A public relations specialist in Chicago, recently recounted a 2 a.m. visit to a chain pharmacy in his home city. His son had a severe earache and rather than wait in an ER for an hour or two, he, his wife and son headed to a national pharmacy chain where a nurse practitioner (NP) was on duty. The NP examined his son and made the determination that he had an ear infection, prescribed some antibiotics and they were on their way. But the story didn’t end there. “When my wife mentioned it to our family doctor, he was livid,” he recalls. “He was on the phone and yelling so much that my wife just walked over and handed me the phone.”

It seems the doctor’s fury was based on his perception that the NP shouldn’t have been examining the boy—and it’s a perception shared my many doctors who believe NPs are not qualified to diagnose or prescribe a treatment. However, that perception is just one of the arguments presented by those opposed to allowing NPs more autonomy and one that the nurses are working hard to combat.

Decades in the making
The role of an NP was established in the mid 1960s. Loretta Ford, a registered nurse, and Henry Silver, a pediatrician, founded a master’s level program at the University of Colorado’s School of Nursing. Ford and Silver created the program at a time when there was a shortage of health care services across the country.

Although NPs focused at first on pediatric care, today, the scope of practice has expanded to provide additional competencies and areas of focus with family practice, psychiatric-mental health, gerontology and midwifery.

Proponents of providing greater independence for these professionals are circling back to the reason the profession was created in the first place — a shortage of health care services for a population with growing needs for them.

Fifty years after the first NPs graduated, the U.S. is again looking at dire health care provisions. With the baby boomers getting to the age where more care will be needed, and with life expectancy also up, the country could see shortages of care for decades to come. Couple the increased need for care with dwindling tax revenue as a large portion of the population heads into retirement and it’s apparent any stop-gaps will be difficult to fund. Unfortunately, the bad news doesn’t end there. The final piece to the health care house of cards also goes back to the shortage of the ‘60s. Many of the professionals who jumped into the health care field during that time can be counted among the number of those retiring.

All these points are what help to make the case for the expanded recognition for NPs, the push to let them practice independently and the increased recruiting efforts to fill the ranks. While NPs can legally practice in every state in the country, their level of independence differs as they cross state borders. That is a situation that some, including health care experts and politicians, take exception to.

Physician oversight and physicians out of sight
The difference between a state where nurse practitioners are able to fully practice and those where they have reduced ability is significant, with the differences between reduced practice states and restricted being less so.



Even in full practice states, it’s not as easy as hanging up a shingle and opening doors for business though. “When you apply in an unrestricted state, you have to convince them you’re comfortable with all the additional responsibility that entails” says Rodney Hicks, professor at Western University of Health Sciences.

In part, the additional responsibility translates to knowing when to refer a patient to a qualified health care provider, acknowledging limitations in training, but also being able to perform up to their level of training.

However, with the requirements being established on a state level rather than a federal level, what meets the needs in one state may not pass muster crossing into a neighboring state. All states require an RN license, some require national certification, others require an advanced degree and some require all that and more. The Board of Nursing, the Board of Medical Examiners and Board of Medicine all having jurisdiction over nurse practitioners and in some states, more than one regulatory agency has a say.

However, that may change in the near future beginning with nurse practitioners graduating after 2015 who will be required to hold a Doctor in Nursing Practice Masters degree.

Although agency oversight and practice qualifications present challenges, the main gripe from NPs has to do with physician oversight. While the profession is currently free of oversight requirements in 17 states plus
D.C., the majority of states have reduced practice statutes, with 12 having restricted practices — California being a particular standout as the only western state to fall into that category.

In states where it’s a requirement, physician oversight requires the nurse to basically obtain a sponsor to allow him or her to practice. The sponsor, typically a family practitioner, may have to do as little as signing a letter stating the sponsor relationship. In other states, the nurse must check in with the physician, updating them on patient interaction, but that’s not the norm. “Physician oversight varies from state to state,” says Reid Blackwelder, president of the American Academy of Family Physicians. “In many cases, oversight does not require the physician and nurse to be in the same building,” he says.

However, nurses performing their duties from outside of a physician’s practice can run afoul of other requirements. Some physicians may be barred by their malpractice liability insurer from entering into an agreement unless the NP is actually working within their practice.

With the loose structure and minimal oversight, a common assumption is that the dust up is due to bruised egos, but that’s not the case according to Tay Kopanos, vice president of State Government Affairs for the American Association of Nurse Practitioners. She says the requirements needlessly put stress on nurse practitioners especially with certain aspects of the requirements completely beyond their control. “If a physician retires, sells his or her practice, is disciplined by the medical board and loses their license, for instance, even if it has nothing to do with the nurse practitioner, that oversight requirement is no longer being met,” she says. Kopanos acknowledges that physicians can also pull their agreement for other reasons without having to provide justification.

Semantics generating the mess we’re in?
For the nurse, there’s generally little benefit unless a patient’s needs are beyond the scope of practice the nurse has been trained to handle. “Any person in independent practice will develop a referral network,” says Hicks.

NPs need to make connections with family physicians and specialists and know who to send a patient to and when they should be sent, says Hicks. For their part, doctors aren’t required to take the referrals, so in order to have the ability to refer patients, the NPs have to have social skills that expand beyond their clientele.

Referrals are an area Blackwelder is concerned about. “For some, when a patient arrives with a heart issue, they might be referred to a cardiac specialist immediately,” he says. “But as a family practitioner, we’re often able to handle those issues.”

Blackwelder says that although heart issues may be beyond the scope of practice for NPs, they can often be addressed by family physicians.

Still, he is reluctant to get into a debate about NP independence and feels it’s an issue health care professionals need to move beyond. “What we’re learning through different practice models is that it’s all about team-based care,” he says. “Our focus needs to be about adopting the best care.”

In that at least, Hicks agrees. “Providing effective health care requires the right treatment at the right time, for the right cost in the right place,” he says.

Whether the “right person” will be a nurse practitioner or some other health care professional still remains to be seen.