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OP-ED | All ‘Independent Practice’ for APRNs is Not Created Equal

by Robert M. McLean | Apr 20, 2014 8:48pm
(3) Comments | Commenting has expired
Posted to: Opinion

As Connecticut legislators and Gov. Dannel P. Malloy seem intent on passing a bill to allow advanced practice registered nurses (APRNs) to “practice independently,” I would urge some caution.

The lobby pushing for this change in state statute has repeatedly made it appear that Connecticut is “behind the times” since 19 other states already allow independent practice for APRNs. And the sky is not falling in those states with any epidemics of sub-standard care being provided by APRNs, so how can there be any problem with allowing the same in Connecticut?

Has anybody done some legislative homework and examined exactly how “independence” is defined in the laws of those 19 states? As usual, the devil is in the details. There are three specific areas that vary greatly among these states: regulatory oversight, education requirements, and prescriptive authority definition.

According to the National Council of State Boards of Nursing, there are 22 states allowing independent practice for nurse practitioners, meaning “no requirement for a written collaborative agreement, no supervision, no conditions for practice.” And 17 states allow prescriptive authority, defined as authority “to prescribe pharmacologic and non-pharmacologic therapies beyond the peri-operative and peri-procedural periods.” Several of these states such as West Virginia, Massachusetts, and Rhode Island established that prescribing may only occur within limits set up by formularies.

Several other states like Colorado, Washington, Maine, New Hampshire, and Massachusetts mandate specific education in pharmacology, above and beyond whatever was obtained in nursing education. Explicit requirements are set out by several states such as Maine, New Hampshire, and Massachusetts for specific amounts of continuing education at specified intervals. To maintain licensure in Connecticut, physicians must document 50 hours of continuing education every two years. Some states (Maine, New Hampshire, Vermont, Ohio, Massachusetts, Rhode Island) establish specific regulatory processes to oversee and define what a “scope of practice” is for an APRN in a given specialty.

The current bill before the Connecticut state House includes NONE of these provisions which other states have had the wisdom and foresight to include in their state statutes. So while rhetoric from the APRN lobby states that this bill will merely bring Connecticut to the same type of “independent practice” as these other states, in reality it takes our state beyond and with far less regulation of APRNs than these other states. It even makes APRNs LESS regulated than physicians in the state. WOW! Is it logical that APRNs with an average of 500 hours of clinical training in school and no required residency training have less ongoing educational requirement in our state than physicians with over 3,000 hours of clinical training in medical school and 9,000 hours in residency training?

I fully believe it is the intent of our legislators to improve the access of our citizens to healthcare providers, and also to ensure that practitioners of all types in our state are adequately trained and regulated to deliver safe and effective care. If the time is right for “independent APRN practice” in our state, a statute should be crafted with appropriate regulatory oversight.

This bill does NOT do that, and it should NOT be passed into law in its current form. The examples of other states’ statutory details need to be examined as Connecticut moves forward with considerations for APRN independence. And whether greater “independence” of APRN practice will truly increase access to care remains a theory that has not yet been proven by any data — it is a hope, but not an established fact.

Robert M. McLean, M.D. practices internal medicine and rheumatology in New Haven. He is immediate past-Governor of the Connecticut Chapter of the American College of Physicians (ACP) and currently serves on the ACP’s Board of Regents and its Medical Practice & Quality Committee.

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(3) Comments

posted by: Stan Muzyk | April 24, 2014  3:32pm

Dr. Edward Volpintesta,MD, from Bethel—wrote a letter in the editorial page of Connecticut Post today where he gave a valid summation:  “Innovation is needed in primary care. Allowing the APRNs to help solve the primary care shortage makes good sense.  It is hoped that our lawmakers can see clearly through a cloud of prejudice and narrow-mindedness that so far have stifled constructive and positive discussion.”

posted by: FNP-DNP | April 24, 2014  11:54pm

Dr. McLean,
I appreciate your comments on urging caution about allowing ARNP’s to practice to the fullest scope of their educational scope of practice.  I have to wonder, though, do you understand what ARNP’s do and what exactly is their scope of practice? I happen to live and practice in Iowa, which has a very liberal practice act. If I am not mistaken, we have some of the best healthcare outcomes in the country and lower healthcare costs. If your concern is about training, support the role of the Doctor of Nursing Practice (DNP) as an entry to practice for ARNP’s please. DNP’s have greater depth of knowledge in healthcare leadership, policy, evidence-based practice and more clinical hours.  Not to mention the years of patient-care at the bedside already working collaboratively with physicians. The DNP requires 4 years or undergrad and 4 years of graduate school. The same exact amount for a 1st year medical resident has entering the healthcare world for the very first time.  Whereas NP’s have been practicing nurses and have more interaction with patient care than any 1st year family medical student.

It would behoove you to inquire about what nursing truly is which is exponentially not medicine but the human experience along the healthcare continuum of care as well as reviewing the Nursing Code of Ethics. Our expectations for our profession and practice are exceptional.

Several studies published in the New England Journal of Medicine demonstrate ARNP’s provide the same if not better primary care to patients. In addition, that same journal published NP’s are the least likely to get sued compared to MD’s and Physician’s Assistants who have less training then the ARNP. 

In my opinion, a ARNP is more concerned with developing relationships not with patients but also with physicians. In order to do this, physicians have to stop thinking less of us and remove the “mid-level” mentality and respect what we bring to the table in the change of healthcare change. A lot of the ideas listed in the Affordable Care Act are things nurses in hospitals have been doing for years. Quality evidenced-based care and tracking patient populations are not done by hospital administrators but by nurses themselves working at the bedside to improve outcomes, decrease infections, falls…and numerous other things.  Those concepts are not being transferred to the primary care area and having highly educated NP’s who are creative and work with, not under, physicians is the key.  Respect for our profession is needed to bridge this gap. 

And I will be the first to admit, I know what I know and what I don’t know I don’t know, instead of becoming frustrated and attacking the nursing profession, how about you teach us? Because we could certainly teach you a few things about how to develop the trusting patient-provider relationship. We have always be trained that no matter what we believe, we must take off ourselves and look at it from the patient perspective.

posted by: docaltmed | April 25, 2014  7:25am

Often overlooked in the coverage of physician shortage is the role of chiropractic physicians as primary care providers. For the past 20 years, I have been providing primary care services to my patients in Litchfield county; multiple studies have shown that patients who use a chiropractor as their primary care doctor need fewer surgeries and are less dependent on prescription medications for their health.

Chiropractic care is less expensive, safer, and equally effective as the alternative. Connecticut’s legislators should be finding ways to make more effective use of this largely untapped resource.