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Letter to the Editor

  • As the general public slowly recognizes the nurse practitioner as a primary care provider, society has a right to question whether or not the profession is in keeping with their own unique code of ethics.

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May 1-3, 1997


Scopes of Practice

"In an era of increasing national uniformity in educational preparation, competence examinations, and practice settings, it is counterproductive to continue the use of different, legislatively designated titles for practitioners who are similarly educated, who pass the same examinations, and who practice in the same ways. The easiest solution would be to have a single statutory designation--Advanced Practice Nurse, or APN--in each state, and to leave any subsequent regulatory or professional designation to the state Boards of Nursing and the national professional associations."
  • Barbara J. Safriet on "Health Care Dollars & Regulatory Sense: The Role of Advanced Practice Nursing", Yale Journal on Regulation, Vol., No. 2, p. 447
Mandatory physician direction and supervision intrudes unduly upon the professional judgment and recognized expertise of APNs. Once the state has legally recognized the APN as a competent provider, it is odd indeed to condition practice upon the agreement or permission of a private individual.

Limiting direct reimbursement for NPs to rural health clinics dramatically impairs their ability to provide high quality care to diverse populations.

  • Barbara J. Safriet on "Health Care Dollars & Regulatory Sense: The Role of Advanced Practice Nursing", Yale Journal on Regulation, Vol.9, No. 2, p. 478.
States should eliminate all reference to mixed-regulator entities, and vest sole governmental authority over advanced practice nursing in the Board of Nursing.
  • Barbara J. Safriet on "Health Care Dollars & Regulatory Sense: The Role of Advanced Practice Nursing", Yale Journal on Regulation, Vol. 9, No. 2, p. 478.
APNs providing services within their scope of practice should be paid the same as physicians providing the same services.
  • Barbara J. Safriet on "Health Care Dollars & Regulatory Sense: The Role of Advance Practice Nursing", Yale Journal on Regulation, Vol. 9, No. 2, p. 483.
For scopes of practice to effectively protect the public's health, legislators who craft them must balance the competing interests of quality, cost and access. Because quality of services rendered is nearly impossible to guarantee, states use measures of minimum competence, followed by disciplinary enforcement, to serve as proxies. Current scopes of practice, however, are not restricted to competence. Despite one profession's demonstration of competence to provide services -- by clinical outcome studies, education, testing, and training --- this same profession must also engage in political battles with other professions authorized to provide those services. Additionally, critics contend that present regulations not only restrict the practice of non-physician practitioners beyond what is justified by skills and training, but grant practice authority to physicians beyond their actual competence.
  • Weed & Weed, 1994, Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, Pew Health Professions Commission, p. 10.
Entry level for any generalist level position is the BSN. The rational for this criterion is that only the baccalaureate curriculum provides theoretical/educational preparation specific to community health nursing practice.
  • Association of Community Health Nursing Educators

Articulation of Education and Practice

"Professional training and practice should place more emphasis on developing qualities of a superb generalist, capable of comprehensive management of care, as opposed to the current orientation toward specialization".
  • The Third Report of the Pew Health Professions Commission, Nov 1995, p. 28
Focus associate preparation on the entry level hospital setting and nursing home practice, baccalaureate on the hospital based care management and community based practice, and masters degree for specialty practice in the hospital and independent practice as a primary care provider.

Strengthen existing career ladder programs in order to make movement through these levels of nursing as easy as possible.

  • The Third Report of the Pew Health Professions Commission, Nov 1995, p. 50
Recover the clinical management role of nursing and recognize it as an increasingly important strength of training and professional practice at all levels.
  • The Third Report of the Pew Health Professions Commission, Nov 1995, p. 51.
The next generation of health professionals must be prepared to practice in settings that are more intensively managed and integrated.
  • The Third Report of the Pew Health Professions Commission, Nov 1995, Executive Summary, p. iii.
Nurses in the 1990s are developing their abilities to work with organizational theory, to work within political realities and to develop scholarship and research skills because caring happens on multiple levels- individual care, population based and system based programs.
  • Nursing Practice Environmental Scan, National Council of State Boards of Nursing, Inc./1996.
Countries must collaborate and pool resources to establish international methods for assessing qualifications and equivalence of education, must inform each other about their regulatory systems and processes, and must exchange ideas, concerns, and expertise.
  • Commission on Graduates of Foreign Nursing Schools
The globalization of nursing can only be achieved through collaboration. We need to recognize the importance of multicultural nursing in a pluralistic society and the responsibility that we, as nurses, have to our colleagues who come from outside the borders of the United States.
  • Commission on Graduates of Foreign Nursing Schools

Regulatory Systems--Evolving Models

The most troublesome regulatory barrier to accessible, cost-effective and high quality care are inflexible scope of practice regulations. Current practice acts do not readily recognize the possibility of overlapping scopes of practice based on demonstrated competency. The need for accessible health care calls for flexible scopes of practice which recognize that different types of competent practitioners may provide the same health services.
  • The Third Report of the Pew Health Professions Commission, Nov. 1995, p. 30.
Concrete objectives for the regulatory system and standards by which to measure its performance must be articulated clearly. Current sunset and self-assessment measures, such as number of complaints processed, timeliness of the adjudication process, and disciplinary actions taken, address the efficiency of internal board operations but say little about regulation's overall effectiveness in protecting the public's health.
  • The Third Report of the Pew Health Professions Commission, Nov. 1995, p. 38.
The lack of uniformity in laws and regulations among the states limits effective professional practice and mobility, confuses the public, and presents barriers to integrated delivery systems and the use of telemedicine and other emerging health technologies. The standardization of entry-to-practice requirements limited to competence assessments for health professions would facilitate the physical and professional mobility of the health professions and improve the accessibility of health care services. Furthermore, reformed entry-to-practice standards not so closely linked with the accreditation process would permit greater flexibility and accountability to the public.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, Pew Health Professions Commission , p. 8.
As private accreditation bodies mirror the function of state agencies to regulate the workforce, accreditation processes and standards have to be accountable and respond to the needs of the health care system and the public. States may consider alternative accreditation standards and structures to complement or supplant those of professional accrediting bodies. Educational accreditation principles will be expected to evolve with public needs, stimulate education programs to improve continuously, and focus on the graduates' demonstrated competence to perform services appropriate for their level or training.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, Pew Health Commission, p. 42

Assuring Continuing Competence--State of the Science

Current regulatory systems do not demand any demonstration of continued competency. Continuing education requirements, however laudable, do not demand demonstration that a licensed professional is still competent to perform everything in his or her scope of practice anytime after initial licensing.
  • The Third Report of the Pew Health Professions Commission, Nov. 1995, p. 30.
Continuing education requirements do not guarantee continuing competence.

Emerging information technologies and the information super-highway offer states unprecendented opportunities to create innovative means of assessing both initial and continuing competence.

Re-testing programs should assess the competence of practitioners according to articulated practice guidelines, provide specific and detailed feedback to practitioners, offer targeted retraining for deficiencies, reassess the practitioner's skills after retraining, and remove those practitioners whose performance, after retraining, does not meet identified standards.

  • The Third Report of the Pew Health Professions Commission, Nov. 1995, p. 28.
States should base practice acts on demonstrated initial and continuing competence. This process must allow and expect different professions to share overlapping scopes of practice. States should explore pathways to allow all professionals to provide services to the full extent of their current knowledge, training, experience and skills.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, The Pew Health Professions Commission, p. 9.
Public protection and practice performance would be improved if states proactively identified practitioners at high risk for poor performance, for example, those without a specialty or private certification or those in solo practice. Even more proactive would be state-required random or targeted peer reviews.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, The Pew Health Professions Commission, p. 27.
Require the regulated health professionals to periodically demonstrate competence through appropriate testing mechanisms. Competence assessment testing could be" "triggered" by a variety of markers, including for example, the number of disciplinary actions, lack of specialty or private certification, length of time in solo practice, number of procedures performed, or other state-determined indiators; and random or targeted peer reviews for practitioners.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, The Pew Health Professions Commission, p. 25
The Board of Nursing needs to develop a recertification process for nurses who have been away from active nursing practice for twenty years.
  • Health Professions Regulation Newsletter, Maine, Feb 1997, p. 24.
Standards for competence must be applicable to every nurse in every practice role and address the continuum of practitioner experience, i.e., competence at entry, continued competence, competence upon re-entry and after disciplinary action.
  • Assuring Competence: A Regulatory Responsibility, National Council of State Boards of Nursing, Inc./1996

Legal Issues of Delegation/Accountability

ANNA supports the least restrictive form of regulation for unlicensed personnel in dialysis and efforts to standardize patient-care technician education/training, demonstration, and documentation of minimum competency level.
  • Health Policy Agenda, The American Nephrology Nurses' Association.
States should redesign health professional boards and their functions to reflect the interdisciplinary and public accountability demands of the changing health care delivery system.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, The Pew Health Professions Commission, p. 14.
Make public access to the complaints and discipline process simple and clear. Information about filing a complaint, the standards by which complaints are judged, investigation procedures, discipline, and appeals should be explained in a manner that is simple and clear.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, The Pew Health Professions Commission, p. 30.
The central question is not whether the APNs ( and other nurses) "can" prescribe, but rather what legal authority for prescribing they will be granted.
  • Barbara J. Safriet on "Health Care Dollars and Regulatory Sense: The Role of Advanced Practice Nursing", Yale Journal on Regulation, Vol. 9, No. 2, p. 457.
Delegation as a tool for implementing and responding to change must be based on client needs and professional judgment, not on inadequate staffing, external cost control measures, or rigid regulations.
  • Nadine Schwab, RN and Marykay Haas, RN on "Delegation and Supervision in School Settings, Standards, Issues and Guidelines for Practice", Journal of School Nursing, Feb 1995, p. 25.
Maintaining flexibility in the interest of the client while learning to identify professional boundaries is an important aspect of professional accountability.
  • " Professional Accountability--Using the Collaboration Model for the Identification of Strategies for the Promotion of Professional Accountability", National Council of State Boards of Nursing, Inc./1995.

Roles and Responsibilities of Professional Associations and Licensure Bodies

States should standardize entry-to-practice requirements and limit them to competence assessments for health professions to facilitate the physical and professional mobility of the health professions.

The lack of uniformity in language among the states and the professions limits effective professional practice and mobility, creates barriers to high quality health care, and confuses regulators, legislators, professionals, and the public.

  • Report of the Taskforce on Health Care Workforce Regulation Dec. 1995, The Pew Health Professions Commission, p. 5.
When properly designed and administered, occupational licensing can protect the public's health and safety by increasing the quality of professionals' services through mandatory entry requirements -- such as education and business practice restrictions-- such as advertising restrictions. Occupational licensure frequently increases prices and imposes substantial costs on consumers. At the same time, many occupational licensing restrictions do not appear to realize the goal of increasing the quality of professionals' services. While the majority of the evidence indicates that licensing proposals are often not in the consumers' best interest, we cannot conclude that the costs of licensing always exceed the benefit to consumers. In considering any licensing proposal , it is important to weigh carefully the likely costs against the prospective benefits on a case by case basis.
  • Cox & Foster, Excerpt from the Federal Trade Commission Report in a Study of the Costs and Benefits of Occupational Regulation, 1990.
Boards should educate consumers to assist them in obtaining the information necessary to make decisions about practitioners and to improve the boards' public accountability. It should develop individual profiles for regulated health care professionals who deal directly with consumers. These profiles should include legally disclosable information about demographics, education, practice, employment, disciplinary actions, criminal convictions, and malpractice judgments.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, The Pew Health Professions Commission, p. 18.
State boards and national credentialing organizations will be required to ensure that exams are not only psychometrically sound, but measure competency in those areas that put the public at risk. These organizations also will be challenged to justify why they should determine a candidate's competence beyond the components of practice that place the public at risk. Moreover, states should review the accountability of examination development and ask who should determine the knowledge, skills and abilities required for competent practice in the workplace.
  • The Report of the Taskforce on Health Care Workforce Regulation, Dec. 1995, The Pew Health Professions Commission, p. 45

© 1997 Online Journal of Issues in Nursing
Published May 12, 1997


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