By Christopher Guadagnino, Ph.D

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Published September 2000

• Nurse prescribing regulations, Part II:
  Medical society ready to compromise
  

• Nursing scope of practice regulations (May 2000)
  

• Advancing the battle for nursing autonomy (Oct 1999)
  

• React to this article in the Discussion Forum.

Melinda Jenkins, Ph.D., CRNP, is co-coordinator of the Alliance of Advanced Practice Nurses and assistant professor of Primary Care at the School of Nursing, University of Pennsylvania.

In mid-July, Pennsylvania’s Independent Regulatory Review Commission (IRRC) disapproved by a 3-2 vote regulations jointly promulgated by the boards of Medicine and Nursing regarding prescriptive authority for nurse practitioners in Pa.

PND: What is the status of the nurse prescribing regulations jointly promulgated by the Pa. Boards of Medicine and Nursing?

MJ: Regulations for CRNP practice were promulgated in 1977, but there has been disagreement about the interpretation of those regs and whether they include the authority to prescribe medicine. Draft regulations were published in October 1999 for public comment, after which the Board of Nursing and the Board of Medicine, who jointly regulate Certified Registered Nurse Practitioners (CRNPs) in the state, worked on revised regulations. Those revisions went to Pa.’s Independent Regulatory Review Commission (IRRC), which reviewed and disapproved the regs. IRRC has not yet released its report, but the two boards have met again separately and voted that they will consider looking at IRRC’s report and writing revisions to meet IRRC’s points. We’re waiting now for the language from IRRC, and my understanding is that it will be released sometime in mid-September. The boards have three options: withdraw the regs totally, revise them according to IRRC’s report—which is what they’ve agreed in principle to do, or they could send them forward without any changes.

PND: Why do advanced practice nurses oppose the regulations?

MJ: The main problems we had were restrictive changes that were made after the regs were published in October. The worst one is the requirement of a ratio of two CRNPs for one collaborating physician. Another is the requirement of a discreet 45-hour, advanced pharmacology course that was not in the original published version. A waiver process was offered for the ratio requirement, but the cause for the waiver was totally undefined. The new regs also include specifics about a collaborative agreement that seem to assume there is one model of care: a private practice physician hiring a CRNP. But if you look at what’s really happening in practice, there are many models of care. For example, I have friends who work as CRNPs in an emergency room who will be collaborating with a variety of physicians, depending on who is assigned or scheduled that day. It could be a handful of different residents. It could be different specialists. It could be a per diem ER physician who is just filling in there. It would be simply impossible to have the same kind of collaborative agreement with each of those physicians as required by the new regs. There are group practices of many sorts that would have great difficulty with this.

PND: Would the regulations prohibit those sorts of collaborations?

MJ: That, I think, has not been clarified. That is an issue that we brought to IRRC. I believe that, if you were going to follow the language to the letter, you would be looking at sitting down every time a new physician rotates in that ER with whoever the CRNP is scheduled that day and drafting a collaborative agreement between those two individuals. That’s crazy.

PND: Were you surprised that the Board of Nursing adopted these changes?

MJ: We lobbied the Board of Nursing with our points many times. I believe they were facing great political pressure from the administration to move these revisions, which were certainly not in the best interest of nurse practitioners.

PND: Given that IRRC voted down regulations that were supported by Pa. Physician General Robert Muscalus, D.O., and presumably by the Ridge administration, how did nurses go about influencing IRRC’s decision?

MJ: IRRC is separate from the administration. We asked people to write to IRRC and to ask their legislators to contact IRRC. We met with IRRC and had supporters, including two physicians, come to talk and answer questions. The only people who were at the IRRC meeting in support of the regs were Muscalus and a representative of the Pennsylvania Medical Society. All the other witnesses there were in opposition. Rep. Patricia Vance (R-Cumberland) testified to IRRC in opposition to the regs, and so did Rep. Mary Ann Dailey (R-Montgomery). There were other letters that came to IRRC from legislators and almost every letter was in opposition.

I think our grassroots message had the force of reality. Get with the year 2000. Get with the evolution that’s happening in health care. Forty-seven other states allow nurse practitioners to prescribe. Physicians have not given us any evidence that what we do is dangerous or that what we do in Pennsylvania should be different from what we do in 47 other states. My students at Penn are part of Pennsylvania’s brain-drain. They don’t want to put up with this environment. They know how to prescribe. They’ll go somewhere else. That’s what’s happening: we are losing smart, educated providers at the time when we have lack of access to basic primary health care in this state. The majority of counties in Pennsylvania are medically underserved areas, yet there’s a protectionism ideal that the Board of Medicine is using regarding nurse practitioners.

PND: What specific changes would you like to see in the regulations?

MJ: We wrote to the boards and to IRRC the changes that we wanted. A lot of CRNPs who are perfectly safe prescribers would have difficulty showing a 45 hour course. We recommended that the board look at some alternatives. The easiest would be to grandmother in people who are currently practicing who can show that they have national certification or some background of continuing education that has kept them up-to-date. When we presented this to the boards months ago, they rejected it. We want to have recognition of the pharmacology education of people who have been practicing for many years. Other states recognize a national certifying body that nursing has, just as medicine has. Nurse practitioners have a national certifying exam that many people take. It has not been required in Pennsylvania in the past, but that is a logical way to show that people have the education and the credentials to practice. The ANCC has a national certifying exam, which I encourage my students to take. The requirement is, every five years, to show that you had 75 hours of continuing education and you have had so many hours of clinical hands-on practice.

PND: Besides removing the 45-hour course requirement, what other changes would you like to see in the regulations?

MJ: Remove the ratio. The waiver is bogus. The ratio is unnecessary. It’s not happening in any other state. There’s no evidence to support it.

PND: Isn’t there a limit on the number of CRNPs that a physician can practically supervise?

MJ: The word supervision is inaccurate in terms of the relationship that goes on. That is one of the difficulties in the discussion. The word that we use and that it is in the regulations is collaborative agreement, and that is quite different from supervision. Of the 47 states in which nurse practitioners prescribe, I have only been able to find two states where there’s any limit provided, and neither one of them has as strict a ratio as two-to-one. There’s no evidence to show that a limit is needed. It blocks progress in terms of evolving models of care and making the health care system more accessible, more efficient and of higher quality, where you’re using the highly educated people to the full extent of their knowledge and you’re providing continuity and linkage to the next level of care. In a collaboration model, we are working as a team and don’t always have one captain of the ship always a physician. That isn’t always the best way.

PND: Rep. Vance has introduced House Bill 50 that, among other things, would no longer require joint licensure of CRNPs by the boards of Medicine and Nursing. Are you still planning to push that legislation?

MJ: What we aim to do in that legislation is to present the reality that advanced practice nursing has a common core. It’s not easy to pull us apart and have CRNPs jointly regulated by the Board of Medicine and the Board of Nursing, have certified registered nurse anesthetists only regulated by the Board of Nursing and have clinical nurse specialists not even named anywhere in the laws of the state except for a reimbursement law. We need to bring Pennsylvania into the 21st century, and that’s what our legislation was to do. Part of that is to provide self regulation for nursing as it is in almost every other state in the country. We need to have a definition of advanced practice nurses in the state that includes all the groups that I named. House Bill 50 is stalled in committee right now. I’m told that there’s not going to be a lot happening until after the Nov. election so, in order to have a bill next session, we would have to reintroduce it. That is one option. I think there’s a lot of attention on these regulations right now, so the onus is on the Board of Medicine to make a compromise. We have written to both boards and we’ve sent copies to our legislators and the to the Governor’s office. It’s my understanding that IRRC’s comments will be released when, or shortly before, the legislature is in session.