Amid a flurry of legislation to pass in the final days of spring state legislative sessions last week, nurses won two more victories in a long war for independence.
For decades, most of the country has required physician oversight for nurses to conduct certain procedures, and especially to prescribe drugs. But that’s slowly changing, as the nation’s health-care needs rise, and nurses fight for the right to practice everything they learned in school.
The most recent wins came in West Virginia and Florida, where after many years of trying, lawmakers passed measures freeing up “advanced practice” nurses — those with more graduate education than just a nursing degree — to administer a wider range of care and prescribe most drugs without having to maintain a relationship with a physician.
For Beth Baldwin, president of the West Virginia Nurses Association, the measure was aimed at meeting the needs of people who live in rural areas where the nearest physicians might be miles away — especially as the Affordable Care Act has expanded the pool of those with access to insurance.
“Who’s going to provide the care for that? If there’s nowhere for them to take the card and get the care, it’s not helpful,” Baldwin says. In some places, when a doctor retires, another has to be brought in on a temporary basis to make sure patients can still get their medications. “We in no way feel that we’ll be replacing physicians," Baldwin says. "But physicians can be focusing on the people they need to see.”
Physicians, whom the nurses call “organized medicine," are the main people standing in the way of bills that expand the scope of what nurses are allowed to practice.
The battle to allow nurses to fulfill all the functions for which they were educated began back in the 1960s, when degree programs for nurse practitioners were created to extend care to people rural areas. A few states gave them early on what’s known as “full practice authority," but many didn’t, and little changed for decades.
The American Medical Association, the powerful doctors' trade group, has long opposed granting nurses the ability to prescribe drugs or set up their own primary care offices. They say that physician-led medical teams provide better integration and coordination.
“Independent practice and team-based care take health care delivery in two very different directions,” the Association said in a statement. “One approach would further compartmentalize and fragment healthcare delivery, while team-based care fosters greater integration and coordination.”
Nurses, however, say that they can form their own teams if doctors aren’t available, and refer patients out to specialized services if needed. That perspective was bolstered by a seminal report from the National Academies of Science in 2010, which recommended that states remove barriers to nurses practicing “to the full extent of their education and training.” In 2012, the National Governors Association agreed.
More states started moving in that direction after 2013. Twenty-one states plus the District of Columbia, including Maryland, now have laws establishing full practice authority for nurses. But especially in the South, it’s been a tough slog; Virginia nurses must practice with a physician.
In West Virginia, nurses had tried to free themselves of a law that required “collaborative agreements” with physicians for more than a decade. This year, however, they got some key backing: The Federal Trade Commission endorsed the bill in a staff comment noting that restrictions on their ability to operate without supervision hamper competition.
They also had political muscle. After years of sitting on the sidelines, AARP made the bill a top priority, arguing that freeing up nurses is essential to care for the state’s aging population. The liberal West Virginia Citizen Action Group got involved. And Americans For Prosperity, the Koch-funded free markets organization, took up the cause as part of a broader push to wipe out barriers to entry in skilled fields.
"The stars aligned in West Virginia. We felt the political landscape was ripe for us to engage in this issue,” says Gaylene Miller, AARP’s West Virginia state director. The partnership with the conservative Americans For Prosperity helped proponents reach legislators across the political spectrum. “We utilized our relationships, and they utilized theirs,” Miller says.
In the last days of the legislative session, however, the motley coalition didn’t get everything it wanted. West Virginia’s opioid-abuse epidemic had made lawmakers concerned that expanding the number of people who could prescribe drugs might worsen the problem, so the final version they passed maintained the prohibition on nurses dispensing Schedule II substances. That significantly confines their powers, says Janet Haebler, senior associate director for state government affairs at the American Nursing Association.
“I want to congratulate the state,” Haebler says. “At the same time, this is not full practice authority, so it's a bit disappointing.”
Of course, the physicians weren’t happy either. The local chapter of the AMA had maintained that West Virginia doesn’t have a serious doctor shortage, and that nurses need to be supervised to prevent them from over-prescribing medications. But this year, the tide had turned.
"All we had was data, as well as a sincere concern for public health and safety,” said West Virginia State Medical Association government affairs director Susan Baek. "The bill that passed does not represent a compromise, and WVSMA feels that it will be detrimental to public health."