Scope of Practice
Scope of Practice | Scope of Practice Regulations, Advance Practice Nurses, APNs, Nurse Practitioners, Mary D. Naylor, Bonnie Pilon, Michael Minch, TMA, Tennessee Medical Association

APNs Tout Primary Care Capabilities

For advance practice nurses (APNs), it’s a matter of simple math … the fastest-growing population segment is over 65, more than 30 million Americans will be added to the insurance rolls through healthcare reform, and the number of primary care physicians is decreasing. To fill the looming gaps, APNs want to ensure they are allowed to practice to the fullest extent of their training. 
Mary D. Naylor, PhD, RN, the Marian S. Ware Professor of Gerontology for the School of Nursing, University of Pennsylvania, co-authored an article published last month in Health Affairs. “The Role of Nurse Practitioners in Reinventing Primary Care” explores the challenges facing primary care in America, research on quality of care provided by nurse practitioners and the existing barriers that keep APNs from filling the provider void.
“The main goal of that paper was to present the case from rigorous science of the contributions of advance practice nurses in primary care,” she said of the article. With some estimates predicting a shortage of 46,000 physicians by the year 2025, Naylor said it is imperative to capitalize on all providers who can meaningfully contribute to the delivery of primary care. “We need all hands to practice at the top of their licenses.”
APNs make up about 8 percent of the nursing workforce and have at least a master’s degree in their field of specialty. According to the U.S. Department of Health and Human Services, Bureau of Labor Statistics, approximately 70-80 percent of APNs work in primary care.
Naylor said the case for allowing nurses to practice to their full capabilities is borne out in more than 30 years of evidence-based studies. “Nurse practitioners deliver primary care that is equivalent to … and in some cases, like length of time spent with patients, better than … physicians,” she said.
At issue is the variation on the scope of practice found across the nation. Each state sets its own parameters, and Naylor said only 11 states currently allow nurses to function at the top of their licenses. She noted that all the nursing organizations have banded together to create a model for licensure, which calls for standardizing laws that govern nursing practice nationwide.
Naylor said opposition to loosening restrictive scope of practice laws comes largely from organized medicine. However, she was quick to add, a large number of physicians work collaboratively with APNs and have a strong professional relationship. “It’s not opposition from individual physicians,” she added.
Furthermore, she noted the concept of a nurse-led clinic is hardly a new notion. “Since the 1960s, we’ve had nurse-managed centers largely in underserved areas,” Naylor pointed out. She added the expectation under healthcare reform is that the number of these centers would increase with the influx of $50 million in federal funding beginning this October.
“Professional medical societies have really gotten together to say primary care practices should be physician-led. I don’t think it has to be one way or the other,” she continued. “The ultimate desire is to have team-based practices.”
In addition to standardized scope of practice laws, Naylor and her co-author, Ellen T. Kurzman, assistant research professor in the Department of Nursing at George Washington University, made the case for equal compensation for the same services, federal investment in nursing education so that qualified candidates aren’t turned away due to faculty shortages or space constraints, and public disclosure of nurse practitioner performance to stimulate quality improvement and give consumers an accurate picture of care providers and resulting quality outcomes.
Bonnie Pilon, BSN, DSN, senior associate dean for Faculty Practice at Vanderbilt University School of Nursing, said Tennessee is considered one of the more tightly regulated states. “The western states tend to be far less regulated,” she noted, adding their health outcomes are typically better than those of our state. “What are we accomplishing through overregulation in Tennessee?” she questioned. “When existing rules and proposed regulations seek to constrain the practice of advance practice nurses, services become encumbered. That’s a waste of a precious resource in my opinion, and those resources are badly, badly needed.”
Pilon said another issue with the Tennessee nurse practice regulations is that they are outdated in several areas. “Our current regulatory environment doesn’t support any rational use of electronic medical record communications between advance practice nurses and their supervising physicians,” she said. In addition to record reviews, Tennessee law requires monthly site visits by the supervising physician. “Today it’s possible for physicians to review data almost in real time from a remote location,” she pointed out. “We’re adding cost to a system that’s trying to take cost out,” she said of not maximizing the technology.
Another sticking point in the state is the use of “supervisory” instead of “collaborative” in describing the physician/nurse practitioner relationship. “The law describes a subservient relationship,” she added instead of using the collegial words favored by several other states.
Pilon said in the continuum of care from primary prevention to secondary prevention to tertiary care, nurse practitioners are well positioned to be heavily involved in the middle span of time. She noted APNs should help maximize a physician’s time and effectiveness by bumping patients out to doctors for specialty services or to create a care plan but then managing those patients once the acute need has been resolved. “You keep patients at the lowest cost level of care and at optimal health,” she noted of this type of triage system.
“The reason why these things have not been fixed is because organized medicine has a stated public agenda to halt any loosening of restrictions,” she charged. “This is not a secret agenda.” Like Naylor, she said many physicians value the work of APNs and are very supportive. Of limiting efforts by medical associations, she said, “I really believe this is a vocal minority in medicine, but unfortunately they are vocal and have money and the (movement) has legs.”
Michael Minch, MD, president-elect of the Tennessee Medical Association, said the organization believes physicians should follow the mandates of state law and not just sign off on charts without actually reviewing them. “That’s not to say the nurses don’t do a good job … most of them do a great job … but physicians have been to school a lot longer.” He added that is it a bit disconcerting to have a nurse with a brand new advance practice degree, but with very limited real world experience, working without supervision.
Minch also chaired the TMA task force on Advance Practice Nursing. Originally, the committee focused on the proliferation of nurse-run clinics in retail grocery and drugstore outlets. The initial concern was that corporations with a vested interest in selling medications might have undue influence on the nurse providers. “But we really didn’t see that was the case,” he said.
In fact, Minch philosophically agreed with many of the points being made by APN advocates. “We need the nurses to practice to their full ability,” he noted in response to the looming physician shortages. “Patients want the convenience,” he continued. “Ninety-nine percent of the time it’s fine, and it’s needed, and we’re going to need more of it.”
However, he noted, patients have a right to know whether it’s an nurse practitioner or physician caring for them. Also, Minch continued, “It never hurts to have someone who has more training to look over your shoulder.” After all, he pointed out, physicians consult with each other routinely.
For the most part, he said, “Right now nurse practitioners can do anything their supervising physician can do. They just have to have agreement on it, and they have to have protocols.”
While Minch doesn’t feel strongly about whether or not physicians are referred to as “consulting” or “supervising,” he does feel it’s important to keep direct communication open between the physician and APN. Minch said that when APNs talk about fewer restrictions in the scope of practice, “Generally it means they want to do the procedures or give the care independently, and we don’t think that’s beneficial to patients. We believe if they wanted to practice medicine, they should go to medical school.”
Although there are clearly sticking points between physician and nursing associations, there seems to be a collegial feeling of mutual respect among individual doctors and nurse practitioners.
“We’ve got to get beyond focusing on our own professions and focus on the people we serve,” Naylor concluded. “If we can get to that point, that’s when I think we have the greatest opportunity to solve the healthcare issues of our society.”