It feels like I've been talking about the issues facing advanced practice nurses a lot lately. But I'm not the only one. Issues surrounding advanced practice registered nurses seem to be on everyone's mind as nurses become more educated, and take on greater responsibility.
Whether it's by earning their doctor of nursing practice degrees or by participating in short educational programs that ensure a smooth transition from school to clinical practice, nurses are hitting the books.
And across the country, APRNs are making strides toward practicing independently. One state currently considering autonomy for APRNs is Michigan. Its Senate Health Policy Committee heard testimony last Wednesday about providing licenses for APRNs.
The bill in question would define APRNs, "as an individual licensed under Part 172 as a certified nurse midwife, certified nurse practitioner, or clinical nurse specialist-certified."
I caught up via email with MaryLee Pakieser MSN RN BC-FNP, president of the Michigan Council of Nurse Practitioners (MICNP) and Joanne Pohl, PhD, ANP-BC, FAAN, FAANP, Professor Emeritus, The University of Michigan School of Nursing and MICNP member. Both provided testimony before the Health Policy Committee. And both discussed the importance of the legislation with me.
HLM: You say that the legislation "would bring the state into line with national standards and end a disincentive to nurse practitioners." Can you explain this? How is Michigan different than other states? What's the national standard that's not met in Michigan? What's the current disincentive to NPs?
Joanne Pohl: Michigan currently requires physician collaboration, which is often interpreted as "supervision." In reality, it is virtually impossible to sustain such supervision in actual practice. And, again such required collaboration/supervision is not based on any evidence. That is, there is no evidence that patients get better or safer care with such restrictive regulations.
This unnecessarily supervised care—if it is really followed—is also costly, as physicians need to be more involved than necessary and the physicians could be used in better ways such as seeing more patients. Collaboration is a professional ethic that is expected of every provider, not just one. So mandating collaboration for one provider and not others makes no sense, and is frankly impossible to regulate.
This legislation—SB 481—will not expand the scope of practice of Nurse Practitioners. It will simply bring the scope of practice into alignment with what is currently required of every nurse practitioner to graduate and pass Certification Boards. Sixteen other states and the District of Columbia have full plenary authority for nurse practitioners; that means they practice within their required education and training under their own license and are accountable for the care they deliver.
Joanne Pohl: NPs have national competencies. Those competencies are now used and required when every program in Michigan (and nationally) is accredited by one of the two national Department of Education accreditors (NLNAC/National League for Nursing Accreditation Commission or CCNE/Commission on Collegiate Nursing Education). And, before a new program can start, it must be approved by the above national accreditors to ensure they are following national guidelines and competencies.
The national Board exams that Nurse Practitioners take after graduating (the certification process in regulation) and required in Michigan for one to be legally titled as a nurse practitioner are now based on the same national competencies.
And finally, our educational programs use the same national competencies to develop our curricula. We have come full circle, except for the last step, that of state licensure and regulation in Michigan. We prepare our students to diagnose and treat patients within their scope or area of practice. In fact, we are required to do so.
Students have to demonstrate that they are successful at their full scope of practice independently in order to graduate and pass certification exams that measure the scope and competency REQUIRED of them. (They cannot pick up the phone and call a physician in the middle of their educational exams or national Board exams to find out if they are on track).
Yet, once they graduate and pass their national Board exams, they may need to practice very differently, depending on the state in which they practice. This is not because of their preparation, but because of the mish mash of different state regulations that are not based on evidence but based on long held, out of date, beliefs and policies.
HLM: Did anyone testify against the legislation, and if so, what did they say?
Joanne Pohl: Interestingly, no one testified against the bill and there were no questions from the Health Policy Committee.
HLM: What's the next step for this legislation? Is there support for it in the senate?
MaryLee Pakieser: There is growing support as our bill in alignment with Gov. Snyder's 2011 Health and Wellness message. This bill would improve patient's choice and access to high quality and cost effective health care providers. Removing unnecessary barriers and regulation in health care was part of Governors Snyder's health care agenda for Michigan. It is recognized that in Michigan we are facing a severe shortage of primary care physicians, APRNs are already in place to help mitigate this shortage .
HLM: Can you talk more about what "title protection" is and why it's important?
MaryLee Pakieser: The bill clearly defines NP, CNS, and CNM roles. This defining process will help with reimbursement issues… As we are not clearly identified it has made it difficult for APRNs to be reimbursed for care we deliver because insurance companies indicate we are not defined as independent health care professionals
Also, without title protection there is very limited data available on CNSs e.g. as they are not represented in any specific category, or they may be merged with other APRNs such as NPs giving inaccurate data on each provider. This change would also remove the invisibility of all four APRN roles and decrease confusion to the public.
Alexandra Wilson Pecci is an editor for HealthLeaders.
