health.  These are registered nurses with graduate degrees (masters or doctorate) in advanced practice nursing who have specialized clinical training and education in physical assessment, diagnosing, and prescribing therapeutic intervention including therapies and mental health counseling for families and patients.  They conduct research, develop health policy, translate evidence based clinical guidelines into practice, and serve as leaders in health care settings for quality improvement, most notably in psychiatric settings.

 

Nationally and in South Carolina, APRNs practice in a variety of settings such as outpatient clinics, private physician offices, nurse practitioner-managed centers/practices, specialty practices (examples: cardiology, heart failure clinics, oncology, neurosurgery), rural health care centers, outpatient surgery centers, homeless shelters, teen clinics, mental health settings, prison clinics, hospice, and hospitals.¹   In South Carolina, there are approximately 2253 advanced practice nurses, and 50% provide services in rural areas or to underserved populations.^1,3   The trend, regardless of practice location, is for many advanced practice nurses to transcend their role across many settings that include acute, primary, hospice, and long term care.³¹  

 

In spite of the scope of practice restrictions, the South Carolina Board of Nursing has over the years supported the expansion of the scope of practice for increased autonomy for APRNs.  This support has been driven by the demand for the services of advanced practice nurses in SC.  For example, the Board of Nursing has authorized Nurse Practitioners and Certified Nurse Midwives to prescribe controlled substances in schedules 3-5 and to request, receive, sign, and distribute professional medication samples as appropriate.^32-33   

 

With the increase in scope of practice, the South Carolina Board of Nursing requires that all advanced practice nurses who graduate after 1995 must hold at least a master’s degree and comply with all National Certification requirements for continuing education and practice.^33-34   Additionally, advanced practice nurses (NPs and CNMs) must obtain at least twenty (20) hours of continuing education in pharmacotherapeutics, with two (2) of those hours in controlled substances every two (2) years as a requirement to maintain the prescriptive authority license.³³   Credentialing organizations require up to 150 hours of continuing education in a five year period and direct patient care up to 1500 hours.  These Board of Nursing approved organizations are listed on the SC Board of Nursing website.¹⁵⁰ 

 

 

Purposes of the White Paper

The purpose of the White Paper is to synthesize the research on the quality of care, effectiveness, safety, and credentials of the advanced practice registered nurse to practice at the highest level in order to provide access to affordable quality care.  This White Paper will define the roles of the APRN, and also clarify the issues related to the scope of practice restrictions on advanced practice registered nurses and the impact on patient care delivery.

 

In spite of data which documents that APRNs deliver safe, effective, and high quality care, the legal limitations of supervision, the 45 mile restriction, and the inability of APRNs to prescribe to the fullest extent of their education continue to impede access to affordable quality care to the citizens of SC.  These road blocks are found in statutes and regulations governing the practice of nursing as well as institutional policies that mandate physician involvement because the Nurse Practice Act stipulates that APRNs must have physician supervisors.   Examples of such impediments that impede access to care include but are not limited to:

 

·        the inability of NPs to order disability stickers for disabled patients

·        the inability to order durable medical equipment (DME)

·        closure of NP practices due to the loss of a physician consultant resulting in the loss of care to a community, job losses, and financial bankruptcy to the NP

·        the inability to place patients on home bound care

·        the inability to certify hospice patients needing Medicare (CMS) certification for ongoing hospice care. 

·        the inability to place patients in hospice

·        inability to order home health care

·        inability to order controlled medications Class Two (2) for patients needing pain management or selected psychotropic medication, even in acute care facilities

·        inability to certify patients needing disability

·        inability to enroll as a provider in some payer systems

·        inability to obtain hospital privileges

·        inability to certify patients needing long term care

·        inability to sign for samples with some pharmaceutical companies

·        inability to care for patients that are in enrolled payer systems that refuse to credential or reimburse APRNs as providers

·        inability to refer patients for diagnostic testing to selected diagnostic and hospital facilities

·        inability to obtain diagnostic reports from selected diagnostic and hospital facilities

·        inability to enroll as NP solo practices within the Medical Home Network

·        surgical physicians fear legal retribution and increased liability because of the required physician signature on the anesthesia record

·        physicians fear legal retribution and increased liability because of the required physician signature on the APRN Prescriptive Authority licensure application and Annual Protocol Collaborative Agreement.

 

 

What is the Difference in the Cost of Physician and APRN Education?

There is a huge cost difference between educating an advance practice nurse and a physician.  Much of this cost, approximately $9 billion dollars per year in the United States, is paid through Medicare for graduate medical physician education while all of nursing only receives $500 million dollars per year.  Approximately 10 nurse anesthetists can be educated for the cost of educating one anesthesiologist.  The cost of educating a CRNA is about $161,809 while a physician anesthesiologist education and residency training is around $1,083,795.¹²⁹   It is often noted that both the CRNA and physician anesthesiologist perform similar functions.    

The estimated cost of educating a NP is about $30,700 (three years of graduate NP school) versus the estimated total cost of educating a primary care physician at about $200,000 (four (4) years of medical school plus three (3) years of family practice internship/residency).  NPs can complete an additional three years for a clinical doctorate at about another $40,000. 

 

Fortunately, most APRN students in the NP, CNM, CRNA, and Clinical Doctorate Programs can continue to work part time.  Typical differences and similarities between physician and APRN education are highlighted by the following Table 1.

 

Table 1:   APRN and Physician Education

APRN	Physician
Complete 4 year Undergraduate Baccalaureate Degree in Nursing	Complete 3 to 4 years of Undergraduate work before entering Medical School.
Complete 3 years of APRN education.  Students graduate with a master’s degree in APRN specialty. a.        Course work includes: advanced pathophysiology advanced health assessment advanced physical assessment advanced pharmacotherapeutics advanced diagnostics advanced management of family practice advanced management of acute care advanced management of women’s health advanced management of pediatrics advanced management of anesthesia care advanced management of psychiatric care   b.       Clinical practicum over three years totaling at least 1000 hours where by the APRN student is managing the patient	Complete 4 years of Medical School.  Students graduate with a medical degree.  a.        Course work includes: anatomy        physiology        histology advanced diagnostics advanced assessment Observation rotations in areas of medicine: pediatrics internal medicine obstetrics-gynecology surgery psychiatry   b.       Senior year clinical practicum involves shadowing and observation of preceptors who may be Nurse Practitioners, CRNAs, CNMs, and physicians.
Complete a Doctorate Degree involving 3-4 years of full time education. a.        Intensive clinical focusing on an area of selected practice for at least 3 years.  b.       Clinical hours are approximately 1000 per year.	Complete a residency in area of practice (i.e.: Pediatrics, Internal Medicine, Family Practice, Women’s Health, Anesthesia Care) involving at least 3 years a.        Intensive clinical focusing on an area of selected practice for at least 3 years.  b.       Clinical hours are approximately 1850 per year.

 

 

 

APRN Quality of Care:  What Does the Literature Demonstrate?

Quality of care, usually measured in terms of patient outcomes or adherence to evidence based guidelines, is an important component in understanding the potential advantages and disadvantages of using APRN delivery models to provide care. 

 

For example, the body of evidence demonstrates that Nurse Practitioners provide exceptional quality care and the prescribing practices are safe and typically more conservative, even when APRNs are practicing independently.^{3, 11, 20-30, 44}   Studies demonstrate that the care is excellent and comparable to or exceeds physician care in following standard evidence based guidelines.  Data also shows that patient health outcomes are improved and patient satisfaction is high with NP care.^{3, 11, 20-30, 42-49, 51-58}   This data is especially important because many primary care offices and rural areas depend on the NP to increase access to care.

 

For CRNAs, the research shows no significant differences in rates of anesthesia complications or mortality between CRNAs and anesthesiologists.  This includes delivering care to the obstetrical patient’s need of anesthesia care.^114-120   Furthermore, sixteen (16) states have opted out of the Medicare requirement for physician supervisors fro CRNAs.   Mortality and complication rates for anesthesia care provided by the CRNAs in those states did not vary between the period before opting out and the period after.  According to the investigators, data does not support the hypothesis that patients are exposed to increased surgical risk if nurse anesthetists work without physician supervision.¹²⁸   There simply is no evidence to support the claims that physician supervision is necessary.  This data is especially important because many rural hospitals depend on the CRNAs to deliver anesthesia in order to increase access to surgical care.

 

In addition to reviewing the evidence from the literature for CRNA care, healthcare claims and discharge data were used to assess adverse anesthesia outcomes including death and anesthesia complications.  Anesthesia complications were identified using the International Classification of Diseases, 9^th Revision, Clinical Modification (ICD-9-CM) diagnosis codes.  The Ingenix national database contains integrated medical and financial claims data from commercial payers in 2008.  A total of 52,636 claims that included anesthesia were reviewed. There were no complications arising from anesthesia from independent/autonomous CRNAs in these claims.^121-122   The National Survey of Ambulatory Surgery (2006) contains information about surgical and non-surgical procedures performed on an ambulatory (outpatient) basis in hospitals or freestanding ambulatory surgery centers for 2006.  There are 52,233 sampled visits, representing almost 35 million total visits in the United States.  Only one visit resulted in a complication from anesthesia.  For that visit, anesthesia was provided by an anesthesiologist and a CRNA.^121-122

 

Unfortunately, physician groups have argued to restrain the scope of practice of advanced practice nurses in providing comprehensive independent patient care.  They have alluded to the diminished quality of care necessitating physician supervision and oversight.  The substantive literature has demonstrated that this is not the case.  Care provided by APRNs (NPs, CNMs, CRNAs) is safe, competent, cost effective, and increases access to care, even when these APRNs are independent/autonomous providers. 

 

 

 

 

APRN Cost effectiveness:  What Does the Literature Demonstrate?

Studies overwhelmingly demonstrate that advanced practice nurses (APRNs) increase access to care ^{2-20, 97} and provide cost effective care.^{21-30, 96}   Studies show reduced costs savings, even in independent roles, in both rural and urban settings and in major agencies and health care institutions such as the Veterans Administration Health System, Geisinger Health System, and Kaiser Permanente .^{21-30, 41, 89}   Other data indicate that APRNs (NPs) saved over $5,000 per patient in the Care Transition Model and reduced hospitalization and ER use by 50% in the Evercare Model in Texas, saving the state over $23 million in past two years.¹⁴⁵

 

In U.S. retail clinics, where cost savings have been documented, nurse practitioners provide most of the care.  But retail clinics have been slow to expand in states with more restrictive scope-of-practice regulations, such as SC.  Research in Massachusetts shows that retail clinics and out-patient clinics using nurse practitioners to their fullest capacity saved the state $4.2 billion to $8.4 billion over the past 10 years and that greater use of retail clinics staffed primarily by nurse practitioners could save an additional $6 billion in the next five years.^{89-90, 131} 

 

In the above studies, cost effectiveness was demonstrated by savings in a variety of ways including reduced lab utilizations, reduced hospitalization rates, reduced annualized per member monthly costs in payer systems by almost 50%, reduced emergency use by patients, lower medication use in patients with chronic diseases but yet with improved outcomes, shorter hospital stays, and decreases in morbidity rates.^60-80

 

 

APRN Safety:  What Does the Literature Demonstrate?

            Again, the literature review demonstrated that in the absence of physician oversight or supervision, advanced practice nurses (APRNs) are safe providers and prescribers, often proving to be more cautious, spending more time with the patient, and less likely to prescribe medication as the only therapy or intervention.^{3, 11, 20-30, 98}   According to the Office of Technology, APRNs can provide 80 to 90% of the care in primary care settings in a safe and comprehensive manner.²⁸ 

 

                As stated earlier, a survey was conducted for comparisons on anesthesia care as delivered by physicians and CRNAs.   Of the 52,233 sampled visits, representing almost 35 million total visits in the United States in surgery care, only one visit resulted in a complication from anesthesia.  For that visit, anesthesia was provided by an anesthesiologist and a CRNA.^121-122

 

Evidence emanating from a wide body of literature show there are no data to indicate or suggest that APRNs in states that impose greater restrictions on APRN practice provide safer and better care than those in less restrictive states, or that the role of physicians in less restrictive states has changed or deteriorated.  In fact the evidence overwhelmingly demonstrated that APRNs are safe providers, provide quality care, are cost effective, and patient satisfaction is high. ^{3,11,20-30, 42-49, 51-58, 60-80, 114-122}  Moreover, APRNs possess the necessary skills, knowledge, and licensure requirements to practice in many settings, in collaborative and independent roles.  Finally, research in South Carolina shows that physicians overall trust the care given by APRNs and that patients have confidence in the APRNs’ decision making.³

 

APRN Educational Preparation and National Certification:  What Does the Literature Demonstrate?

Some physicians’ organizations argue that the physicians’ longer, more intensive training means that nurse practitioners cannot deliver health care services that are as high-quality or safe as those of physicians.  Physicians’ additional training, though, has not been shown to result in a difference from that of nurse practitioners’ in the quality of primary care services but did prove to be very costly in terms of training, whom taxpayers subsidized.^41,49   As stated earlier, the total estimated cost of educating a CRNA is about $161,809.  The estimated cost of education a physician anesthesiologist is about $1,083,795.  The estimated cost of educating a NP is about $30,700 (3 years of NP school) versus the estimated total cost of educating a primary care physician at about $200,000 (4 years of medical school plus 3 years of family practice internship/residency).  An additional three years of full time study to obtain a clinical doctorate for APRNs would add another $40,000 which is still less than the cost of physician training.  Taxpayers usually bear the costs of educating APRNs and physicians since most public universities are supported in part by the state’s General Fund budget, monies collected through various taxes. 

 

Nationally, APRNs must obtain at least a master’s degree in advanced practice nursing.  As of 1995 in South Carolina, all APRNs must graduate with at least a master’s degree.  All graduate level APRN education systems are required to include a broad-based education in the role and in the population to be served.^81-85  The curriculum includes advanced physical assessment, advanced pharmacotherapeutics, and advanced pathophysiology.   Additional required courses focus on researching and solving clinical problems using statistics, databases, and research design/methods.  Core required clinical courses prove to be labor intensive with clinical (direct patent care) ranging 3-5 days per week for at least two (2) years focusing on patient care management at the advanced practice nursing level.^{50, 81-85}  

 

Curriculum must meet American Association of Colleges of Nursing (AACN) and Central Collegiate Nursing Education (CCNE) criteria for graduate education accreditation (masters and doctorate).⁸¹   For CRNAs, curriculum must meet accreditation standards through the Council on Accreditation of Nurse Anesthesia Educational Programs.⁵⁰  Additionally, curriculum must meet the standards for advanced practice by the respective credentialing organizations, such as the National Organization of Nurse Practitioner Faculties (NONPF) and the Council on Certification of Nurse Anesthetists.^82-83  APRNs seeking clinical doctorates obtain another three years of clinical practice and study. 

 

All graduate level APRN education programs or tracks go through a pre-approval, pre-accreditation, and ongoing accreditation process prior to admitting any students to that program or track.  APRN educational programs must be housed within graduate programs at Universities that are nationally accredited, and they must ensure that their programs adequately prepare their graduates to meet eligibility for national certification which leads to state licensure.^81-85

 

 As stated earlier, as of 1995 in South Carolina, APRNs must have graduated with a minimum of a master’s degree in advanced practice nursing.⁸⁶  Of particular interest, by the year 2015, the standard for NPs will mandate a doctorate degree that will add  additional clinical training and course work to address and improve patient outcomes.  The APRN clinical doctorate is already in place at the University of South Carolina and the Medical University of South Carolina.  Enrollments are full, given the anticipated mandate of 2015 to obtain a clinical doctorate. 

 

In addition to the solid educational preparation for APRNs, is the requirement for national certification by the Boards of Nursing across the US.  All APRNs in South Carolina must achieve and maintain national certification in the advanced practice nursing specialty.⁸⁶   Certification verifies that a professional has mastered a body of knowledge and competency for licensure.   As a criterion for APRN licensure, the South Carolina Board of Nursing readily accepts the APRN graduate education and National Certification examinations for meeting APRN competency.⁵⁰   These organizations are listed on the Board of Nursing’s website.⁵⁰

 

 

APRN Regulation:  What Does the Literature Report?

            The critical factors limiting the APRNs capacity to practice to the fullest extent of their education, training, and competence are state based laws and regulations.   States vary in terms of what they allow APRNs to do.  States that have restrictive scope of practice laws for APRNs are not correlated with any performance measure of quality or safety.^88-89   Rather, scope of practice restrictions have been the result of political battles over turf.  This is true in SC.  Unfortunately, research shows that APRNs tend to move from more restrictive to less restrictive states, resulting in a loss of providers and access to care for patients.^{41, 89-90}

 

A review of the states’ laws governing APRNs shows that there are variations in several aspects of practice, including requirements for prescribing authority, oversight and chart reviews, and the maximum “collaboration ratios” for nurse practitioners working with physicians.  According to Pearson (2011), a state-by-state analysis of APRN practice indicates that twenty-four (24) states recognize APRNs as licensed independent practitioners requiring no physician involvement, four (4) states require physician involvement but do not require a written protocol or collaborative agreement, and twenty-three states (23) require physician involvement (Appendix A).¹⁴⁶  SC law requires physician oversight and an annual collaborative protocol agreement.⁸⁶

 

In some states, APRNs cannot certify home health care visits or length of stays in skilled nursing facilities or hospice, order durable medical equipment, admit patients to hospitals without a physician’s supervision or collaborative agreement, or prescribe medications without physician oversight (Appendices A-C).^{89, 92, 146}  This is true in SC.⁸⁶

 

APRNs in SC cannot place patients in hospice care or order durable medical equipment (i.e. diabetic shoes) because payers have interpreted that the APRN is dependent to the physician.   Again, there is nothing in the literature that supports that APRNs are not competent to order equipment or place patients in hospice.  However, payers have interpreted the APRN as dependent, and therefore require physician orders for durable medical equipment and placing patients in hospice.  These restrictions place unnecessary burdens on patients seeking full care. 

 

In SC, APRNs are required to collaborate with a supervising physician.^{86, 146} Prescriptive authority is linked to physician approval and signature.⁸⁶  This has been problematic because if physicians move, retire, or change employment settings, the APRN no longer has the necessary physician to maintain prescriptive authority  or provide care.   This leads to APRN unemployment and the loss of a provider for a particular set of patients.  As a result, access to care is diminished or reduced.  Again, the literature overwhelming demonstrates that APRNs are safe prescribers and physician supervision for this activity is not warranted or justified. 

 

In SC, CRNAs are required to have the supervising physician’s name listed on the anesthesia record and written guidlines.^{86 , 146}  Again, this has been problematic, especially for rural areas needing anesthesia care, whereby surgeons fear patient liability relating to anesthesia since their name is listed on the anesthesia record.  In 2001 the Centers for Medicare and Medicaid Services (CMS) allowed states to opt out of the requirement for reimbursement that a surgeon or anesthesiologist oversee the provision of anesthesia by certified registered nurse anesthetists (CRNA).  By 2005, fourteen states had exercised this option.  South Carolina did not opt out of this provision.   An analysis of Medicare data for 1999–2005 finds no evidence that opting out of the oversight requirement resulted in increased inpatient deaths or complications.  Based on these findings, the literature supports that CRNAs can work safely and competently to provide care without the supervision of a surgeon or anesthesiologist.¹²⁸  

 

In addition to the requirement for physician supervision, South Carolina NPs, CNMs, and CNS must adhere to a radius of 45 miles from the physician and a ratio of 3:1 (3NPs to 1MD) in practice settings.⁸⁶   There is nothing in the literature to support that this mileage or ratio is warranted, appropriate, safe, or reasonable.  If the physician travels outside the 45 mile radius, the APRN cannot see patients, make rounds, or take call.  This restriction is further compounded for those APRNs serving rural or underserved populations.  The resulting scenario is that patients are not being served.

 

Over the past 18 years (since 1992 when APRNs were authorized by the Nurse Practice Act to prescribe), there have been very few cases of inappropriate prescribing by an APRN in SC.^32-33    Like physicians and other providers, there have been some cases involving impaired APRNs.  In these cases, the Board of Nursing applies the same process and procedures for investigating and disciplining APRNs as does other regulatory health professions.⁸⁶   Disciplinary actions against licensees are posted on the Labor Licensing and Regulation website.⁸⁷ 

Credentialing and payment are also linked to state regulations: more restrictive states are less likely than those allowing independent practice to credential nurse practitioners as primary care providers.^{41, 90}   In South Carolina, some payers will not credential NPs unless the supervising physician is credentialed as a provider.  Examples of payers are United, Medcost, and Premier.⁹¹   Also, some companies in SC purchase less expensive insurance from another state.  That state may have restrictions of payment to APRNs who fall under supervision, which disallows APRNs to receive payment if the scope of practice requires physician supervision of APRNs.  The resulting scenario is that patients are not being served.

 

In summary, in South Carolina APRNs are regulated by the Board of Nursing but the statutory limitations imposed on scope of practice and regulations often prove to impede care, access, and even employment.^{3, 86}    These obstacles include, but are not limited to:

 

·        the inability of NPs to order disability stickers for disabled patients

·        the inability to order durable medical equipment (DME)

·        closure of NP practices due to the loss of a physician consultant/collaborator  resulting in loss of care to a community, job losses, and financial bankruptcy to the NP

·        the inability to place patients on home bound care

·        the inability to certify hospice patients needing Medicare (CMS) certification for ongoing hospice care. 

·        the inability to place patients in hospice

·        inability to order home health care

·        inability to order controlled medications Class Two (2) for patients needing pain management or selected psychotropic medication, even in acute care facilities

·        inability to certify patients needing disability

·        inability to enroll as a provider in some payer systems

·        inability to obtain hospital privileges

·        inability to certify patients needing long term care

·        inability to sign for samples with some pharmaceutical companies

·        inability to care for patients that are in enrolled payer systems that refuse to credential or reimburse APRNs as providers

·        inability to refer patients for diagnostic testing to selected diagnostic and hospital facilities

·        inability to obtain diagnostic reports from selected diagnostic and hospital facilities

·        inability to enroll as NP solo practices within the Medical Home Network

·        surgical physicians fear legal retribution and increased liability because of the required physician signature on the anesthesia record

·        physicians fear legal retribution and increased liability because of the required physician signature on the APRN Prescriptive Authority licensure application and Annual Protocol Collaborative Agreement.

The above access or care impediments are tied to the following that can be found in regulations, statute, or policies:

^·          the legal requirement for physician supervision that impedes or closes a practice, ordering equipment, placing high school students on homebound, referring patients for diagnostic testing, enrolling in payer systems, certifying patients for long term care needs, obtaining hospital privileges, certifying patients needing hospice care, etc.

^·          limitations in prescribing or delivering anesthesia care

^·          maximum of 45 mile distance from supervisor and APRN (NP, CNM and CNS)

^·          limited ratios of physicians to APRNs in practice settings

 

Recently in collaboration with the Robert Wood Johnson Foundation, the Institute of Medicine (IOM) recognized regulatory and institutional obstacles and limits on APRN’s scope of practice as a major problem in access to care.  The IOM (2010) recommends that these obstacles be removed so that the health system can reap the full benefit of the APRNs’ training, skills, and knowledge in patient care for improved access to care and improved health status of the population.⁴¹

 

 

Case Law and the Captain of the Ship Doctrine and Liability

            “Captain of the Ship Doctrine” is a doctrine that courts previously used to deem that a physician was liable for any negligence that occurred while they had “command” of the patient.¹³⁷   Over the years, courts have ruled that the doctrine was not credible with some states’ courts citing that the doctrine was never applicable.¹³⁷  In other words, physicians were found not to be responsible for the other professionals’ actions in the care of the patient.^138-139   Rather, the emphasis should be on team work, interdependent roles of providers, and the recognition of independent professionals.¹³⁹

 

Thus, over the years case law has determined that the physician is not held responsible for the APRN’s actions.^135-140   In fact, case law does not support the assertion that physicians are automatically responsible for a patient’s outcome.  For example, legal briefs cited that the surgeon or physician anesthesiologists are not responsible for the anesthesia outcome of a patient when anesthesia is delivered by the CRNA.^{136-138, 140}

 

Pearson included, within her yearly assessment of APRN legislation and healthcare issues, statistics from the National Practitioner Data Bank (NPDB).  The NPDB collects information about health care practitioners (APRNs, MD, & DO) as the result of judgments in malpractice suits or those who have entered into settlements as it relates to APRNs who were found responsible for their actions in the course of patient care and outcomes.¹⁴⁴  Pearson also includes the Healthcare Integrity and Protection Data Bank (HIPDB) report for NPs, Dos and MDs.    Healthcare Integrity and Protection Data Bank collects data on adverse action reports (licensure, civil, or criminal actions). The HIPDB was created to combat fraud and abuse in health insurance and healthcare delivery.¹⁴⁴

 

Pearson compared the rates of medical malpractice for NPs by state to the type of practice required by state law (independent practice vs. supervisory practice) to determine a relationship between autonomy in NP practice and malpractice claims.  Data did not show any correlation between APRN autonomy scope of practice and an increase in rates of malpractice reported or judgments awarded (p < .005).  However, the second highest NPDB reporting rate came from states that were more restrictive in APRN practice or those states requiring physician supervision.¹⁴⁴  The rates of malpractice for the three providers in the United States as of 2009 were as follows in Table 2:

                                     

Table 2:  Comparison of NPDB and HIPDB Rates Among  Providers: Two Years and the “Worst” States

	NPDB Ratio for NPs	NPDB Ratio for DOs	NPDB Ratio for MDs	HIPDB Ratio for NPs	HIPDB Ratio for DOs	HIPDB Ratio for MDs
Overall ratio for 2008	1:173	1:4	1:4	1:226	1:13	1:23
Overall ratio for 2009	1:166	1:4	1:4	1:215	1:14	1:20
2009 “Worst” state NPDB ratio for NPs: NEW MEXICO	1:32
2009 “Worst” state NPDB ratio for MDs: LOUISIANA, MONTANA, NEW YORK, PENNSYLVANIA, and WEST VIRGINIA			1:2
2009 “Worst” state HIPDB ratio for NPs: ALABAMA				1:11
2009 “Worst” state HIPDB ratio for MDs: MARYLAND						1:3

 

 

 

Discipline and APRNs in SC

            Disciplinary actions against APRNs that have occurred since 1993 are now posted on the Board of Nursing’s website.¹⁴³   Approximately thirty-seven (37) APRNs have been disciplined since 1993.  This averages to be two (2) APRNs per year who are disciplined by the Board of Nursing or less than 0.1% of the total licensed APRNs per year (denominator estimated to be 2000).  Over the years, the number of APRNs disciplined overall also represents less than 0.1% (denominator 36,000 APRNs x 18 years).  Typical infractions involved APRNs prescribing for non-patients, substance abuse, or drug diversion for personal use.  APRNs found to have substance abuse or drug diversion issues were ordered to enter the Recovering Professional Program.  Table 3 shows the data for the past eighteen (18) years. 

 

Table 3.   South Carolina Discipline Data for APRNs 1993-2011:  Represents less than 0.1% of total APRNs licensed in South Carolina per year.   Represents less than 0.003% of the total RN licensees per year. 

http://www.llr.state.sc.us/POL/Nursing/index.asp?file=FinalOrders/Alpha/Alphaorders

 

Year and Types of infractions

Numbers and # of APRNs disciplined

1999   One case involved a failure to provide evidence of National Certification   2004   One case involved a failure to obtain annual protocol   2005   One case involved inappropriate delegation.  Two cases involved substance abuse/drug diversion and were ordered to enter RPP.   2006  Three cases involved substance abuse/diversion and were ordered to enter RPP.  One case involved a medication error      2007  Three cases involved substance abuse/diversion and were ordered to enter RPP.   2008  One case involved a failure to renew APRN license on time.  One case involved a failure to identify patient scheduled for surgery.   2009  Eight cases involving substance abuse and were ordered to enter RPP.  One case involved  obtaining medications for a physician planning a mission trip.   2010  One case involved a medication error.  One case involved inappropriate delegation.  Eight cases involved substance abuse/diversion and were ordered to enter RPP.      2011  One case involved entering into a person and financial relationship with a patient.   Three cases involved substance abuse.  One case involved writing prescriptions for non-patients.

1993  None 1994  None 1995  None 1996  None 1997  None 1998  None 1999  1 2000  None 2001  None 2002  None 2003  None 2004  1 2005  3 2006  4 2007  3 2008  2 2009  9 2010  10 2011  4

 

 

Broadening the Scope of Practice for APRNs

The Boards of Nursing in twenty-four states authorize APRNs to practice and prescribe independently and to the fullest extent based on level of education and credentialing (Appendices A-C).¹⁴⁶  Several other states are reconsidering their laws to allow independent practice and to adopt the Advance Practice Nurse (APRN) Model Act generated by the National Council of State Boards of Nursing.⁸⁸  Under such laws, APRNs practice independently and are accountable “for recognizing limits of knowledge and experience, planning for the management of situations beyond their expertise; and for consulting with or referring patients to other health care providers as appropriate.”⁸⁸

The trend toward revamping state regulatory scope of practice restrictions to increase access to care is propelled by recent reports from several blue-ribbon panels.  In addition to the IOM report, which specifically targets regulatory barriers, several policy briefs from other organizations, including the Macy Foundation, support broader scope-of-practice boundaries.  One of the largest consumer groups, the AARP (formerly the American Association of Retired Persons), also supports an expanded role for APRNs in primary care.⁴¹

 

Effective October 2011, the Department of Veterans Affairs (VA) will authorize APRNs to practice independently provided that the APRN has graduated from an accredited (AACN, CCNE) post-graduate program, attained national board certification in the APRN role, and demonstrated competence in their area of practice (i.e. family practice, adult general practice, women’s health, anesthesia).^147-149  The impetus is to reduce variability in APRN practice across the VA healthcare system, be consistent with the IOM report recommendations to remove practice barriers and improve access, and to require health professionals to practice at the top of their education, experience, and competence.¹⁴⁷  Under Federal Law 38 USC 7402(b), the Department of Veterans Affairs is authorized to establish licensure requirements, qualifications, and scopes of practice for the employment of health professionals in the VA system.^148-149   The US Supreme Court has held that federal laws are supreme, and that States may not regulate or control the activities of the Federal Government or the activities of federal employees acting within the scope of their employment.^148-149   Thus, the VA Handbook for Nursing has been revamped to authorize APRNs as independent providers within the VA system effective October 2011.¹⁴⁷

 

Evidence emanating from a wide body of literature demonstrate there are no data to indicate or suggest that APRNs in states that impose greater restrictions on APRN practice provide safer and better care than those in less restrictive states or that the role of physicians in less restrictive states has changed or deteriorated.  In fact the evidence overwhelmingly demonstrates that APRNs are safe providers, provide quality care, are cost effective, and deliver a high degree of patient satisfaction, even in independent roles. ^{3,11,20-30, 42-49, 51-58, 60-80, 114-122}  Moreover, APRNs possess the necessary skills, knowledge, and licensure requirements to practice in many settings, in collaborative and independent roles.  Finally, research in South Carolina shows that physicians overall trust the care given by APRNs and that patients have confidence in the APRNs’ decision making.³

 

In addition to the data on the quality of care from APRNs, the expected dramatic increase in demand for primary care services, and the impending shortage of primary care providers, there are several other reasons to improve state regulations in order to increase access to care.⁹⁵  First, effective implementation of delivery models, such as medical homes, nurse practitioner practices, and accountable care organizations are needed to handle the increase in chronic disease management and transitional care.  This will require the establishment of interdisciplinary teams in which APRNs provide a range of services, from case management to health and illness management as independent APRNs.⁴¹  

As an  example, a new VA delivery model for increasing access to care and making care more efficient and cost effective will go into effect October 2011.  This new model of delivery will authorize APRNs to practice independently within the VA system.^147-149  These APRNs will be managing patients in primary care and specialty outpatient clinics, VA nursing homes, hospice, and conducting case management. 

 

Second, nurse practitioner education is supported by federal and state funding, and some report that health care systems are underutilizing a valuable government investment.^{41, 93} Moreover, APRN training is the fastest and least expensive way to address the primary care shortage.  Between three (3) and twelve (12) nurse practitioners can be educated for the price of educating one physician, and more quickly.⁹³   For CRNAs, the cost of educating a CRNA is half the cost of educating an anesthesia physician provider.¹²⁹

 

Third, legal considerations also seem to favor revamping regulations.  The Federal Trade Commission recently evaluated laws in three states and found several whose stringent requirements for physician supervision of advanced practice nurses are considered anticompetitive or foster an economic monopoly.  The agency has also investigated and found state policies protect professional interests of physicians rather than consumers.⁴¹ 

 

Despite the robust rationale and supporting evidence for broadening APRNs’ scope of practice, several medical organizations oppose the idea.  The American Medical Association,  the American Osteopathic Association, the American Academy of Pediatrics, the American Society of Anesthesiologists, and the American Academy of Family Physicians all support the requirement for direct supervision of APRNs by physicians.⁹⁴  Of interest, surveys of individual family practice physicians show that they trust and support the role of the APRN.^{3, 99} 

 

Fighting the expansion of APRN’s scope of practice is no longer a defensible or economical viable strategy.  The challenge is for all health care professionals, government regulators, and policy makers to embrace these changes and come together to improve U.S. health care.

 

In summary, this is a critical time to support an expanded standardized scope of practice for APRNs by removing state barriers to practice in order to increase access to care.  Economic forces, poor health statistics, rising poverty demographics, the gap between supply and demand, and the expansion of care necessitate changes in health care delivery.  A growing shortage of primary care providers demands that APRNs be required to practice to their fullest capacity.  Research overwhelmingly supports that APRNs are safe, cost effective, and competent providers who possess the necessary training, knowledge, and skills to provide autonomous care.

 

 

 

 

APRN Scope of Practice:  Suggestions for Change

            In addition to changing the Nurse Practice Act, it is recommended that the Board of Nursing adopt the Consensus Model for Licensure, Accreditation, Credentialing, and Education.^151-152  The following represent proposed changes in the SC Nurse Practice Act for APRNs.  The Advanced Practice Committee is looking forward to developing specific language changes in the Nurse Practice Act.  Conceptually, the changes include: 

 

1. Authorize APRNs to practice to the fullest extent based on their education and training
2. Remove all requirements and references to physician supervision
3. Expand prescribing to include Class 2
4. Remove all references to delegated acts
5. Redefine delegated acts as APRN acts
6. Remove all references to a protocol/guideline agreement and replace with evidence based guidelines
7. Remove all references to a ratio of APRNs to physician
8. Remove all references to a mileage requirement for APRNs practicing at a distance from physicians
9. Insert words “autonomous practice” for APRNs
10. Re-define APRNs as autonomous providers
11. Delete any references to a physician supervisor listed on the anesthesia record
12. Delete any references to physician signature on APRN documents for licensure and or practice

 

The timeline for mapping legislative changes in the Nurse Practice Act is targeted for 2013.  Sufficient time is warranted to dialogue and achieve consensus for proposed language changes in the Nurse Practice Act.  The South Carolina Nurses Association and the South Carolina Association of Nurse Anesthetists are looking forward to collaborating with each other and other groups and agencies to discuss and craft proposed changes to the Nurse Practice Act.