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Nurse Education Key to Scope-of-Care Debate

Cheryl Clark, for HealthLeaders Media, August 15, 2011
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He was the 15th governor to exercise that option, but most of the other states were smaller and much more rural than California. The CMA lost the first round, but its appeal is scheduled this month.

Chief nursing officers are largely opposed to the scattered array of state rules that limit nursing scope of practice.

“In order to meet the influx of patients due to healthcare reform, state laws will have to come in line ultimately in order for nurses to practice to their full ability,” says Susan Stone, PhD, RN, CNO and COO for Sharp Memorial, a 400-staffed-bed hospital in San Diego. “If not, then the burden would fall on the physicians to identify how they will meet this large coming need for patient care,” she says.

Stone adds that two key issues in scope-of-practice battles focus on a nurse’s ability to write a prescription without a physician’s signature or supervision, and the ability to be paid independently.

“We need to flesh this out better, so there isn’t a feeling that nurses are impinging on physicians practices,” she says.

The IOM report catalogues what Stone is talking about in an elaborate table showing enormous variation among the 50 states over, for example, whether a physician needs to be involved in the writing of a patient’s prescription. While some states are starting to relax their rules, “the majority of state laws lag behind,” the report says.

Some efforts toward expanding nurses’ roles are already playing out. For example, the Federal Trade Commission released opinions in March and May that favor expanded scope of practice in Florida and Texas. The FTC said that proposed legislation in those states appears to offer “procompetitive improvements” that will benefit patients.

Linda Aiken, PhD, FAAN, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, studies these issues. She says that much of the opposition to expanding nurse practitioners’ ability to practice to the full limits of their education and expertise is coming from “a small minority of physicians [who are] making a lot of noise about nurses’ roles in care delivery that have already been decided by the public and the market.

“Literally hundreds of studies have shown nurses with advanced education improve access to primary care, provide safe and patient-centered care, and contribute to containing escalating costs of care.

“The horse is out of the barn on expanded scope of practice for nurses and other health professionals, and the protests of a small group of self-interested physicians will not reverse this trend.”

“It really is all a matter of turf wars,” says Cheryl Peterson, MSN, RN, director of nursing practice and policy for the American Nurses Association. “Organized medicine argues that advanced practice registered nurses don’t do primary care because they don’t have the education that physicians have. But we would say an APRN who has gone through postgraduate education is in fact well educated enough to do the work of a primary care provider, to manage chronic care, perform treatment reviews, and give recommendations that the patient needs to move on to a specialist if necessary.”

Two other recommendations in the IOM report deal with expanding the education and training levels for registered nurses. One proposes that at least 80% of all nurses have at least a four-year nursing baccalaureate degree by 2020, rather than a two-year associate’s degree, up from 40% or 50% today. The concern is that two-year degrees, which more than half of today’s nurses have, don’t prepare nurses for critical thinking and management skills that they
will need when they get on the floor and need to prioritize their workflow.

There’s a great need to standardize minimum credentials for registered nurses because “we have too much variation in the way nurses are educated for entry into the profession today,” says Polly Bednash, PhD, RN, FAAN, the CEO of the American Association of Colleges of Nursing. “Whether you have an associate’s degree or a baccalaureate degree, you come in with very different skills and knowledge about the care delivery process. And the others you’re working with don’t know where you are within that spectrum, and perhaps, they don’t trust what’s there.”

Bednash says a number of initiatives are in play to make sure that two-year, associate-degree nurses receive tuition help and are encouraged to move ahead to get that four-year credential, without missing time away from work if possible. 

To do that, however, requires faculty and funding,
and that’s a major problem because there aren’t enough nurses available to hire faculty, nor the salaries to pay them, to teach the hundreds of thousands of nurses who will need to seek advancement.

Bednash says some two-year community colleges have changed their mission to offer baccalaureate nursing programs, such as St. Petersburg College in Florida, and that’s a good sign. But many more need to follow suit.

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6 comments on "Nurse Education Key to Scope-of-Care Debate"


D. Andrews, CRNA, MHS (9/27/2011 at 10:05 PM)
Shi Zang, We do carry our own liability insurance at the same limits as physicians. The difference is, our rates have dropped over the past decade due to decreased claims. Do your homework before commenting.

Phyllis Carmichael RN, BSN (9/25/2011 at 3:05 PM)
I enjoyed your article. I am currently in an masters program. A recent discussion centered on nursing skills post graduation. I came from a diploma school in 1998. The hospital was next door to school. Thus, I was confident in my hands-on skills regarding starting IVs, inserting naso-gastric tubes, inserting urinary catheters, performing sterile dressing changes, etc. I wish that I would have gone on to obtain my advanced degree straight away. Now I see how valuable the added education is to my practice. Our discussion turned briefly to nurse residency programs. Little information exists on that subject. Part of the "upheaval" you spoke of? Phyllis

Julia Harris CRNA (9/5/2011 at 3:18 PM)
In response to the previous comment, I do in fact carry my own malpractice insurance and I am very much liable for the outcomes of the patients that I care for. With increased autonomy comes increase in responsibility and I have embraced that as part of my profession.