Public Policy

Regulation of Advanced Practice Nursing- The Cog in the Health Policy Engine

I+ HE AMERICAN health care system, or lack thereof,

.k has b ecome one of the biggest issues of this year’s

presidential election campaign. Everyone from consumers to policymakers understands the engines that drive our

health care system-access, cost and quality-are out of

control. All of the major health professions have proposed

their own comprehensive plans to fix the current system

and put consumers and providers back in the driver’s seat.

None of the plans, not even nursing’s, sufficiently ana- lyze and address the problems associated with the regula-

tion of advanced practice nursing-problems that raise un-

necessary barriers and restrictions to practice for clinical

nurse specialists, nurse practitioners, and nurse-midwives,

thus limiting consumer access to high-quality, reasonable-

cost care. Indeed, with the exception of nursing, all of the

plans are based on an assumption of medical model care, the net effect of which is to make all other care additive and

cost-inflating. It is evident that it has not yet dawned on anyone that the problem with the current system is the singular reliance on the medical model and the resultant

limiting ways in which we define scope of practice and

prescriptive practice of so-called nonphysician providers, physician extenders, or midlevel practitioners.

Have you ever pondered what it must mean from a con-

sumer’s point of view to be cared for by a midlevel practi-

tioner? I recall hearing Inge Mauksch liken the concept of

physician extender to “Hamburger Helper”-something

you use as filler to extend an otherwise inadequate meal! Do

we really want or need a health care system in which pro- viders are reduced to only two important categories: phy-

sicians and nonphysicians? No one would argue with the observation that nursing

has made great strides in the past 10 years in broadening

scope of practice and securing prescriptive practice legisla-

tion for advanced practice nurses. But, just how much progress has really been made? The reliance of our legisla- tive system on states rights has made it impossible to im-

plement model laws and regulations. There are literally as many different prescriptive practice laws as there are states who have implemented them, and there is astounding vari- ation in nurse practice acts and licensure provisions that define scope of practice! Nearly all of the variation can be attributed to efforts to restrict nursing practice by defining

JUDITH B. KRAUSS, RN, MSN Dun and Profssor

School of Nursing

Yale University

25 Park St, PO Box 9740

New Harm, CT 05536

Copyright 0 1992 by W.B. Saunders Company

8755/7223/92/0804-0002$03.00/O

the physician as supervisor, delegator, or collaborator, and

by limiting prescriptive practices to protocols under phy- sician supervision or direction.

In Nzlvse Practitioner, Pearson t 1991) estimated that 35

states now grant some form of prescriptive authority to

advanced practice nurses. The majority define prescriptive practice for nurses as a dependent function, ie, under the

supervision, delegating authority, or protocol of a physi-

cian. Very few states define prescriptive practice for nurses as an independent function; Oregon, where the definition

of the advanced practice nurse is left to the Board of Nurs-

ing as is the approval process that authorizes the prescrip-

tion of drugs listed in a formulary, including controlled

substances, is a prime example. In many states, joint com-

mittees of the boards of nursing and medicine define the

scope of practice of the advanced practice nurse and oversee the granting of prescriptive authority, as if physicians had a working knowledge of the practice of nursing and could

make decisions concerning the scope of nursing practice that would be in the public’s best interest (free of economic

conflict of interest)!

There is ample evidence of the effectiveness and safety of advanced practice nursing services. It is beyond the scope of

this column to review the extensive literature that favorably

compares advanced practice nursing services with similar physician services. Suffice it to say, data exist to support

the claim that advanced practice nursing services are cost-

effective substitutes for comparable physician services and,

in some instances, cost-effective compliments that reduce risk and prevent higher cost-negative sequela of illness.

Nursing is certainly recognized as one of the independent

health professions. Yet the preponderance of laws and reg- ulations that define scope of practice and prescriptive prac-

tices for nursing would seem to be based on a different set

of assumptions that ignore the fact, eg, that nursing is a dependent profession (surely a contradiction in terms) that can neither define nor regulate its own practice due to lack of public confidence in their competence and safety.

In this presidential election year, with much focus on health care reform, it is time to revisit and reform our scope

of practice and prescriptive practice laws and regulations. The goal should be definition of nursing as an independent

practice profession with independent and sole autharity over matters of scope and practice. The only way to improve access, control cost, and assure quality in our health care system is to modify the singular medical model approach to care and to enable other qualified practitioners to practice free of unnecessary restrictions and barriers. Although many of us have just implemented legislation in our own states, the time for reform, while the nation’s collective attention is focused on the invention of a better health care engine, is now.

200 Jownal of ProfesGonal Nursing, Vol 8, No 4 (July-August), 1992: p 200