House Bill 1160 (Hammer) - the APRN Scope of Practice bill. It would allow Advanced Practice Registered Nurses (APRNs) who practice in "medically underserved" areas (73 of the 75 Arkansas counties), to obtain a permit from the Nursing Board allowing them to:
- Prescribe ALL Schedule II drugs.
- Serve as the equivalent to a primary care physician and lead a Patient-Centered Medical Home (PCMH).
- Receive reimbursement equal to a physician.
- Practice without a Collaborative Practice Agreement (total independence) if Nursing Board exemption is granted after showing two years practice under a Collaborative Practice Agreement.
I have been speaking with my state representative and one of the responses was
"It is my understanding the there are many states that allow this practice. Can you help me understand why this is a bad idea if so many other states allow?"
Anyone have some good feedback I could pass along?
I am by no means an expert on this, but I have some generalities to pass along.
1.) First, point out the differences in training. Use publicly available Nursing curricula and allow comparisons to medical school. Your represenative may not be familiar with the differences in training.
2.) There are a number of studies highlighting these differences, showing that NPs often fail our board exams (step 3) which is considered easier/more clinical than the others). Emphasize that these exams are considered the absolute minimum standard for physician practice.
3.) The precautionary principle: it isn't our job to prove they are unsafe. It is their job to prove that they are safe.
You could not sell a generic drug on the market with a "we think it's safe." You must prove it is equivalent in every manner, pharmokinetically, dynamically, dosing, etc.
4.) The number of nurses who actually practice primary care is comparable to that of physicians. Many of them specialize.
5. ) These political nursing organizations are not attempting to reduce costs. As soon as they establish independent practice, they'll attempt to mandate "equal pay for equal work" (see Oregon).
6.) It is extraordinarily difficult to measure differences in patient outcomes between providers: the studies they frequently point to measure BP or satisfaction, which are basically useless. BP is heavily influenced by compliance.
In a general practice, there are three basic types of patients:
i.) Patient is normal, and does not need intervention
ii.) Patient is abnormal, but cannot be helped
iii.) Patient is abnormal, and can be treated.
The only place you're likely to see differences in outcomes is in group iii. Even in group iii, you are only likely to see differences in less common conditions. The nursing studies look at overall outcomes. This is not adequately powered to find the differences in outcomes that are necessary.
7.) The advanced practice of nurses was supposedly a method for highly experienced nurses to contribute more independently to the field. However, the way it is used, nurses with the absolute minimum requirements (a year or two of experience) are entering independent practice.
In short: nurses have not proven themselves safe. They have not proven themselves cost-effective. They have not shown that they are especially interested in primary care. Nurses have failed tests of basic clinical acumen required for independent practice. The path to advanced nurse practice was never meant to be so swiftly entered.
Finally, let's expand on the 3rd point, the precautionary principle. Medicine is a field that is about high minimum standards: explore the absolute minimum standard for becoming a physician (4 years undergrad, 4 years medical school, 3 years residency) with those of nurse practitioners. The differences are enormous.
Just my thoughts. I'm sure you already knew many of them.
