Discussion: Professional Nursing and State-Level Regulations NURS 6050

Discussion: Professional Nursing and State-Level Regulations NURS 6050

Discussion Professional Nursing and State-Level Regulations NURS 6050

Boards of Nursing (BONs) exist in all 50 states, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, and the Virgin Islands. Similar entities may also exist for different regions. The mission of BONs is the protection of the public through the regulation of nursing practice. BONs put into practice state/region regulations for nurses that, among other things, lay out the requirements for licensure and define the scope of nursing practice in that state/region.

It can be a valuable exercise to compare regulations among various state/regional boards of nursing. Doing so can help share insights that could be useful should there be future changes in a state/region. In addition, nurses may find the need to be licensed in multiple states or regions.

        As nurses we are held to extremely high standards; we are entrusted with the lives of others, so we must adhere to the set regulations and guidelines.  Milstead & Short tell us that each state governs their own regulations and they all do so differently, and it is the practitioner’s responsibility to know these regulations (2019).  The first regulation for Missouri deals with collaborative practice between an advanced practitioner and a physician.  In 1993 a bill was passed that allowed nurses more freedom to see and care for patients without direct supervision from a physician.  The terms were negotiated for several years and finally went into effect in 1996.  There are pages of specifics on the regulation so I will touch briefly on the highlights.  It was not until an amendment to The Nurse Practice Act in 1975 that nurses could operate the basics such as assessments, nursing diagnoses, and basic standing orders without the direct observation of a physician.  In 1993 the changes made were not wide sweeping for APRN’s but stated  “the only substantive differences in the provision governing delegation to APNs is that they may be delegated the right to prescribe as well as administer or dispense drugs” (The Climate Change and Public Health Law Site., n.d.).  The second regulation in Missouri I will focus on is a bit more straight forward.  “To be recognized as an APRN in Missouri the individual must first hold a current, unencumbered license to practice as a registered nurse” (Missouri House of Representatives., n.d.)

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Discussion: Professional Nursing and State-Level Regulations NURS 6050

Comparatively the Wyoming Nurse Practice act states “An APRN issued a multistate license is authorized to assume responsibility and accountability for patient care independent of a supervisory or collaborative relationship with a physician.” (Wyoming State Board of Nursing, n.d.).  The second regulation is regarding being recognized as an APRN in Wyoming and the states participating in compact agreement.  According to the Wyoming State Board of Nursing “In order to obtain or retain a multistate license, an APRN must meet, in addition to the uniform licensure requirements, the home state’s qualifications for licensure or renewal of licensure, as well as, all other applicable home state laws.” (n.d.).

Both regulations directly impact an APRN’s ability to practice.  The first regulation discussed is important as it tells

how an advanced practice nurse can practice regarding their association with a physician.  According to the regulations in Missouri an APRN must be associated with and collaborate with a physician to practice.  This limits how an APRN can see patients.  One specific example of how an APRN would adhere to this is to work directly with a physician out of an office or at a hospital and see patients that are already established only offering the services that are within their scope of practice.  This does take a huge load of work of the physician allowing for more patients to be seen but does limit what the practitioner can do on their own.  This also limits the number of practitioners available because each APRN must be associated with a physician and there are only so many physicians.

In contrast in Wyoming an APRN can practice independently of a physician.  There are still limitations to what the APRN can prescribe and other matters that are still considered out of their scope of practice.  However, being able to operate independently allows more freedom for providers to run their own practice and provide care for a larger number of patients.

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The second regulation in Missouri simply states that an APRN must have a license that is unencumbered and current to practice.  The specific example for how to abide by this regulation is for the nurse to keep their license current and adhere to all standards of care and regulation to ensure their license remains unencumbered.  In Wyoming there is more to keeping a license because there are multistate agreements.  In this situation the APRN must be familiar with the requirements and regulations from all the states in the compact agreement and be sure to adhere to those.

References:

Milstead, J. A., & Short, N. M. (2019). Health policy and politics: A nurse’s guide (6th ed.). Burlington, MA: Jones & Bartlett Learning.

Missouri House of Representatives. (n.d.). APRN Scope of Practice Report. https://house.mo.gov/Billtracking/bills171/commit/rpt1510/Scope%20of%20Practice%20Report.pdf

The Climate Change and Public Health Law Site. (n.d.) Advanced Nurse Practice: New Regulations for Missouri. https://biotech.law.lsu.edu/articles/apn.html#Heading1

Wyoming State Board of Nursing. (n.d.). https://www.wyoleg.gov/NXT/gateway.dll?f=templates&fn=default.htm

Discussion: A comparison of Advanced Practice Registered Nurse (APRN) jobs in my current state versus jobs in another state.

CALIFORNIA STATE/REGION REGULATIONS

In 2017, over 20 states passed legislation that emphatically impacted access to and delivery of healthcare to patients nationwide. As in previous years, professional advanced registered nurses (APRN) organizations and Boards of Nursing (BON) have worked indefatigably in their respective legislative sessions to ensure patients had access to high-quality healthcare in their states.

I currently work and live in the State of California. In this discussion, I will explain the differences in legislative law and the scope of practice of APRNs within California and Alaska.

APRN’s are registered nurses who have completed further education to prepare them to convey a broad range of services including diagnosis and treatment of acute and chronic illnesses.

California up until recently was 1 of 22 states that restricted APRN’s by requiring them to work with physician oversight (Joanne Spetz, 2018).

On October 12, 2019, Senate Bill number 323 (SB 323), chapter 848 was authorized by Senator Edward Hernandez, and assembly member Susan Eggman and approved by our Governor, which granted over 18,000 California nurse practitioners full practice authority (CANP, 2020).

Full Practice Authority is the authorization of NP’s to evaluate patients, diagnose, order and interpret diagnostic tests and initiate and manage treatments, including prescribing medications under the exclusive licensure authority of state board of nursing (BON) (CANP, 2020).

Even though APRN’s in California have been given the privilege to full practice authority, under the scope of practice for California APRN’s they must have a standardized procedure or protocol that must be developed and approved by a supervising physician.

Discussion: Professional Nursing and State-Level Regulations NURS 6050

According to Ed Hernandez, SB 323 has been a fight for some time. Senator Ed Hernandez felt SB 323 was a necessary law that needed to be passed related to the 2.5 million previously uninsured Californians receiving health coverage under the Affordable Care Act, to ensure more trained health care professionals (CANP, 2020).

APRN’s in California also have the prescriptive authority which means, drugs or devices furnished by the APRN must be ordered in accordance with the policies and protocols set forth in the agreement with the supervising physician. The APRN may furnish drugs and devices within the APRN’s area of practice. Physician involvement is required when an APRN is furnishing schedule ll or lll controlled substances, and a patient-specific protocol is required (California Scope of Practice Policy: State Profile, 2020).

APRN as a primary care provider is recognized in state policy as primary care providers.  This means a person responsible for coordinating and providing primary care to members, within the scope of practice of their license to practice, for initiating referrals and maintaining continuity of care. A primary care provider may be a primary care physician or nonphysician medical practitioner including a nurse practitioner, certified nurse-midwife or physician assistant (California Scope of Practice Policy: State Profile, 2020).

APRN’s in California and under the legislative SB 323 to summarize are given the privileges to full practice authority and have prescriptive authority, while under physician authority.

But as California continues to face a growing shortage of primary care physicians, the Legislature is considering allowing NP’s who get additional training and certification to work independently (Aguilera, 2020). According to author Elizabeth Aguilera, the State Assembly passed Assemble Bill 890, which would free many NP’s from needing to operate under a supervising physician’s agreement (Aguilera, 2020). Assembly Bill 890 will create a path for NP’s who want to work independently by opening their own practice. The bill, carried by Santa Rosa Democratic Assemblyman Jim Wood, now goes to the Senate (Aguilera, 2020).

Discussion: Professional Nursing and State-Level Regulations NURS 6050

The California Board of Nursing (BRN) grants legal authority to practice and regulate/issues separate certification to APRN. Defined in statute APRN includes certified nurse practitioner (CNP), NP (in statute), clinical nurse specialist (CNS), Certified Nurse Midwife (CNM), and, certified registered nurse anesthetist (CRNA) roles. NP’s function under standardized procedures or protocol when performing medical functions, collaboratively developed and approved by the NP, physician, and the administration in the organized healthcare facility in which they work (Philips DNP, APRN, FNP-BC, FAANP, 2018)).

NP standard of procedure (SOP), is defined within the standardized procedures commensurate with the NP’s education and training, not in statute or regulation (Philips DNP, APRN, FNP-BC, FAANP, 2018).

APRN’s are not legally in California authorized to admit patients to the hospital; however, individual hospitals may grant APRN’s hospital privileges (Philips DNP, APRN, FNP-BC, FAANP, 2018). Also, APRN’s do not require in California national certification to enter practice (Philips DNP, APRN, FNP-BC, FAANP, 2018).

APRN’s in California are regulated by a BON or a combination of a BON and  BOM (the board of medicine) oversight exists, requirement or attestation for physician supervisors, delegation, consultation or collaboration for authority to practice and/or prescriptive authority (Phillips, DNP, APRN, FNP-BC-FAANP, 2018).

Discussion: Professional Nursing and State-Level Regulations NURS 6050

APRN certification in California requires completion of a master’s, postgraduate, or doctorate degree from an accredited NP program, and then a certification from a nationally recognized certifying body such as the American Academy of Nurse Practitioners or the American Nurse Credentialing Center (California Health Care Foundation, 2018). NP certification in Californian can be obtained by the successful completion of an NP education program that meets BRN standards or by certification through a national organization whose standards are equivalent to those of the BRN (California Health Care Foundation, 2018). There are 23 approved NP programs in California (California Health Care Foundation, 2018). Since January 2008, California requires NP applicants who have not been qualified or certified as an NP in California or any other state possess a master’s degree in nursing, or a graduate degree in nursing, and complete an NP program approved by the board. An NP must have BRN certification to practice in California, but certification from a national professional association is not required California Health Care Foundation, 2018 (California Health Care Foundation, 2018).

In California, NP practice is governed by the state nurse practice act California Health Care Foundation, 2018 (California Health Care Foundation, 2018). The Board of Registered Nursing has promulgated regulations that require NP to work under standardized procedures for authorization to perform medical functions (California Health Care Foundation, 2018). This means that NP’s work under collaboration with a physician and adhere to standardized procedures developed through collaboration among administrators and health professionals.  There are no rules regarding the proximity of the physician to the NP, meaning a physician can provide supervision from hundreds of miles away.

Discussion: Professional Nursing and State-Level Regulations NURS 6050

State regulations regarding APRN scope of practice varies from state to state. The Model Act defines the scope of practice for APRN’s to include conducting assessments, ordering and interpreting diagnostic procedures, establishing diagnoses, prescribing, ordering, administering, dispensing, and furnishing therapeutic measures, delegating to assistive personnel, and consulting with other disciplines and providing referrals (California Health Care Foundation, 2018). The Model Act recommends that APRN’s be licensed independent practitioners. (California Health Care Foundation, 2018).

ALASKA STATE/REGION REGULATIONS

Alaska is one of the first states to embrace the role of the APRN. Alaska began to adapt state laws giving NPs more freedom as early as the 1980s. On July 21, 1984, Eileen Mountano RN, Chairperson of the Alaska Board of Nursing signed an adoption order for new regulations regarding ANPs in Alaska. ANPs at the time included Certified Nurse Practitioners, and Certified Nurse-Midwives (Hartz MSN, FNP, 2014). The new regulations would repeal a requirement for a signed collaborative agreement between a physician and ANP that also had to be approved by the Alaska Medical Board (). In 1987, additional regulations gave ANPs independent authority to prescribe controlled drugs Scheduled ll-lV (Hartz MSN, FNP, 2014). According to the author, Alaska was one of the first states to adopt broader licensing authority in the 1960s and remains one of the only 19 states along with the District of Columbia that allows NP’s to practice with full autonomy (Hartz MSN, FNP, 2014).

Discussion: Professional Nursing and State-Level Regulations NURS 6050

The nursing statutes in Alaska are the result of legislation passed by the legislature. They are what gives the Board of Nursing its powers and authority to regulate nurses for the protection of the public (Hartz MSN, FNP, 2014).

In 1981 SB 238 was introduced to update the nursing statutes. It included the current definition of “advanced nurse practitioner” and “nurse anesthetist” and gave the BON authority to regulate the groups.  (Hartz MSN, FNP, 2014).

The bill was passed in 1982 and by 1983 work had begun on new ANP regulations, and in 1984 was passed (Hartz MSN, FNP, 2014).

Currently, APRNs working in Alaska have the freedom to practice independently, with the supervision of a physician. Physician involvement is not necessary for diagnosing, treating, or prescribing for patients in anyway. Alaska’s laws for APRNs are some of the most liberal in the nation (Nurse Practitioner Scope of Practice: Alaska, 2014).

Discussion: Professional Nursing and State-Level Regulations NURS 6050

Prescribing laws allow APRNs freedom in their practice. Again, physician involvement is not necessary for the NP to prescribe. In order, though for NPs to write prescriptions an NP must submit an application to the state board of nursing as well as complete 15 contact hours of education in advanced pharmacology and clinical management within the two-year period immediately before the date of the initial application (Nurse Practitioner Scope of Practice: Alaska, 2014). NP’s in Alaska must also renew their authority to prescribe every two years, and in order to renew their prescribed privileges the NP has to take 12 hours of continuing education in advanced pharmacotherapeutics and 12 hours of continuing education in clinical management (Nurse Practitioner Scope of Practice: Alaska, 2014).

APRNs in Alaska are regulated by a BON and have full, autonomous practice and prescriptive authority without a requirement or attestation for physician supervision, delegation, consultation, or collaboration (Nurse Practitioner Scope of Practice: Alaska, 2014)

Discussion: Professional Nursing and State-Level Regulations NURS 6050

REFERENCES

California Scope of Practice Policy: State Profile (2020). Retrieved March 21, 2020, from

www.httpps://scopeofpracticepolicy.org>states>ca

California Association for Nurse Practitioner (2013). New Full Practice Authority Bill Introduced. Retrieved March 21, 2020, from

www.https://canpweb.org>press-releases

Joanne Spetz (May 2, 2019). California’s Nurse Practitioners: How Scope of Practice Laws Impact Care. Retrieved March 21, 2020, from

https://www.chcf.org>publication

Elizabeth Aguilera (February 13, 2020). Facing doctor shortage, will California give nurse practitioners more authority to treat patients? Retrieved March 21, 2020, from

https://www.CaliMatters<projects>doctors-short

Nurse Practitioner Scope of Practice: Alaska (May 23, 2014). Retrieved from

https://www.MidlevelU>blog

Lynn Hartz MSN, FNP (June 2014). Alaska Nursing Today vol 2. Retrieved March 22, 2020, from

Https://www.NursingALD.com>pdf>Ala

California Health Care Foundation. California’s Nurse Practitioners: How Scope of Practice Laws Impact Care (September 2018). Retrieved from

https://www.chcf.org>2018/09

Susanne J. Philips, DNP, APRN, FNP-BC-FAANP (January 2018). 30th Annual APRN Legislative Update. Improving Access to healthcare one time at a time. Retrieved from

https://www.ncbi,nlh.gov>pub

Main Response

Healthcare Regulations

As healthcare has evolved over the years, regulation has become a necessity. Regulation grew from the need to protect the public, by assuring that certain safeguards were in place. From guaranteeing that physicians and nurses are licensed and in good standing to defining the scope of practice, these regulations were born of good intentions. The Federal Government allows each state to create rules through agencies called boards. Members who have experience in the area they are governing, such licensed nurses, comprise each state board (Milstead & Short, 2019, p. 67).

In some states, Advanced Practice Nurses (APRN) have the authority to practice to the fullest extent of their knowledge without a physician’s oversight. Others require supervision, which adds to the cost of APRN services. As the “baby boomers” age, they utilize healthcare at an increased rate, straining the economics of Medicare (Laureate, 2018). Making use of APRNs, by allowing them to work independently, will increase access to healthcare and reduce the costs.

APRN Regulations: California VS. Oregon

While Oregon allows APRNs to practice in full scope without a physician’s supervision, California does not. The California Board of Registered Nurses requires that APRNs collaborate with a physician (Rn.ca.gov, 2020). As for attaining prescriptive authority, in California, one must complete a certification class and apply for a furnishing number and DEA number for controlled substances. All prescriptions must be authorized by the physician with whom the APRN works. The Oregon State Board of Nurses allows APRNs to order medications, including controlled substances, after submitting an application and showing proof of 45 hours of an APRN level pharmacology course (Sos.state.or.us, 2020). In Oregon APRNs can prescribe without supervision.

Benefits of APRNs with full scope of practice

With the passing of the Affordable Care Act, more people have insurance than ever before. However, having a primary care physician is often required to make appointments for everything, from general care to specialized care. Many poor or rural areas do not have enough physicians to take on this growing number of patients. In some states, Nurse Practitioners can help to fill the void. However, many states do not allow Nurse Practitioners to work independently to treat, write referrals, and prescribe medications. Changing the regulations in these states would help mitigate the lack of healthcare for vulnerable populations. In states where APRNs are mandated to work in collaboration with physicians increases the cost of health care. Federal law leaves the scope of practice details up to the state. States who allow Full Practice Authority (FNP) for APRNs have been shown to have lower ER visits, lower hospital admission, fewer controlled substances prescribed, lower healthcare costs, and provide greater access to healthcare (Bosse et al., 2017). As healthcare evolves, so should the laws and regulations. Advanced Practice Nurses need to be authorized to give the care of which they are safely capable.

Discussion: Professional Nursing and State-Level Regulations NURS 6050

References

Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Poghosyan, L. (2017). Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care. Nursing Outlook, 65(6), 761–765. doi:10.1016/j.outlook.2017.10.002

Laureate Education (Producer). (2018). Healthcare economics and financing [Video file]. Baltimore, MD: Author.

Milstead, J. A., & Short, N. M. (2019). Health policy and politics: A nurse’s guide (6th ed.). Chapter 4, pp. Burlington, MA: Jones & Bartlett Learning.

Sos.state.or.us. (2020). Oregon Secretary of State Administrative Rules. Retrieved 30 September 2020, from https://secure.sos.state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=264597.

Rn.ca.gov. (2020). Retrieved 30 September 2020, from https://www.rn.ca.gov/pdfs/regulations/npr-i-15.pdf.

RE: Discussion – Week 5
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Nurs 6050, Week 5 discussion, response 1.

I honestly just found out that APRN’s cannot practice independently in the State of California from your post. Apparently, California is 1 of 22 States that restricts NP’s from practicing independently. A large body of research has linked such restrictions to a lower supply of NPs, poorer access to care for state residents, lower use of primary care services, and greater rates of hospitalization and emergency department visits. “Although dozens of studies demonstrate that the quality of NP care is comparable to the quality of physician care, and that there is no difference in care when there is no physician oversight, proponents of scope of practice restrictions continue to argue that oversight is necessary for quality care” (Anon, 2018)

Having Nurse Practitioners practice independently could really help in addressing the shortage of primary care doctors in California, especially in the underserve communitie

References.

Anon, C. 2018. California’s Nurse Practitioners: How Scope of Practice Laws Impact Care – California Health Care Foundation, 2018)

Purpose

To apply lessons in nursing history to living nurses contributing to nursing history through an interview and recording of historical information

Course Outcomes

The Course Project enables the student to meet the following Course Outcomes:

CO 1.   Incorporate appropriate historical perspectives into current professional nursing practice. (PO #2)

CO 4.   Compare current professional nursing practice roles with historical roles of the nurse. (PO #7)

Points

The entire project is worth 600 points. Milestone 1 is worth 100 points of this total.

Due Date

Submit your completed NR390 Milestone 1 to its Dropbox by Sunday at 11:59 p.m. MT at the end of Week 1.

Requirements and Guidelines

  1. Nursing history is being made today by exemplary nurses throughout the world. Select one registered nurse who is creating nursing history to be the subject of this project. This RN must have at least 15 years of RN licensure. The nurse could be a family member, friend, colleague, acquaintance, manager, former instructor, or other nurse who is creating, delivering, or influencing the practice of nursing in your area. Do not select a former or current patient. Remember that a nurse does not have to create a nursing theory, write textbooks, or be the head of a nursing organization to make nursing history. The chief nurse executive who manages to deliver quality care in a small rural hospital with a tiny budget has a story worth telling. The nurse who served in the military has a story that is important to document as nursing history. The staff nurse who consistently provides high-quality care is making history. History is not merely the major accomplishments or events, but includes the activities nurses everywhere do in their nursing lives. Milestone 1 is due at the end of Week 1.
  2. Clearly explain to the selected nurse that statements made in the interview will be recorded (audio, video, and/or written) and submitted to instructor. The interview is not intended for public access.
  3. Obtain permission from the selected nurse to participate in an interview about his or her
    1. memories of nursing and nursing education;
    2. contributions to nursing; and
    3. persons or events that have influenced his or her nursing practice.
  4. Carefully review the Milestone 1 Grading Criteria and Grading Rubric. Complete only Milestone 1 requirements at this time.
  5. Download the Milestone 1 Template. Save it to your computer in Microsoft Word 2010 (or later) as a .docx file with the file name Your Last Name Milestone 1.docx. Type directly on your saved Milestone 1 Template. Submit your completed Milestone 1 as instructed by Sunday of Week 1.
  6. NOTE: Do not complete the interview at this time.

Grading Criteria

CategoryPoints%Description
Name of Selected Nurse1515%Provides first and last name of selected nurse with credentials.
Years Selected Nurse Has Been an RN1515%States the number of years the selected nurse has been an RN. Nurse must have held an RN license for at least 15 years.
Your Relationship With Selected Nurse2525%Describes details of your relationship with the selected nurse.
Why You Selected This Nurse4545%Explains details of why the selected nurse is making nursing history and was chosen as the subject of this Course Project.
Total100 points100% 

Grading Rubric

Assignment CriteriaA (100%)

 

Exceptional

 

Outstanding or highest level of performance

B (88%)

 

Exceeds

 

Very good or high level of performance

C (80%)

 

Meets

 

Competent or satisfactory level of performance

NI (38%)

 

Needs Improvement

Poor or failing level of performance

F (0%)

 

Developing

 

Unsatisfactory level of performance

Name of Selected Nurse

 

15 points

States first and last name of the selected nurse and credentials (example, BSN, RN, FNP, etc.). Explains the meaning for each credential (example, RN is registered nurse).

 

15 points ☐

States first and last name of the selected nurse and credentials but with no explanation for the credentials.

 

13 points ☐

States first AND last name of the selected nurse.

 

12 points ☐

State first OR last name of the selected nurse.

 

6 points ☐

Does not state names or credentials of the selected nurse.

 

0 points ☐

Years Selected Nurse Has Been an RN

 

15 points

Selects a nurse who has been an RN for at least 15. States specific number of years the selected nurse has been an RN.

 

15 points ☐

Selects a nurse who has been employed for at least 15 years, but not necessarily as an RN. States specific number of years selected nurse has been employed.

 

13 points ☐

States incorrectly the number of years selected nurse has been an RN. 12 points ☐Selects a nurse who has less than 15 years of experience as an RN.

 

6 points ☐

Does not state years the selected nurse has been an RN.

 

0 points ☐

Your Relationship With Selected Nurse

 

25 points

Clearly identifies the relationship of student to the selected nurse with details of length of relationship and circumstances.

 

25 points ☐

Mostly identifies the relationship of student to the selected nurse but generally describes the length of the relationship and/or the circumstances.

 

22 points ☐

Somewhat identifies relationship of student to the selected nurse but provides few details of the length of the relationship or the circumstances.

 

20 points ☐

Minimally identifies the relationship of student to the selected nurse and provides minimal details about the relationship.

 

10 points ☐

Does not clearly identify relationship of student to selected nurse and/or length of the relationship.

 

0 points ☐

Why You Selected This Nurse

 

45 points

Clearly explains details about why this nurse was selected.

 

45 points ☐

Mostly explains details about why this nurse was selected.

 

40 points ☐

Somewhat explains details about why this nurse was selected.

 

36 points ☐

Minimally explains details about why this nurse was selected.

 

17 points ☐

No information provided as to why this nurse was selected.

 

0 points ☐

Total Points Possible = 100 points

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