Explain ways of Overcoming Barriers to Full APRN Practice
The Idaho Story
Margaret Wainwright Henbest, Sandra Evans, Randall Steven Hudspeth
“There is nothing more difficult to take in hand, more perilous to conduct, or more certain in its success, than to take the lead in the introduction of a new order of things.”
I (Margaret Henbest) was a licensed and practicing certified pediatric nurse practitioner (CPNP) when our family moved from Oregon to Idaho in 1986, 15 years after Idaho first began licensing nurse practitioners (NPs). When I came to Idaho, I experienced firsthand the restrictions that this early enabling legislation had created, then in 1996 became involved in changing them as a Representative in the Idaho State Legislature. It was only with the cooperation of other legislators, organizations, and leaders in nursing that ultimately an autonomous and full scope of practice was achieved in 2006. Sandy Evans, Executive Director of the Idaho Board of Nursing (IBN), played a significant leadership role on behalf of the IBN in 1998. Randy Hudspeth, Director of Patient Care at St. Alphonsus Regional Medical Center, followed by creating a vision, and then organizing and galvanizing the NP community to action in 2003.
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Idaho has a long history of NP practice recognition beginning in 1971 when Idaho became the first state to license NPs. During the ensuing 40 years, the state circled from being an early adopter of the role to one of the most restrictive and then back to being one of the most progressive nationally. This story chronicles that work and highlights the critical importance of professional and legislative leadership, perseverance, collaboration, compromise, and relationship building, all instrumental in achieving legislative success.
In the late 1960s and early 1970s, the emergence of the NP role in other states also received attention in Idaho as a means to improve rural access to health care. Supportive physicians, nurses, and citizens recruited two registered nurses (RNs) to complete the certificate NP program at Stanford University in 1971. The IBN and the Idaho Board of Medicine (BOM) came together as partners to design a mechanism to license and regulate this new professional entity, subsequently drafting a bill that created a dual regulatory framework for NP licensure. This meant the boards would jointly write the specific regulations that would apply to licensed NP practice. Regulations interpret the law and provide specificity that otherwise would be cumbersome in statute, and have the advantage of being much more adaptable to change. Regulations in most states are written and revised with the approval of the Governor and Attorney General. In Idaho, regulations must also be approved by the Legislature. This initial NP legislation was shepherded through the process by two legislators, one an RN and one a physician. Idaho was in the forefront nationally in the regulation of this new role with no experience to act as a guide. Controversy between the boards quickly emerged related to NP scope of practice and prescriptive authority. Overcoming Barriers to Full APRN Practice.
FIGURE 68-1 Margaret Henbest, MSN, APRN-CNP. (Photo courtesy of the author.)
Nurturing the Passion to Achieve Statutory Change
After moving to Boise, I was readily granted an Idaho RN license, but I could not be licensed as an NP without the endorsement of a physician and the completion of an interview by the BOM, both requirements put in place through the joint rule-making process. In 1992, I joined with other NPs across Idaho who were frustrated by the stifling regulatory environment and recognized that access to health care for the underserved could be improved through a stronger and empowered NP workforce. As a group, we worked to introduce legislation to remove the dual regulation of NPs in Idaho, freeing the IBN alone to write rules for NP licensure and practice. Although the legislative effort was coordinated, and the NP community robustly engaged in lobbying legislators, the bill was defeated by a tie vote along partisan lines. Regrouping in the aftermath of defeat, a concerted effort was made to ensure that from that point forward, NPs were included in forums and discussions related to health care policy and that citizens and legislators had an accurate understanding of the role and preparation of NPs. This was accomplished over the ensuing years by putting ourselves in the room and at the table of health care discussions. We did not wait for invitations. In addition, a brochure and video was created and disseminated to all legislators explaining the preparation and role of the NP.
My growing immersion in Idaho health care politics made me realize the importance of getting personally involved in the political process to achieve change. I sought election to the Idaho House of Representatives in 1996 and won, defeating a three-term incumbent by seven votes, never to forget again that every vote counts. I served for 12 years.
Building Broad Coalitions and Relationships
Evolutionary changes to NP practice and general changes to nursing education curricula required the IBN to make major revisions to the act in 1998. The legislation, which was to become H445, removed the authority of the BOM to promulgate rules jointly with the IBN, defined the advanced practice professional nurse (APPN), and created a broad collaborative scope of practice for APPNs. (APPN was the first title used for the advanced practice registered nurse [APRN] in Idaho. When Idaho adopted the Consensus Model, it changed it to APRN.) In preparation for introducing the 1998 legislation, the IBN, led by Executive Director, Sandy Evans, worked with a broad coalition of interested nurses, physicians, health care organizations, citizens, and citizen organizations. The effort was funded by a grant from the American Nurses Association. The committee hosted a reception for legislators, distributed a press release, and published educational materials. As a legislator and finally a practicing NP, I was approached and agreed to be the House sponsor of H445. It was my opportunity to effect the changes that I sought so many years before.
Legislators have an aversion to interprofessional conflict. They label them “turf wars,” recognizing them for what they often are: attempts to control trade and commerce, which may or may not be in the best interest of the public. H445 was referred to a subcommittee for further deliberations and
negotiations, a strategic way to handle this conflict. Compromise was the inevitable and also desired outcome by legislators as it was the only means to save face and maintain relationships with both professions and constituents. The IBN entered negotiations focused on preserving four key points: (1) sole authority to promulgate rules; (2) APPN prescriptive authority for all classes of drugs consistent with nationally defined scope of practice for category and specialty; (3) requirement for a collaborative or consultative relationship with other providers; and (4) licensure based on established qualification, education, and demonstrated competence. The BOM and the Idaho Medicine Association (IMA) continued to demand dual promulgation of the rules for NPs and physician supervision. As a compromise, a new bill was written which removed the dual promulgation of rule making, but added language specifying that the APPN would practice with physician supervision, consultation, and collaborative management. This created a five-member Advanced Practice Advisory Committee to the IBN composed of two NPs, two physicians, and one pharmacist. The IBN had included physicians in the regulation of NPs in an advisory capacity only. With the assistance of three Senate sponsors, two of whom were nurses, the compromise legislation, H662, passed both houses unanimously and was signed into law by the Governor.
Sustaining the Effort and the Vision
It seemed as if progress would be won or lost in the course of continuous skirmishes. After the legislation passed, the IBN began to promulgate new draft rules that for the first time it alone could write. The rules themselves were then opposed by the IMA because they did not require a specific supervising physician, a signed agreement with a physician, or direct physical supervision. Legislative leadership urged compromise on the rules, and during the following 1999 session, the amended rules were adopted over the continued objections of the IMA and BOM. It was becoming clear to me our early and continuous education of legislators was paying off. Policymakers understood what APPNs did, who they were, and what it meant for improved access to care. Nursing had made significant political progress since 1992.Overcoming Barriers to Full APRN Practice
Removing Barriers to Autonomous APRN Practice
By 2003, however, it was apparent that there were unintended consequences from the passage of H662 in 1998. Both physicians and NPs had begun to question the strength and effectiveness of supervisory relationships that were separated in some cases by as much as 100 or more mountainous miles. Both physicians and NPs were concerned that supervision exposed them to increased liability. Clinical nurse specialists (CNSs), commonly employed by hospitals, were required to have supervision under the law, but in practice routinely did not. Finally, the departure of a supervising physician could result in a sudden interruption of APPN-delivered patient services. Legislation is written to solve problems, and it was now clear that there was a problem in need of a solution and that quality and access to care had not been compromised since 1998.
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In an APPN practice meeting, Randy Hudspeth and others in attendance recognized that these problems had created an opportunity to remove the last barrier to autonomous practice: supervision. A workgroup was created, and the keys to success again would be leadership, coordination, communication, and leveraging of relationships and resources.
The NPs of Idaho assumed the lead. The IBN was supportive, as were physicians who worked with APPNs in the federally qualified health centers and hospitals, and citizens who appreciated the access and care that APPNs provided in their communities. A lobbyist with experience in health care was hired, and the representation of a well-respected and connected attorney secured. The attorney drafted the legislative language, which became H659, and I was one of two NP sponsors of the legislation. Together, the two of us represented both political parties and both houses of the Legislature. We recognized that nothing would be possible without compromise. However, the political
environment was shifting; APPNs were significantly better known and valued than a decade and half before, and access to health care was becoming increasingly a critical issue as the uninsured rate in Idaho climbed to 16% to 20%.
The Stars Align
The legislative process from introduction, testimony, and floor debate to final passage lasted about 4 weeks. The committee heard about remote practices where NPs provided the only care available. They heard about physicians being paid $5000 to do monthly chart reviews. They heard about CNSs who were required to be supervised even though much of their practice was more nursing than medicine. They heard sometimes confusing and conflicting testimony from physicians. We were asked once again to meet and work out a compromise, a strategy that we were prepared for. I met with the IMA representative and the discussion centered around organized medicine’s interest in ensuring a standard of APPN care in the absence of physician supervision. At the end of our meeting, we agreed that providing for collaboration with other health care providers and peer review in the statute would ensure professional standards of practice. It was a natural compromise from my perspective. As practitioners it was our responsibility to make sure we worked as a team with others as necessary to provide the wide array of services and expertise our patients needed, and if we could not subject ourselves to the transparent review of our peers, something was wrong. Compromise had been reached.Overcoming Barriers to Full APRN Practice
Again, grassroots lobbying was effective as NPs from each district personally contacted their legislators by e-mail, by phone, or in person. Votes were counted and legislators were personally lobbied. At the end of the 4 weeks, the bill to revise the Nurse Practice Act (NPA) and remove supervision was amended with the compromise wording. H659 passed both Houses by a large majority despite continued objections from the IMA. The rules created by the IBN in the interim, and which passed the following year, required that documentation of a peer-review process would be available to the IBN upon request, and a signed collaborative agreement with a physician would not be required.
The 2012 NPA Revision
After the Consensus Model was released by the National Council of State Boards of Nursing and the 2011 Institute of Medicine report The Future of Nursing called for nurses to work to the full extent of their education, Idaho was poised to adopt the model legislation. The foundation had been laid, and the Idaho Consensus Model Legislation, S1273, introduced in 2012, required only minor changes to the NPA. The IMA requested one change to the draft, that the make-up of the Advanced Practice Advisory Committee would remain equally representative of APRNs and physicians, and then took a neutral position on the legislation, paving the way for its smooth passage.
Although some would consider collaborative language and the creation of an advisory board related to APRN practice a dilution of independent NPA strength, I believe the path Idaho took was visionary. The redesign of health care in the United States places a priority on population health and paying for value, not volume. This can only be achieved effectively through enhanced interprofessional communication and coordination. Idaho has honored this by keeping our physician colleagues at the table of the APRN regulatory discussion and by acknowledging the need for us to collaborate with other health professionals to provide the best care for our patients.
For Idaho, an incremental approach contributed to our success. However, there is no doubt in my mind that the consistent, compelling, and truthful argument that APRNs could help to alleviate serious access to care issues in Idaho impressed legislators who had been intentionally and carefully educated about the role of the APRN. I believe that coordinated advocacy, citizen activism, leadership, nurses assuming key policymaking roles, compromise, and persistence can and will win the day. Overcoming Barriers to Full APRN Practice.