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Balancing nursing autonomy with quality of care

Smith.jpg (4625 bytes)By Donald H. Smith, M.D.
Pennsylvania Medical Society

Since its introduction in March, House Bill 50 has created considerable confusion about what it does and does not do. Your recent interview in the October Physician’s News Digest with the bill’s prime sponsor highlighted the nurses’ arguments for passage of HB 50. I would like to provide some contrasting thoughts on why HB 50 is not in the best interest of good medicine. While all Pennsylvanians support unhindered access to quality health care at affordable costs, most consumers are not aware of the significant changes proposed in this legislation and their negative impact to health care.

Currently in Pennsylvania, the Board of Medicine regulates the practice of medicine. While advanced practice nurses (APNs) claim that HB 50 would not change the scope of practice for any nurses, HB 50 eliminates the regulatory authority of the Board of Medicine and would permit APNs to practice medicine independently of a physician, performing diagnosis and treatment, and unspecified invasive procedures, and prescribing virtually all drugs.

HB 50 adds a new section to the Professional Nursing Law that authorizes APNs to “diagnose and treat illnesses, perform therapeutic and invasive procedures, prescribe, dispense, and administer drugs and devices and order and administer anesthetics. . . .” Clearly, APNs’ scope of practice would be dramatically expanded, and without the direction or supervision of a physician.

If APNs do not intend this dramatic expansion in scope of practice, why does HB 50 also specifically delete from the Professional Nursing Law the current exclusion of “acts of medical diagnosis or prescription of medical therapeutic or corrective measures” from the practice of nursing? If this is not the practice of medicine, as they claim, then what is?

Prior to receiving prescription authority, physicians are required to complete four years of undergraduate pre-medical training, four years of graduate medical school, which includes a specific course in pharmacology, and three to six or more years of specialty training, or a total of 11 years of medical training, at a minimum. APNs, on the other hand, complete four undergraduate years for a Bachelor of Science in nursing and two to three years of graduate and hands-on training of varying degrees. APNs largely prefer to work with physicians as part of the care team, but not independent of them, and their education and training reinforce this cooperative and dependent relationship. But consider this: Paralegals assist attorneys; they don’t practice law. Why should APNs be permitted to practice medicine without the requisite training and qualifications?

Nurses say that certified registered nurse practitioners (CRNPs) in 46 other states can sign prescriptions. What they don’t say is that CRNPs in most of these 46 states must have either a counter signature by a physician or a collaborative practice agreement, or must adhere to an established protocol with a physician, all before they can prescribe. HB 50 would give APNs full prescriptive authority without the requirements for specific pharmacological training or collaboration with a physician. Even nurses who have trained to become physicians have testified that medicine today is extremely complex, and that our increasing understanding of disease and medical conditions indicates the need for more, not less, training and preparation.

Nurses’ claim that HB 50 would provide increased access to health care. However, without the proposed expansion of APNs’ scope of practice, one must ask how this access would be improved. Current studies show that only seven percent of masters’ degree nurse practitioners are likely to practice in rural areas. But that’s not surprising, since nurses and physicians cite the same reasons for their reluctance to live permanently in underserved areas: They don’t have sufficient free time, satisfactory quality of life, or professional collegiality.

Nurses say that HB 50 would relieve physicians of the liability for the actions of APNs under their supervision. But HB 50, while giving APNs the authority to practice medicine, requires neither mandatory liability insurance nor continuing medical education, as is required of a physician.

The Pennsylvania Medical Society recognizes the great value and important role of APNs in the delivery of medical care, and supports the existing statutes permitting APNs to operate within the current definition of professional nursing, which is to practice “in collaboration with and under the direction of” a physician licensed to practice in our Commonwealth.

This legislation must specifically retain the Board of Medicine’s regulatory authority over the practice of medicine and must incorporate appropriately defined physician supervision. This supervision must include the immediate availability of a licensed physician by direct communication; a predetermined, jointly-developed plan for emergencies; a cooperative plan for referrals; a review of standards of medical practice; and a periodic updating of standing orders, drugs, and medical protocols within the practice setting. Further, examination by a physician upon request should be a right of every patient. These are the safeguards our patients have come to expect, and no legislation should abrogate them.

Solutions for the issues, which HB 50 purports to address, are found in the proposed regulations, jointly published by the Boards of Medicine and Nursing, which provide prescriptive authority for CRNPs. These regulations properly retain the joint promulgation authority of both Boards but do not destroy the current requirement for nurse practice in collaboration with and under the direction of a physician. These regulations are acceptable to the Pennsylvania Medical Society with some minor modifications.

Physicians have gone on record for generations in their support of the nursing profession and unhindered access to quality health care at a reasonable cost, but HB 50 does not provide that. It proposes a lesser quality of medicine by lesser-trained practitioners. Is that what our patients should be forced to settle for by passage of this legislation?

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