While researching health professionals' efforts nationally to expand their scope of practices, someone sent me an interesting link to this clickable map of the United States.
It's called "The US Nurse Practitioner Prescribing Law: A State-by-State Summary."
The map shows, from coast to coast, the substantial variation in the extent to which nurses are allowed to function state by state.
If you select Louisiana, for example, you see that state officials have imposed limits on nurses' abilities to assure their patients supply of medication. This state's nurses can't write a prescription unless their collaborating physician's name is on the form.
They can't prescribe drugs for weight management, or to control chronic, intractable pain, and nurses can only prescribe drugs classified as Schedule III or IV or V.
However, if you click on some other states, for example Maine, such restrictions are not to be found. A nurse can prescribe any drug in category II as well. Otherwise, he or she is said to have "general authority."
Meanwhile, in West Virginia nurses' "authority to prescribe is limited by exclusionary formulary covering general anesthetics, anticoagulants, antineoplastics (cancer therapies), and radiopharmaceuticals. While in Alabama, Florida and Missouri, nurses may not prescribe any controlled substance.
Moreover, from state to state, the degree to which nurses must have signed "collaborative agreements" with physicians, and what kind of physician, varies.
And it's precisely this variation that irks the American Nurses Association.
"In states that are more rural, what you might end up seeing, like Idaho or New Mexico, is nurse practitioners, nurse midwives and nurse anesthetists, functioning to the full extent of their training in hospitals," says Rebecca Patton, ANA president.
"But other states, like Ohio that are more urban, they have restrictions in not being able to prescribe some medications. None of this makes any sense that a nurse in Idaho has none of the restrictions that a nurse in Ohio has—both graduated from the same school of nursing."
Certified registered nurse anesthetists, nurse practitioners, nurse midwives, and clinical nurse specialists all have different levels of allowable function depending on which state they're working in, not their training or recertification, adds Lisa Summers, senior policy fellow with the ANA.
"That's what makes it really hard for us. It's one of the things that was negotiated differently in many states because of the influence of organized medicine," she says.
A few weeks ago, a story posted by the Associated Press carried the lead: "A nurse may soon be your doctor," and said that 28 states have bills that would expand the authority of nurse practitioners. They would do this in large part to get recognized for the care they already provide, as well as to meet the anticipated demand from so many patients who may seek care for the first time under health reform.
Mainly, they want to practice without having to contract with physicians who would agree to supervise them, a practice many nurses I spoke with called "a sham," because in reality, true observation and supervision is impractical and impossible in much of their nursing practice.
As expected, AMA President J. James Rohack, M.D., says expanding purview of nurses is not the way to respond to the healthcare workforce shortage.
"Increasing the responsibility of nurses is not the answer," he says. "Physicians undertake a decade or more of postgraduate medical education and thousands of hours of clinical experience that provides them with the in-depth knowledge and ability to diagnose and treat patients.
"(While) many nurse practitioners have just 3 years of postgraduate education, limited prescription drug training, and clinical experience that is less than that obtained in the first year of a three year medical residency.
"Each and every member of the health team plays a critical role, but we need to recognize the additional years of training and experience physicians undertake in order to maintain the high standard of medical care in the United States. We should focus our attention on increasing the number of healthcare professionals overall—physicians and nurses—so patients have access to the quality care they need," Rohack says.
Nursing organizations including the ANA deny they are striving to expand their turf. What they are really spending much of their time on, they say, is defending the abilities they already have, which organized physician groups in many states keep trying to erode, says Summers.
"The sad truth is, we're very frustrated about the time we're spending on the defensive," she says. "Really, there have always been plenty of sick people to go around, and now there's really going to be enough sick people to go around."
Nursing organizations blame state medical societies for "restricting practice."
Jodi Hicks, vice president of government relations for the California Medical Association, says that doctors aren't saying nurses "are unsafe." But there have been several efforts over the years when nursing organizations in her state have pushed for expanded practice. For one thing, she says, they have expressed a desire to lead the medical home—in essence practice without physician supervision – something state regulations now prohibit.
And Hicks thinks those rules should remain. "Nurses don't go through 12 years of school," as many doctors do, she says.
"When people started taking courses (to become nurses), it was never the thought process that they would develop to replace physicians. No. Their appropriate role is to be an extended paraprofessional, a help to the physician and an integral part of the healthcare system."
Stephen Collier, director of the Office of Health Professions Education and Workforce Development at the University of Alabama at Birmingham, says that nurses are already working at many levels to obtain doctorate degrees as part of their continuing education.
By 2015, most nurse practitioners will reportedly hold doctorate degrees, which will be the standard for all graduating nurse practitioners, Polly Bednash, executive director of the American Association of Colleges of Nursing, told the Associated Press.
Financial reimbursement is starting to go up for RNs as well, and under health reform for example, nurse midwives will earn just what an obstetrician-gynecologist makes.
And therein may lie the rub. Patton, president of the ANA, advises one to "Follow the money," suggesting that somehow, physician groups are starting to get worried that giving nurses more purview, greater scope of practice, will affect the amount they are able to bill, and in turn affect their own earning potential.
How will this tug of war play out? Will we ever call a nurse, "Doctor?"
Only time will tell.
Note: You can sign up to receive HealthLeaders Media Community and Rural Hospital Weekly, a free weekly e-newsletter that provides news and information tailored to the specific needs of community hospitals.