By Emily J. Tipping

Pa. state Rep. Patricia H. Vance

Published May 2000

• Advancing the battle for nursing autonomy

• Balancing nursing autonomy with quality of care

• React to this article in the Discussion Forum.

More than 20 years after the state passed a law allowing certified registered nurse practitioners (CRNPs) to prescribe and dispense medications without a physician’s signature, the state boards of nursing and medicine have ratified the regulations that will put the law into effect.

The catalyst for the March approvals from the boards was House Bill 50, legislation that sought to place CRNPs and all nurses under the sole authority of the Board of Nursing and not the dual authority of that board and the Board of Medicine.

In light of this initial regulatory approval—the regs now go to the Independent Regulatory Review Commission and the Professional Licensure Committees in the House and the Senate—House Bill 50 is presumed dead.

But the implications of the bill’s rapid groundswell of support—and the resulting turf war that made clear physicians’ resistance to broadened scope of practice for nurses—are expected to live on.

The Board of Nursing’s approval of the regulations is contingent upon the Board of Medicine including omitted groups of medications—including eye, ear, nose and throat medications and hormones—in the overall formulary open to CRNPs. Under the regulations approved by the nursing and medicine boards, a CRNP can prescribe and dispense drugs:

• If the CRNP completes a 45-hour, advanced pharmacology course.

• Only under a signed, written collaborative agreement with a physician that, among other things, provides for a substitute physician if necessary, identifies the categories of drugs from which the CRNP may prescribe and specifies the amount of liability insurance carried by the CRNP. Physicians are limited to working under agreement with two CRNPs at any given time.

The original version of HB 50 proposed broader changes:

• A new definition of the basic practice of professional nursing.

• Prescriptive and dispensing power for CRNPs as well as elimination of the dual licensing requirements for those and other advanced practice nurses.

• Establishment of an advisory council composed of nurses and consumers to draft and recommend for the Board of Nursing’s approval rules and regulations for the practice of CRNPs, nurse anesthetists and nurse specialists.

The Alliance of Advanced Nurse Practitioners got little response to its proposed amendments to HB 50 that would have required CRNPs and certified clinical nurse specialists to pursue continuing education, obtain malpractice insurance and collaborate under written agreement with a physician in order to prescribe medication. The amendment also proposed that the scope of practice of non-specialty registered nurses remain as it is under current law, and eliminated an advisory council.

"Will this issue go away? No. Do I understand that the legislative process is incremental? Yes," said state Rep. Patricia H. Vance (R-Cumberland), who introduced HB 50. If nothing else, Vance said, the bill made the Board of Medicine revisit regulations that had sat for 25 years.

But Vance and many nursing advocates are unhappy with the current regulations as ratified by the nursing board. Wording has been changed to require CRNPs who want prescriptive power to complete, not 30 hours of pharmacology courses, but a 45-hour course in pharmacology. Vance said continuing education is not the issue, but that having to complete such a course at one time could prove too costly and time-consuming for working CRNPs.

A provision in the regulations that limits to two the number of CRNPs who can collaborate with one physician could negatively impact women’s access to health care, Vance said.

"The argument is that unscrupulous doctors will be out playing golf and letting CRNPs do the work. I don’t think that’s a good example, for one, but the important issue is that most women’s health clinics are staffed by CRNPs who work part-time or even one day a week," she said.

Only two states out of the 46 that allow nurses to prescribe set similar limits, Vance said, and both limit physicians to working with five CRNPs.

Don McCoy, director of policy and regulatory affairs for the Pennsylvania Medical Society, called the maintenance and clarification of the collaborative agreement between physicians and CRNPs the most significant component of the ratified regulations. Also of crucial importance to PMS, which launched a strong lobby against HB 50, is retention of the dual authority of the boards of medicine and nursing.

Both boards, McCoy said, heard and addressed PMS concerns about the proposed regulations. McCoy suggested it might be helpful for the boards to come up with a template or model collaborative agreement to avoid interpretation problems later.

Physicians, so far, have been supportive of what PMS has done, said McCoy. The Society supported the regulations because "they retained joint promulgation and the collaborative agreement," he said, adding that he sees no negative impact of the regulations. Under the state Medical Practice Act, he said, physicians can delegate prescriptive authority to any practitioner they feel is qualified and that they are willing to take responsibility for, so in some instances nurse practitioners already are writing prescriptions without a doctor’s signature.

Not all physician groups agree with the stance PMS has taken.

Ernie Gelb, D.O., who testified against HB 50 on behalf of the Pennsylvania Osteopathic Medical Association, said he thinks PMS should have pushed for even more stringent regulations. Gelb said the Association’s position is that physician extenders should not be allowed to practice medicine without direct supervision, and a collaborative agreement "between a physician and a nurse practitioner that might be 20 miles away isn’t good enough."

PMS initially had submitted concerns about HB 50 in an effort to amend that legislation, Gelb said, but he and the Osteopathic Medical Association truly opposed the bill.

"I think prescriptive rights are inappropriate," he said.

Gwen Lehman, executive director of the Pennsylvania Psychiatric Society in Harrisburg, said while her group opposed HB 50 because it would have taken control from the Board of Medicine, it supports the current regulations as "a responsible way to regulate under current law."

McCoy said HB 50 could have raised patient safety issues by "giving the nursing board authority and changing the definition of practice so the profession could have set its own standards and rubberstamped them with no opportunity for the Board of Medicine to object."

Jessie Rohner, RN, DrPH, executive administrator for the Pennsylvania State Nurses Association, said the main goal of HB 50 was to get CRNPs and all of nursing under the sole authority of the Board of Nursing, as is done in all but eight other states. Prescription rights were secondary.

Despite concerns of the medical establishment, which Rohner said "had everyone tap dancing, saying nurses wanted to do brain surgery," HB 50 gained unexpected steam. Rohner credited a grass roots movement of nurses; nearly 300 nurses rallied in Harrisburg last March to support the bill, and a second Lobby Day this past March coincided with publication of editorials in the Pittsburgh Post-Gazette, Philadelphia Inquirer and Harrisburg Patriot-News supporting HB 50 and decrying the need for dual board authority over CRNPs.

In the end, said a lobbyist for the bill who asked not to be identified, the nursing lobby was no match for the money and political clout of PMS, and many supporters of the bill were caught off guard by the Board of Nursing’s vote to ratify the regulations.

McCoy said PMS succeeded in its efforts because it offered a solution instead of simply opposing HB 50. State Physician General Robert S. Muscalus, D.O. who sits on the Board of Medicine, was instrumental in addressing physician concerns, said McCoy.

"It’s my belief he also had some communication with the Board of Nursing," McCoy said.

Pressure created by HB 50 provided the solution—getting the two boards to work together toward ratifying existing regulations.

But Rohner said the most recent version of the regulations is more prohibitive than existing law because of the two-to-one CRNP-physician limit. Physicians are able to apply for a waiver to the limit under the proposed regulations, but Rohner wondered who will decide on waiver applications and how long they would take to be processed. Once CRNPs begin writing their own prescriptions, Rohner said they will be able to see more patients.

One provision of HB 50 that the Pennsylvania State Nurses Association plans to continue pursuing through legislation, Rohner said, is title recognition for clinical nurse specialists. That group is authorized to practice through 1986 third-party reimbursement legislation, but is recognized nowhere else in state statues.

As for expanding the scope of nursing practice, Rohner said the profession will continue to broaden itself, as most professions do. No matter how nurses expand their duties, she pointed out, there should be, and always will be, things outside the scope of nursing.

"Medicine has been assaulted by optometrists, psychologists and CRNPs, wanting to prescribe. There’s some real belief that their scope of practice is being eroded," said Rohner. "It’s not unreasonable for them to think that way. But what would be a more reasonable approach is to say there are people who need health care, there’s room for everyone, and let’s be a team of professionals and deliver the best care we can."