By Christopher Guadagnino, Ph.D.

Published September 2000

• Nurse prescribing regulations, Part I:
  Regulations need to be less restrictive
  

• Nursing scope of practice regulations (May 2000)
  

• Advancing the battle for nursing autonomy (Oct 1999)
  

• React to this article in the Discussion Forum.

Carol E. Rose, M.D., is president-elect of the Pennsylvania Medical Society (PMS). Dr. Rose is an anesthesiologist and assistant professor of Anesthesia at University of Pittsburgh Medical Center.

In mid-July, Pennsylvania’s Independent Regulatory Review Commission (IRRC) disapproved by a 3-2 vote regulations jointly promulgated by the boards of Medicine and Nursing regarding prescriptive authority for nurse practitioners in Pa.

PND: What is your understanding of the status of the nurse prescribing regulations jointly promulgated by the boards of Medicine and Nursing?

CER: Currently they are in abeyance because the IRRC has turned them down. Once IRRC issues their formal statement, the joint board has seven days to respond.

PND: Were you surprised by the IRRC’s decision?

CER: I was surprised and disappointed because citizens of the state and the nurse practitioners need to have meaningful regulations. However, I think that it gives the joint board a good opportunity to make the regulations even better than they were as originally proposed.

PND: The joint board ultimately included a 45-hour pharmacology course and a two-to-one nurse-to-physician ratio requirement. How was the PMS able to influence the Board of Nursing to agree to that?

CER: We at PMS were not able to influence the Board of Nursing. It really was between the nursing board and the medical board to come to that agreement. I was delighted that the Board of Nursing and the Board of Medicine finally came to terms and I was kind of surprised at the tight, two-to-one control and that the nursing board agreed to it.

PND: In the wake of IRRC’s rejection, what revisions to the regulations will PMS support?

CER: We believe that they should be putting in a four-to-one ratio. There also needs to be a further explanation about what we mean by four-to-one. We believe that a physician should be able to work in such a manner as to supervise the full time equivalent (FTE) of four nurse practitioners because there are many nurse practitioners who do not practice full time. Or perhaps they practice full time as nurses but their work as nurse practitioners, for which they would need to prescribe, is not full time. Therefore, allowing a physician only to collaborate with four nurse practitioners, ever, is unrealistic. We certainly don’t believe that a physician should supervise 16 nurse practitioners all working at once. But a physician whose office is heavily invested in nurse practitioners could have 16 nurse practitioners all working part-time but should be able to supervise a maximum of four at any one time. The two-to-one ratio was drafted with wording allowing a higher number to be approved through a waiver. I think that was intending to accomplish the same thing, but regulations get interpreted depending on who’s reading them. It’s conceivable you could ask for a waiver today and not get your waiver for three months. So the regulations need to be clear, concise and easy to follow up front. And perhaps that’s where the nurse practitioner objections were coming from, and I think that’s appropriate.

PND: Are there any other revisions to the regulations that PMS will be advocating?

CER: The other issue is the pharmacology course credit requirement. I believe that the final draft of the regulations was written in such a manner that it’s hard to interpret whether nurses have to get those credits before they can get their certificate. Can they get their certificate and then fulfill the requirement over a certain amount of time? Where will they get those continuing education credits? How much of it can they claim because of various experiences or courses that they have taken? That needs to be clarified because it takes a long time to get 45 credit hours in any profession. It means going to one really heavy-duty course for one entire week, which many people can’t do no matter what their profession. Or going to many long weekend courses. Or doing a lot of home study. There are many nurse practitioners that may already have some of those equivalent credits from other courses that they’ve already taken. So I think that the regulations need to be written a little bit more clearly. It’s my understanding that the regulations would have permitted those nurse practitioners who became certified since 1992 to have already met those requirements, because in 1992 the education required for nurse practitioner certification changed and it included that kind of study in pharmacology.

PND: The regulations that were voted down by IRRC would not have required additional pharmacology course credits for those nurse practitioners?

CER: Right. For about 3,000 of the 5,000 of nurse practitioners in the state. But, of the 2,000 who were not exempt, who would have to go back and take courses, the exact manner in which they could obtain those CME credits needed to be spelled out a little bit better because I believe there are some that probably already have some of those credits. There is, from what I understand, a national organization of nurse practitioners that has some national standards. If there is a well-written national standard, then perhaps Pennsylvania’s joint board would benefit from using that national standard. For example, when I passed my boards given by the American Board of Anesthesiologists, I had the equivalent of 150 CME credits, even though the board itself does not issue continuing medical education. The PMS requires its members to have, every three years, 150 CME credits. That’s probably the kind of thing the nurses are promoting and I think it’s probably a good idea. The joint board should be able to research that well enough to get it properly written in the regulations.

PND: It sounds like you’re in agreement with two of the primary objections of the nurse practitioners.

CER: Absolutely. And I think that’s a good position to be in. I don’t think that the medical society and the group of advanced practice nurses need to be adversarial. We are interested in seeing the nurse practitioners have meaningful regulations so that they can write prescriptions in a manner that’s acceptable to both groups.

PND: If the PMS did not object to these modifications in the regulations, why weren’t they part of the version that went to IRRC?

CER: That is a political question. Prior to the addition of a two-to-one supervision ratio, we did give testimony and also wrote a letter to the board saying that four-to-one was okay with us.

PND: Did the PMS say anything about alternatives to the 45-hour course before the final draft of regulations emerged?

CER: No, we did not.

PND: The nurses also objected to what they regard as the lack of an adequate definition in the regulations of what constitutes a collaborative agreement. They maintain that the regulations assume a single supervisory model of care that does not allow flexibility for other models of care.

CER: If the nurses are saying that, within the context of the current regulations, some kinds of collaborative arrangements are unworkable, I would have to see the wording that they’re suggesting to say whether or not the PMS could endorse it. I also would not be able to understand why we would say no. We want to allow reasonable, responsible, collaborative arrangements between physicians and nurse practitioners such that the physician is still in the picture.

PND: It appears that the nurses plan to pursue the agenda of Rep. Vance’s HB 50, seeking to make the Board of Nursing an autonomous agency rather than being tethered to the Board of Medicine for CRNP licensure. What is your view of that agenda?

CER: The Board of Nursing and the Board of Medicine are only tethered through the nurse practitioners because they are indeed separate and on their own. It is still the PMS’s policy that the nurse practitioners need to be under the joint board. There has to be the right kind of relationship between the physician and the nurse, and there are responsibilities that the physician has to the nurse and to the patient that makes the joint relationship appropriate. It’s conceivable that, if they were separated and if there weren’t these appropriate regulations for the numbers of nurse practitioners that any physician could supervise at any one time, you could have nurse practitioners mills, perhaps under the supervision of a physician running the mill in an inappropriate manner. So the medical board needs to be involved in how a physician supervises the nurse practitioner and it has to be done appropriately.

PND: A second item not addressed by the regulations but still on the nurse practitioner agenda is to include in the definition of advanced practice nurses certified nurse practitioners, certified registered nurse anesthetists and certified nurse specialists.

CER: We’re also opposed to that. They’re not the same. They have different kinds of training. They have different backgrounds. They have different methods of practice. Nurse practitioners are the only ones among those three types of advanced practice nurses that are under the supervision of the joint boards. The way we read the Vance Bill is that it just about gave independent practice to all three kinds of advanced practice nurses. We are very much opposed to that. If nurses want to become doctors, they should go to medical school. House Bill 50 permitted those groups of nurses to do so much that it was the practice of medicine—invasive procedures, diagnosis, treatment—without having to collaborate with physicians. That’s very inappropriate.

PND: Allowing CRNPs to prescribe, as set out in the joint regulations, does not cross that threshold?

CER: No, because the way the regulations are written, the written collaborative agreement has to be there and it requires the physician to be responsible. We’re looking for doctors to be responsible in the manner in which they set up their practice. And of course, it doesn’t force this type of practice on any physician who doesn’t feel comfortable with it.