Often, patients who are readmitted after being sent home from the hospital return through the emergency room. Photo shows nurses rushing a patient on a gurney into a doorway.
Often, patients who are readmitted after being sent home from the hospital return through the emergency room. Image courtesy Trust for America's Health

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<p>Lawmakers say they’re ready to give the rules around nursing practice a vote. Is the health care community ready?

By Rose Hoban

Like so many political debates these days, the rules of engagement had been negotiated ahead of time.

Nurses and nursing students have come to the legislature annually to advocate for their profession. Photo credit: Rose Hoban

On March 8, the Joint Legislative Oversight Committee for Health and Human Services at the General Assembly had a portion of their all-day meeting set aside for representatives from the physician and nursing communities to debate the idea of allowing advanced practice nurses, or APRNs, more leeway in their practice.

Committee Co-chair Sen. Louis Pate (R-Mt Olive) made it clear several times that the “two sides” had agreed beforehand that each would get 45 minutes to present their case: doctors arguing that laws granting them supervision and control over APRNs are fine the way they are, and APRNs arguing that limiting their “scope of practice” keeps them from being as efficient as possible, exacerbates shortages in rural areas and has no benefit for patients.

It’s a topic that’s been talked about extensively at the General Assembly, most recently in 2014 when an interim committee on certified nurse midwives recommended repealing the physician supervision for CNMs and giving them full independence.

Bipartisan bills that would have made any changes have gone nowhere. But at the end of the March 8 meeting, lawmakers said Senate Bill 695 could move ahead to a vote.

“We have the legislation already for the deregulation of all four areas of the scope of nursing practice,” said Sen. Ralph Hise (R-Spruce Pine).

He asked that deregulation be the recommendation of the committee in their final report.

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Much of the debate over APRNs comes down to studies looking at patient outcomes.

Physicians have long argued that having APRNs doing a lot of what doctors traditionally do could potentially pose harm for patients.

“There are benefits for team-based protocols. Team-based protocols require physician-supervised care in the most effective way for maximizing patient safety,” Docia Hickey, a neonatalogist who heads the board of directors for the N.C. Medical Society, told the committee.

A military certified registered nurse anesthetist assists during surgery. CRNAs are widely used throughout the military and have independent practice on post. Photo credit: Army Reserve Staff Sgt. Andrea Merritt

However, Hickey’s committee testimony centered mostly on the overall economic benefits of physician-lead care, citing a recent study in the Journal of the American Medical Association that indicated nurse practitioners order more X-rays and scans than primary care doctors, “implicating for additional costs for the population at large.”

In answer to a request for research on patient safety, the Medical Society provided links to three studies, two of which focused on cost.

One of those studies found that independent practice by nurse practitioners was “associated with a 1-4 percent increase in health care costs” in two of three patient groups studied. However, the authors also noted that “provider prices for primary care services fell by 1-4 percent following the implementation of independent [scope of practice] for NPs.”

A third study focused on comparing the quality of referrals made to academic medical centers by APRNs and physicians, which concluded that physicians’ referrals were better “regarding the clarity of the referral question, understanding of pathophysiology, and adequate pre-referral evaluation and documentation.”

In contrast, the four speakers representing APRNs presented multiple studies done over the past 25 years that found favorable outcomes for APRNs in patient safety, cost and patient satisfaction.

One speaker, Taynin Kopanos from the American Academy of Nurse Practitioners, provided a three-page bibliography of studies performed between 1974 and 2015 showing that nurse practitioners provide safe care that’s cost-effective and that patients are happy with their care.

“Multiple meta-analyses comparing the results of dozens of studies over several decades of patient care continue to show similar rates of safe, high-quality outcomes,” said Kopanos. “The question of safety and quality is no longer a question; decades of evidence have resoundingly answered that debate.”

Robert Gauvin, a member of the board of directors of the American Association of Nurse Anesthetists, referenced at least three studies on the quality and cost-effectiveness of care provided by CRNAs. A study of a half million patient cases conducted by Research Triangle Park-based RTI in 2010 showed there was “no difference in patient outcomes when anesthesia services are provided by CRNAs, physician anesthesiologists or CRNAs supervised by physicians.”

“For any group or individual to assert otherwise without evidence or data clearly has motives that don’t include what’s best for the patients or the health care system as a whole,” Gauvin said.

APRNs who have independent practices would continue to collaborate with their physician colleagues, argued Rebecca Bagley, who heads the nurse midwifery program at East Carolina University. She said that APRNs are obligated to practice within a “health care system that provides for consultation, collaboration or referral as indicated.”

“Removal of supervision from our language is not going to change this requirement,” she said.

Rural-access questions

One argument made by APRNs is that they are more likely to practice in rural areas once they have independence, something that was refuted by Chip Baggett, who represents the N.C. Medical Society at the legislature.

“There are just as many certified nurse midwives in rural areas as there are OB/GYNs spread out in the rural areas across the state,” Baggett told the committee. “But funny, they are also concentrated in the most urban areas, just like the doctors are most concentrated in the most urban areas.

“I take that as an example of why we need to do more to encourage rural health care.”

Bagley retorted the current geographic distribution exists largely because rural nurse-midwives have trouble finding a physician to supervise from afar, leading to midwives to practicing near their urban colleagues. Freed of the supervision requirement, Bagley said, nurse-midwives would be willing to work in rural areas.

That drew skepticism from Sen. Tommy Tucker (R-Waxhaw), who pointed out that most rural patients would be on either Medicaid or Medicare, both of which pay lower rates.

“How would they support their practice out in a rural area?” Tucker asked. “I guess you’d say they’re so much cheaper.”

Bagley responded that “past behavior predicts future outcomes.” She pointed out that research has shown that APRNs have been more willing to work in rural areas in states where they have more autonomy.

Nurses chat in the labor and delivery ward at a hospital in Washington, D.C. In North Carolina, most midwife-attended births take place in hospitals; fewer than 1 percent of births in the state take place in the home. Photo credit: Medill DC, flickr creative commons

“I can’t give you 100 percent guarantee in blood,” Bagley said, “But I think one of the reasons nursing has been so successful … with getting people back to our rural areas is [that] a condition of becoming an advanced practice nurse is that you’re a registered nurse first.”

“They understand the needs in those communities. They understand the hardships and they have a passion for it,” she said.

“Of course, it’d be perfect if every American had a primary care physician and we had it in the proportion of, say, 55 doctors for every 100,000 people,” said Brock Slabach, vice president of the National Rural Health Association. “But often I see the perfect being the enemy of the good.”

Slabach said many rural communities do well having APRNs providing primary care and then referring patients to physicians farther away when necessary.

“There are a lot of conditions that don’t need the services of a physician to be able to fix,” Slabach said. “And if a physician is seeing a lot of low acuity-level patients in the clinic, that may not be the best use of their training and experience.”

He also pointed to the upcoming wave of physician retirements coming to rural America, a trend he called a “cliff.”

“We’ll have a real problem with replacement for providers that are leaving,” he said. “Couple that with the trend of medical graduates going away from generalists to more specialty practices because, frankly, incomes are generally higher if you specialize.”

‘Big knowledge’

in 2010, the U.S. Institute of Medicine released a massive report that called for allowing nurses to practice to their full abilities.

In that same year, the editor-in-chief of the Journal of Family Practice wrote an editorial stating thta it was time for physicians to “abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses.”

Since then, eight states have revised their scopes of practice. Now, 21 states and the District of Columbia allow nurse practitioners full practice authority, 25 states allow nurse-midwives to practice independently and 26 allow autonomy for nurse anesthetists.

But doctors are not happy about it. In a nationwide survey of physicians conducted in 2015, four in 10 doctors viewed increased reliance on nurse practitioners and physician assistants negatively.

The one doctor on the committee, Rep. Gregory Murphy (R-Greenville), a urology surgeon, made it clear he appreciates the skills of APRNs who work for him, but also said he sees no need for change.

“At the present time, a physician is the most highly trained, most broadly trained; therefore they know the entire picture, not just the narrow frame of things,” Murphy told the committee. “Because when things fall outside protocols, that’s when you need the big knowledge to adapt at the moment.”

And that ambivalence was expressed by non-physicians on the committee. Yet when Hise moved to have the committee recommend the scope of practice bill move forward, no one objected.

“The General Assembly is eventually going to decide on this issue, and there’s not a lot of point in continuing to punt on that,” Hise said after the meeting. “At some point, we’re going to have to decide what is the scope of practice for nurses in this state.”

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Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...