Nurses are a common sight standing at a doctor's elbow in clinics, hospitals and doctors' offices. But the idea of a nurse in private practice raises eyebrows and questions.
Nevertheless, the number of nurses in private practice in the District might increase if the City Council adopts a proposal that calls for licensing nurses with advanced training as anesthetists, midwives and practitioners.
In 1983, the council adopted a law that provided for the certification of specialized nursing professions. Ray's proposal would allow nurses to perform even more tasks traditionally reserved for doctors -- provided they do so in collaboration with doctors.
And that's where the controversy erupts.
Doctors and nurses disagree on the amount of collaboration that should be required. Doctors argue that they should not only have a say in establishing the minimal levels of collaboration but that they should also be allowed to increase those levels when they deem it necessary.
The nurses cry foul play. They view the collaboration requirement as a way for doctors to restrict the businesses of nurses and to prevent them from expanding their roles as health care providers.
The issue involves money for the doctors, nurses and consumers. Doctors clearly do not want competition from nurses, but in many cases, a nurse in private practice could reduce medical costs, especially by putting an emphasis on preventive health care.
Last week Ray's bill and a similar bill introduced at the request of the D.C. Law Revision Commission that would reform outdated laws for most of the health care professions in the city were discussed at a two-day City Council public hearing. But one of the most controversial issues centered on expanding the role of nurses as proposed by Ray.
Although some nurses have for years pushed for legislation that would update District nursing laws, Kathleen McIntyre, staff associate for professional and legislative affairs for the 2,000 member D.C. Nurses Association, is annoyed by Ray's bill.
"With the restrictions Ray has given us, I would be happy to back off and let the bill die a quiet death," said McIntyre.
She said nurses wanted changes because some of them, particularly nurse-midwives, were having trouble collecting payments from insurance companies for their services. But she argued that such collaboration would amount to supervision of nurses by doctors.
"Nurses would like to make their services more directly available to consumers," said McIntyre. "In the community, nurses are always sought out for their help and this proposal could put it on more of a fee-for-service basis."
During a council hearing on the health occupations bill, Carol B. Thompson, director of the District's Department of Consumer and Regulatory Affairs, testified that the Barry administration supports the requirement for collaboration between doctors and nurses but has "serious concerns" about the bill's proposal to establish a joint committee of nurses and doctors to determine the scope and level of collaboration.
Such collaboration has not worked in other places, Thompson said. "In both Florida and Maryland, a joint committee structure of doctors and nurses was formed to determine protocols for advanced nurse practices. To date such joint practice committees have been unable to reach agreement regarding the role of nursing and expanded nurse practices."
In his defense, Ray contends that the council must establish an appropriate level of supervision because doctors rather than nurses are ultimately responsible for the care of patients. But nurses stressed that the council proposal questions their skills and professionalism.
Rene Smit, a nurse-midwife who has opened an office on Capitol Hill, testified that the proposal implies a "resounding lack of trust in the competence, judgment and professionalism" of nurse-midwives and the collaborating arrangements they have set up with physicians. She noted that the proposal would require a patient and her husband, if she has one, to consent to the agreement between a doctor and a nurse-midwife.
Smit said such a provision assumes that all nurse-midwives are less competent than all physicians and that all husbands should be considered more capable than their wives to choose a health care professional for pregnancy and delivery of a child.