Two Perspective articles in the New England Journal of Medicine fan the flames of discord about whether scope-of practice should be expanded for nurse practitioners in the face of a primary care physician shortage, especially in rural areas.
Predictably, nursing groups are for the expansion. But some organized physician groups, such as the American Medical Association, have been opposed.
"Although nurses are critical to the healthcare team, there is no substitute for a physician's education and training," American Medical Association President Cecil B. Wilson, MD wrote in a letter. In states that allow nurses to practice without physician supervision, "physicians and nurses continue to work in the same urban areas, so increasing the independent practice of nurses has not helped to resolve the problem of shortages in rural areas," he wrote.
The first Perspective article is co-authored by University of Miami president Donna Shalala and others at the University of Pennsylvania School of Nursing and the Robert Wood Johnson Foundation Initiative on the Future of Nursing.
It points to the wide state-by-state disparity in what nurse practitioners and advanced practice nurses are allowed to do, with or without physician supervision.
"This variance appears not to be correlated with performance on any measure of quality or safety," the authors write. "There are no data to suggest that nurse practitioners in states that impose greater restrictions on their practice provide safer and better care than those in less restrictive states or that the role of physicians in less restrictive states has changed or deteriorated."
The authors wrote, "If we are to bridge the gap in primary care and establish new approaches to care delivery, all healthcare providers must be permitted to practice to the fullest extent of their knowledge and competence," they wrote. "This will require establishing a standardized and broadened scope of practice for advanced-practice registered nurses – in particular nurse practitioners – for all states."
Several recent reports point to a trend of standardization, and the relaxation of restrictions on nursing scope of practice, Shalala and colleagues wrote.
• The Institute of Medicine report , "The Future of Nursing: Leading Change, Advancing Health" recommended that nurses should practice to the full extent of their education and training, should achieve higher levels of education and training through an improved education system that promotes seamless progression, should be full partners with physicians and other healthcare professionals and that effective workforce planning and policymaking require better data collection and information infrastructure.
• Several states are considering laws that would allow independent practice of nurses.
• The AARP supports an expanded role of nurse practitioners in primary care.
• Research in Massachusetts says the use of nurse practitioners or physician assistants to their full capacity could save the state between $4.2 billion to $8.4 billion over 10 years.
"Despite the robust rationale for broadening nurse practitioners' scope of practice, key medical organizations oppose the idea," including the AMA, the American Osteopathic Association, the American Academy of Pediatrics and the American Academy of Family Physicians, which all support direct supervision of nurse practitioners by physicians, Shalala and colleagues wrote in summary.
But with the growing shortage primary care providers, "fighting the expansion of nurse practitioners' scope of practice is no longer a defensible strategy."
In the second Perspective article, nursing policy researcher Linda Aiken of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, pointed to a major obstacle holding back nursing advancement: The lack of nursing school programs that offer bachelor or doctorate degrees.
The IOM report recommended that the proportion of nurses who hold at least a bachelor's degree be expanded from 50% to 80% by 2020.
"Approximately 60% of new nurses graduate from associate's degree programs, 36% from bachelor's degree programs, and 3% from hospital-sponsored diploma programs," Aiken wrote. "But a serious unintended consequence of permitting the majority of new graduates to enter nursing practice with an associate's degree or less is that too few nurses advance through multiple additional degrees to qualify as faculty or advanced-practice registered nurses."
She said that of the approximately 72,000 nurses graduating from associate's degree nursing programs in 2010, only 4,000 are likely to ever obtain a master's or higher degree, "a yield that cannot produce enough faculty to replenish a workforce of more than three million nurses."
She concluded that it will be "extremely difficult, if not impossible, to generate enough nursing faculty, advanced-practice registered nurses, and nurses to fill leadership and executive roles requiring graduate-level education if entry-level nursing education does not shift entirely to the baccalaureate level."