By Christopher Guadagnino, Ph.D

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Published October 1999

• Nursing scope of practice regulations

• Balancing nursing autonomy with quality of care

• React to this article in the Discussion Forum.

PND: How would the bill change the authority of the Board of Nursing?

PV: Presently, the Board of Nursing regulates all the advanced practice nurses except the CRNPs. The nurse anesthetists, for example, are already solely under the Board of Nursing. Many, many states already have the nurses regulated solely by the Board of Nursing. Forty-six states already grant prescriptive powers to advanced practice nurses. But when we think of the licensing boards in the Commonwealth of Pennsylvania, we have cosmetologists, we have funeral directors, we have architects, engineers, you name it, each one responsible for regulating their own profession. So it seems inherently unfair to have nurses being the only profession that is dually licensed.

PND: Why did you feel there was a need to introduce this bill?

PV: I certainly heard from many, many nurses out in the field. But what really was the catalyst, without question, was when the Pennsylvania Medical Society was the driving force to give physician assistants prescriptive powers in the early ‘90s. That really caused a great deal of consternation. In Pennsylvania, although most physician assistants have more education than a high school plus the two years of physician assistant training, there is nothing in the law of Pennsylvania that says they have to have more than that. I thought it was particularly ironic that someone with far less training and education could have prescriptive powers and yet there is so much resistance to advanced practice nurses having this.

PND: What is the training and education for the three nursing specialties: practitioner, anesthetist and specialist?

PV: Advanced practice registered nurses have a four-year bachelor of science and nursing degree and have completed an additional two or three years of graduate classroom and hands-on clinical education. That’s why I think it was particularly ironic.

PND: Can you describe how your past experiences as a nurse have shaped your perspective on this bill?

PV: First of all, let me tell you I am not an advanced practice nurse. So this would not impact on me at all. But it certainly makes me understand the reality of the world out there. Right now, advanced practice nurses are running clinics in a lot of underserved urban and rural areas. I think it makes a lot more sense to allow them to have the ability to do this. In essence, they’re doing it now and you have a physician somewhere signing his name on a whole pad of scripts—prescription pads—not even knowing what’s being done. That makes no sense to me. It’s a facade out there.

PND: Why do you feel there’s a need to change the prerogatives of the advanced practice nurses if Pa. has already allowed them to have prescriptive authority in rural areas?

PV: They really do not have it legally. Medicare and some of the Medicaid managed care allow nurses to run these clinics. They are recognized federally. Advanced practice nurses on a base of one of the armed services or in a veteran’s hospital could prescribe independently without any problems. But as soon as they step off they base they lose their ability to do it. The legislature passed in 1974 and again in 1985 legislation that allowed nurses to have prescriptive powers but, because you have to promulgate regulations through the two boards, the Board of Medicine has always sat on it. Interestingly enough, less than 30 days after we proposed this legislation, they did agree to regulations to allow nurses to have some prescriptive powers. But the regulations have not yet been put out for an independent regulatory review.

PND: Why do you need to change law if the current system can promulgate regulations that appear to accomplish the same thing as this bill?

PV: The current system, as long as you have nurses dually licensed, is not going to make those changes. That’s pretty apparent, since the Boards have been sitting on it since 1982. We are trying to bring to fruition what has been passed in law twice in the Pennsylvania legislature.

PND: Has the Board of Medicine’s failure to act on granting prescriptive authority to advanced practice nurses, in your view, been based on quality of care concerns?

PV: I’m sure that’s what has been said. However, I think it is as much protection of turf as anything else. The Board of Pharmacy was very opposed to physician assistants having prescriptive powers. So the Board of Medicine did exactly what we just now have done and introduced legislation to get around having to deal with the pharmacy board. It’s absolutely no different from what was done earlier by the Board of Medicine. I think that each board probably serves their own interests. I don’t think that’s something unique to the Board of Medicine. But nurses are the only profession that are dually licensed, and that’s where this area comes into question.

PND: Is unsupervised drug prescribing authority specifically in the bill?

PV: It is not, and it does not necessarily grant this to everybody that would be a nurse. But it gives them ability to have prescriptive powers within their scope of practice. Let’s take a nurse anesthetist. It is not within their scope of practice now to prescribe. They give anesthesia, either under the direction of an anesthesiologist or, in rural hospitals where there are no anesthesiologists, the surgeon writes the prescription. That would not change. It is not within their scope of practice and they would not have prescriptive powers.

PND: Since the bill would remove the Board of Medicine’s oversight, wouldn’t the Board of Nursing be able to expand the scope of practice for nurse anesthetists and other nurse specialties?

PV: It’s just not that easy. It still has to go through the regulatory process, which means it goes out in the Pennsylvania Bulletin. It goes to the independent regulatory review commission, which is always very careful of what they do. It comes to the committees in the legislature that would have oversight, which in this case would be Professional Licensure or Health. So, they just can’t automatically wave a magic wand and change that.

PND: And yet, the Board of Nursing would be able to propose those expansions and go through the official regulatory process.

PV: It’s like every other profession that can do that. You’re making a giant assumption that the Board of Nursing would want to do something that was against the quality care for patients. There is no reason to believe that the Board of Nursing would want people who are not qualified to treat patients anymore than physicians would.

PND: What do you envision to be the appropriate expansion of the scope of practice for these three nursing specialties?

PV: I do not see the nurse anesthetists being changed at all. I don’t think their scope of practice will do anything for them except to define exactly what a nurse anesthetist does. We had hearings in Pittsburgh where I think this was clarified that it does not change. HB 50 would remove the CRNPs from the Board of Medicine’s oversight. Certified registered nurse practitioners, yes, would have prescriptive powers. And I know much has been made that we had all scheduled drugs in there, Schedule I though V. Every piece of legislation starts somewhere and doesn’t always end that way. Do I think realistically they would all be in at the end? No I don’t. But do I think advanced practice nurses are doing a lot of needed preventative health care in rural and urban areas? Absolutely. Certified registered nurse specialist is a new specialty that probably needs to be defined and, yes, I think they would probably have prescriptive power, but on a much more limited basis, only within a very narrow scope of what they happen to be doing in their specialty.

PND: Besides prescriptive power, are there any other medical services that these three specialties currently are not authorized to do that you feel would be appropriate for them to be allowed to do?

PV: No, not really.

PND: Are there any areas that you think should be definitely outside of nurses’ scope of practice?

PV: I think there are many things that are outside the nurses’ scope of practice presently. They certainly are not going to do surgery, other than a minor suturing of a laceration. Again, they are not trying to go outside their scope of practice. I know we have had arguments raised about the quality of care. First of all, they are already treating patients and they’re doing a lot of day-to-day preventative health care. Forty six other states already have it in law with no dire consequences at all. The people who are being treated by advanced practice nurses are very happy with the treatments they receive.

PND: How would you characterize the essential difference in training between the professions of nursing and medicine?

PV: Obviously, physicians spend a little bit longer time. The internship, I think, for a osteopath is one year and two years for a medical doctor. If nurses were going to do something much beyond their scope of practice in advanced medicine, I would have a problem with that and no one is trying to do that. If we look at where the advanced practice nurses are now, in the urban and rural areas where there are no physicians and physicians don’t want to go, they are filling a very vital health care need for those communities. They’re doing basic preventative health care where no other health care exists.

PND: How do you assess the political prospects of the bill?

PV: This year? I don’t think it’s going to pass. I never thought it was going to pass in a year. I did managed care legislation last year that took three and a half years. We still have more hearings scheduled. It’s early in the process. When you do what is considered to be major legislation, it will not move quickly.

PND: What is the health insurance industry’s position on the bill?

PV: I do not know theirs, but I do know the Hospital Association of Pennsylvania testified on behalf of the legislation in Pittsburgh.

PND: Have you anything else to say to physicians who may be critical of the bill?

PV: I understand the resistance because I know physicians feel threatened by managed care and a lot of other things right now. But if 46 other states that have successfully implemented this legislation can do it successfully, there is no reason to have these onerous, dire predictions that something different is going to happen in Pennsylvania.