Op-ed: Caution: All ‘independent practice’ for APRNs is not equal
As Connecticut legislators and Governor Malloy seem intent on passing a bill to allow advanced practice registered nurses (APRNs) to “practice independently,” I would urge some caution. The lobby pushing for this change in state statute has repeatedly made it appear that Connecticut is “behind the times” since 19 other states already allow independent practice for APRNs. And the sky is not falling in those states with any epidemics of sub-standard care being provided by APRNs, so how can there be any problem with allowing the same in Connecticut?
Has anybody done some legislative homework and examined exactly how “independence” is defined in the laws of those 19 states? As usual, the devil is in the details. There are three specific areas that vary greatly among these states: regulatory oversight, education requirements, and prescriptive authority definition.
According to the National Council of State Boards of Nursing, there are 22 states allowing independent practice for nurse practitioners, meaning “no requirement for a written collaborative agreement, no supervision, no conditions for practice.” And 17 states allow prescriptive authority, defined as authority “to prescribe pharmacologic and non-pharmacologic therapies beyond the peri-operative and peri-procedural periods.”
Several of these states (West Virginia, Massachusetts, Rhode Island) established that prescribing may only occur within limits set up by formularies. Several other states (Colorado, Washington, Maine, New Hampshire, Massachusetts) mandate specific education in pharmacology, above and beyond whatever was obtained in nursing education. Explicit requirements are set out by several states (Maine, New Hampshire, Massachusetts) for specific amounts of continuing education at specified intervals. To maintain licensure in Connecticut, physicians must document 50 hours of continuing education every two years. Some states (Maine, New Hampshire, Vermont, Ohio, Massachusetts, Rhode Island) establish specific regulatory processes to oversee and define what a “scope of practice” is for an APRN in a given specialty.
The current bill before the Connecticut state House includes NONE of these provisions which other states have had the wisdom and foresight to include in their statutes. So while rhetoric from the APRN lobby states that this bill will merely bring Connecticut to the same type of “independent practice” as these other states, in reality, it takes our state beyond and with far less regulation of APRNs than these other states. It even makes APRNs LESS regulated than physicians in the state.
WOW! Is it logical that APRNs with an average of 500 hours of clinical training in school and no required residency training have less ongoing educational requirements in our state than physicians with over 3,000 hours of clinical training in medical school and 9,000 hours in residency training?
I fully believe it is the intent of our legislators to improve the access of our citizens to health care providers, and also to ensure that practitioners of all types in our state are adequately trained and regulated to deliver safe and effective care. If the time is right for “independent APRN practice” in our state, a statute should be crafted with appropriate regulatory oversight.
This bill does NOT do that, and it should NOT be passed into law in its current form. The examples of other states’ statutory details need to be examined as Connecticut moves forward with considerations for APRN independence. And whether greater “independence” of APRN practice will truly increase access to care remains a theory that has not yet been proven by any data — it is a hope, but not an established fact.
Robert M. McLean, M.D., practices internal medicine and rheumatology in New Haven. He is immediate past-governor of the Connecticut Chapter of the American College of Physicians (ACP) and currently serves on the ACP’s Board of Regents and its Medical Practice & Quality Committee.
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