By Jennifer Decker Arevalo, MA, contributor

Feb. 2, 2010 - As the debate over clinicians’ scope of practice continues, it is increasingly clear that some type of “meeting of the minds” is needed between physicians and non-physicians for the good of the patient. Both want the same thing, but accomplishing what is best for the patient is often mired in the logistics of state law as to who should or should not provide care.

Take, for example, advance practice registered nurses (APRNs) and primary care physicians (PCPs) in Ohio. House Bill 198, which would create patient-centered medical home (PCMH) pilot projects, has stalled as these two groups, along with their respective licensing boards, try to determine if APRNs can lead a PCMH. With a statewide shortage of PCPs, the Ohio Association of Advanced Practice Nurses (OAAPN) is pushing to allow APRN-led medical homes, but the Ohio State Medical Association has opposed this indicating that nurses must have a collaborative relationship with a delegating physician.

“We expect to be held to the same standards and outcomes as physicians,” said Keeley Harding MS, CRNP, legislative co-chair of the OAAPN.

Nationwide physician shortages, along with an aging population and escalating healthcare costs, are some reasons why all healthcare professionals are essential in order to advance the health and well-being of patients, according to the Coalition for Patient Rights (CPR). 

CPR represents a variety of licensed healthcare professionals and is trying to offset efforts by the Federation of State Medical Boards and the American Medical Association’s (AMA) Scope of Practice Partnership (SOPP) that CPR believes was designed to limit patients’ choice of health practitioners.

The AMA feels strongly that the SOPP, which studies the qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review of limited licensure healthcare providers, is necessary to ensure patient safety. 

Additionally, the AMA plans to establish state scope-of-practice review panels, composed of various regulatory board officials, university experts and other healthcare advisers to evaluate plans by non-physicians wishing to expand their practice realm and to advise lawmakers about the underlying medical, educational, and public interest considerations.

Finding common ground

Organized medicine believes that the health and safety of patients are threatened when non-physicians are permitted to perform services that are not commensurate with their education or training.

However, the American College of Physicians, in its recent Nurse Practitioners in Primary Care policy monograph states that nurse practitioners, as well as physicians, must play critical roles in improving access to patient-centered healthcare. Both groups must work together as teammates, with mutual respect for the unique contributions and skills offered by each profession, according to the new policy.

The change in tone is not only based on need, but also on the fact that the responsibilities of NPs have changed over the years.

“There is a growing acceptance of the APRN role, not only by patients, but by colleagues, employers, legislators and regulators,” said Harding. “Nationwide, we have seen a slow but promising removal of barriers to APRN practice.” These include improvements in reimbursement, changes in state laws, increases in the hiring of APRNs, improvements in physician and APRN relationships, and advancements in the entry level/educational preparation for APRNs due to the Doctor of Nursing Practice (DNP) degree.

Although the basic role of physician assistants (PAs) has remained quite constant, there are two areas of change, according to Stephen Hanson, MPA, PA-C, president of the American Academy of Physician Assistants (AAPA).

“State laws are changing to allow PAs to be more effective team members,” said Hanson. “For example, all states now authorize PAs to prescribe, and in 48 states, physicians may delegate prescriptive authority for legend drugs and controlled medications to PAs. We are also seeing PAs utilized in an increasing number of specialties and settings. Just last year, Connecticut passed legislation adding PAs to the law governing neonatal transport teams.”

All of this comes at a critical time as a new era of debate on healthcare reform is sweeping the country, according to a recent report, Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations, published by the National Council of State Boards of Nursing (NCSBN).  The report is designed to help policy makers charged with consumer protection determine how to maximize the use of all healthcare practitioners in order to deliver the most effective and efficient care to Americans.

“Within healthcare reform, there are no foreseeable changes in our scope of practice,” said Harding. “However, in order to provide affordable care and meet demands, states will need to change their laws to decrease existing barriers to APRN practice.” 

A new consensus model, endorsed by the NCSBN, standardizes APRN regulation nationwide within the framework of four areas—education, accreditation, certification, and licensure—and has helped to position APRNs as an integral participant in healthcare reform.

“These standards protect the public, improve mobility, and improve access to safe, quality APRN care,” said Joan Stanley, Ph.D., senior director of education policy for the American Association of Colleges of Nursing. A successful transformation of the nation’s health system will require utilization of all clinicians, particularly primary care providers, to the full extent of their education and scope of practice, stated Stanley in her article, “Positioning Advanced Practice Registered Nurses for Health Care Reform: Consensus on APRN Regulation,” published in the Journal of Professional Nursing.

How can these various healthcare professionals come together for the good of the patient?

“Lifelong inter-professional education is one way,” said Stanley. “It has been shown to improve quality of care, communication and understanding among professionals regarding their practices.”

The AAPA has developed resources to foster communication within the physician/PA practice team. “For instance, a team practice evaluation template and updated guidance for employers on how to successfully integrate PAs within an existing practice are available,” said Hanson. “Both of these would be of interest to healthcare managers concerned with maximizing physician and non-physician effectiveness.”

Harding told AMN Healthcare, “We think clear role responsibilities and expectations are important. Educating physician and nursing staff on the role and scope of practice of the APRN is key.”

Clinicians can find common ground in scope-of-practice discussions if they continue to put patients come first. Each healthcare professional contributes an essential blend of skills and experience, which sometimes overlap, and in order to achieve the highest quality patient care, all must work together to ensure quality, accessibility, affordability and sustainability of care.

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