By Rose Hoban
A couple of years ago, Tom Bush was working as the “nurse of the day” at the General Assembly.
It’s an honorary volunteer position, used to give health care practitioners (there’s a doctor of the day, too) a taste of the legislature, it also gives providers a chance for some one-on-one with lawmakers.
On this particular day, Bush, who’s worked as a nurse practitioner at UNC Health Care for several decades, was visited by a legislator with a nasty cough. Bush thought he needed an antibiotic, and if he had been at UNC, Bush would have taken out his pad and jotted down a prescription.
But in Raleigh, he couldn’t.
“I can’t practice, I can’t function to the extent of my education and experience because I’m not in a UNC facility,” he explained.
That’s because as an NP, Bush’s practice is constrained by a “collaborative practice agreement,” which limits him to UNC.
“My scope of practice as a registered nurse is governed by the Board of Nursing,” Bush explained recently. “My practice as a nurse practitioner is governed by a subcommittee of the Board of Nursing and the Medical Board.”
“I’ve got an RN license and ‘approval to practice medical acts,’ that’s the language in the statute,” he said.
In short, Bush doesn’t have a license to be a nurse practitioner. No NPs in North Carolina do.
This year, though, the nurses think they have a shot at passage.
Weight of white coats
On Wednesday morning, a standing-room crowd in the largest committee room at the legislature gathered to hear HB 88’s main sponsor, Rep. Josh Dobson (R-Nebo), present the bill to the House Health Committee. Both doctors and nurses in white coats filled chairs in the gallery to lend the weight of their presence and to hear the debate.
Dobson argued that moving all the advanced practice nurses (APRNs) – nurse practitioners, certified nurse-midwives, clinical nurse specialists and certified registered nurse anesthetists – to regulation by the Board of Nursing makes sense.
“This legislation will reduce the unnecessary regulatory burden on advanced practice nurses, expand access to care in our underserved areas, reduce the cost of health care,” he said. “I know we can pick and choose which study we want to look at, but studies have shown that we can do this without jeopardizing the quality and safety of care.”
The most controversial parts of the bill would remove the requirement for those collaborative practice agreements between APRNs and physicians.
“Before they can practice in North Carolina, a nurse practitioner or a certified nurse-midwife are required to find a physician who will agree to enter into that supervision agreement,” said Dobson, who explained that his support for the bill comes directly from his experience in rural North Carolina, where it’s been hard to find practitioners. He said that at his small critical access hospital, there’s no anesthesiologist, only nurse anesthetists.
He pointed out that the agreements often come with a steep price tag attached. Nurse practitioners can pay physicians as much as $20,000 a year for their supervision. “This makes it even more difficult for them to practice in underserved areas of our state.”
“Also, if a supervising physician wished to no longer have the agreement, the nurse-midwife and nurse practitioner are no longer, by law, allowed to practice in North Carolina if they can’t find a new physician.”
Dobson has gathered 30 co-sponsors for the bill in the House, including Rep. Donny Lambeth (R-Winston-Salem) who was the president of Wake Forest-Baptist Hospital before he retired.
“We talk about regulatory reform in Raleigh, only when it’s convenient,” Lambeth said. “It’s time to update this outdated law.”
Rep. Gale Adcock (D-Cary) said this year’s push has been in the works for a while.
“It takes years to create some fertile ground for this kind of idea,” she said.
Adcock has been a nurse practitioner for decades and runs the employee health service at the Cary-based data company SAS. Her supervising physician is someone who actually reports to her. Adcock is also a former president of the North Carolina Nurses Association and has been organizing nurses to talk to their legislators.
“The advanced practice nurses in this state have been doing a great job in getting to know their legislators and becoming a kind of a trusted resource,” she said on the day the bill was filed in February. “That way, when they walk into someone’s office talking about HB 88… they’re not saying, ‘Who are you?’ They already know these folks.”
The advanced practice nurses have needed all the persuasion they can muster to offset the influence of North Carolina’s powerful medical lobbies. In February, the nurses held a reception for lawmakers in downtown Raleigh. In the third and fourth quarters of 2016, the North Carolina Nurses Association PAC made $12,000 in donations to lawmakers’ campaigns, while the North Carolina Association of Nurse Anesthetists donated in about $18,000 and the NP PAC, which represents nurse practitioners, chipped in $2,000.
During the same time period, the political action committee for the North Carolina Medical Society alone donated $38,000, more than all the nurses’ groups combined. And three anesthesiology PACs donated more than $34,000 to candidates in the run up to last year’s election.
When asked whether data on patient outcomes could overcome the nurse’s money deficit, Adcock was sanguine.
“That’s a question only the legislators can answer,” she said.
In their presentations to legislators Wednesday, advocates for both doctors and nurses made arguments that have been made in prior years.
Dr. Paul Reiker, past president of the North Carolina Society of Anesthesiologists, spoke in opposition to the bill, saying that he works daily with nurse anesthetists and appreciates what they do.
“Despite what’s being said… it will allow nurses to practice medicine without training, education or licensure,” he said.
Other speakers, including family physician Conrad Flick, argued that nurse practitioners’ shorter training time makes their decision-making skills weaker.
“They are part of a team, they are not an equal substitute,” said Flick, who is past president of the North Carolina Academy of Family Physicians. He argued that the supervision arrangements insured patient safety.
“I believe this issue comes down to one question, who do you want to care for your family?”
Lobbyist Patrick Ballantine, who is representing nurses, came to the podium brandishing a sheaf of research papers.
“This issue of supervision has been in dispute in North Carolina for over three decades. There have been lawsuits, and attorney general opinions and court cases and memoranda of understanding and consent orders.”
He proceeded to synopsize many of the articles.
“I want you to listen to the facts and understand that unsubstantiated anecdotes do not equal 40 years of third-party, research-based evidence,” he said. In particular, Ballentine worked to debunk the patient safety argument.
After the meeting, North Carolina Nurses Association head Tina Gordon admitted the hurdles to getting the bill passed are high, but said she feels better than in years past.
And she said that having Dobson as a “legislative champion” is key.
Dobson wasn’t planning on letting Gordon down. When asked after the meeting, he said, “I’m going to do everything I can to make sure the bill advances.”
“We are struggling to find providers in the rural areas of our state… this is one way that we can alleviate this problem and that’s why I’m fighting for it.
Editor’s note: North Carolina Health News has had the North Carolina Board of Nursing and the North Carolina Academy of Family Physicians as website sponsors. Since 2012, summer interns at NC Health News have been supported by a scholarship offered to students by the North Carolina Medical Society.
Correction: This story originally referred to the NC Academy of Family Physicians incorrectly.