Expanding The Role Of Nurse Practitioners: Licence To Practice Medicine Without A License

An article published by NPR comments on the nationwide movement to expand the role of nurse practitioners in light of the growing deficit of primary care physicians. According to the article:

Nursing leaders say large numbers of [nurse practitioners] …will be needed to fill gaps in primary care left by an increasing shortage of doctors, a problem that would intensify if Congress extends health insurance to millions more Americans. Advocates say nurse practitioners have the extra education and training needed to perform a variety of services, including physical exams, diagnosis and treatment of common ailments and prescribing drugs.

A study published by the Center for Workforce Studies projects that, by 2025, there will be a nationwide shortage of about 124,000 physicians. Researchers note:

Under any set of plausible assumptions, the United States is likely to face a growing shortage of physicians. Due to population growth, aging and other factors, demand will outpace supply through at least 2025. Simply educating and training more physicians will not be enough to address these shortages. Complex changes such as improving efficiency, reconfiguring the way some services are delivered and making better use of our physicians will also be needed.

Based on this rationale, a number nursing organizations, state level legislators, regulatory bodies, and various other national organizations and policy thinktanks advocate for an expanded role, particularly in the field of primary care, for nurse practitioners. According to the article, a number of states have already implemented or are presently considering legislation to expand the role of nurse practitioners. For example, a Colorado bill would enable nurse practitioners to issue orders in the same way as a physician. Practically speaking, this would mean that a nurse practitioner, in addition to being able to order medications, would also be able to issue orders directing the treatment of the patient (e.g., orders to admit the patient, CT/MRI orders, consultation orders, etc.)

While these proposed reforms may be practical and serve a utilitarian purpose, one can’t help but wonder if the quality of health care rendered to millions of Americans is going to be compromised as a consequence. The easy answer is not always the right answer. It may be true that there are more nurse practitioners in the U.S. than there are physicians (there are about 125,000 more nurse practitioners). If allowed, nurse practitioners could certainly fill the void. But, the critical inquiry remains: are nurse practitioners sufficiently qualified to serve as substitutes for physicians? For example,

The American Medical Association (AMA) and doctors’ groups at the state level have been urging state legislators and licensing authorities to move cautiously, arguing that patient care could be compromised.

The AMA issued a report in which it questioned whether nurse practitioners are sufficiently qualified to render medical care in areas currently restricted to physicians.

“To back up its claims, the report cites recent studies that question the prescription methods of some nurse practitioners, as well as a survey that reported only 10 percent of nurse practitioners questioned felt well prepared to practice primary care.”

The idea that nurse practitioners are qualified to serve as substitutes for physicians it truly worrisome. There is a reason why nurse practitioners are not physicians – they don’t have the same level of training and expertise. Surely, there are patients with fairly simple medical complaints, which probably could be addressed by nurse practitioners; however, what about the inevitable complex patient? Are nurse practitioners sufficiently trained to simultaneously recognize the interplay of multiple medical conditions, as well as determine the interplay of necessary medications, radiographic studies and necessary follow up care? I for one will make sure to be seen by a physician.

Contributing author: Jon Stefanuca

Public beware: disciplined nurses crossing state lines to practice anew.

A recent report posted on ProPublica tells a shocking and scary tale of how some nurses, disciplined in one state, have taken up new jobs as licensed nurses in a different jurisdiction.  This story was brought to light by the combined investigative efforts of Charles Ornstein and Tracy Weber of ProPublica and Maloy Moore of the Los Angeles Times on December 27, 2009.

According to this report, there exists a “dangerous gap” in the way states regulate nurses.  As an example of just how serious a problem this may be, the reporters found that in California alone, a months-long review of the 350,000 registered nurses in that state revealed that there were at least 177 nurses, whose licenses had been revoked, suspended, surrendered or denied elsewhere.

The online article gives the following example (among a number they discovered):

In May 2005, a 3 year old boy, Jexier Otero-Cardona, died while under the care of a home health nurse, Orphia Wilson. The child suffered from chronic respiratory failure and muscular dystrophy.  Early one morning, Nurse Wilson frantically summoned the child’s parents for assistance when the child stopped breathing.  After heroic efforts at CPR by his mother, the child died the  next day at a hospital in Connecticut.

This was not the first child to die under Nurse Wilson’s care, the state’s investigation revealed.  Just seven months before, Nurse Wilson had lost her Florida license due to apparent lapses in the care of another child in that state in 2002.

In the months of investigation by Connecticut officials that followed Jexier’s death, it was determined that Wilson “had fallen asleep, then ignored – or possibly turned-off – the ventilator alarms that were intended to warn when the child was not getting enough oxygen.”

The following quote from the article tells the tragic story of a failed system of regulating the licensure of nursing in our country:

“Florida officials, for instance, didn’t notify Connecticut authorities when they sanctioned Wilson – even though she’d told them that she also held a Connecticut license. And Connecticut’s nursing board renewed Wilson’s license three times after Thierry’s death, relying on her pledge that she hadn’t been disciplined or investigated elsewhere.”

The reporters identify several key failures in our country’s system of regulating the licensing of nurses.  First, they note that in some instances some states do not do a simple check of a national database, which can within seconds reveal (if the data  has been timely and accurately supplied) that a nurse has been disciplined elsewhere.  This has dire implications in many hospitals and health care employers rely on state nursing boards to verify a nurse’s licensure status and fitness to practice.  Secondly, they tell a tale of how long a disciplinary process may take and how long the reporting of that finding will occur, if ever.  The tale of horrors goes on and on.

Just a bit of digging (much more to come!) into the background of this issue reveals that The Medicare and Medicaid Patient and Program Protection Act of 1987 led to the creation of the National Practitioner Data Bank (NPDB), which was a tracking system designed to protect program beneficiaries from ‘unfit’ health care practitioners.  The NPDB was implemented in the fall of 1990 and required reporting of adverse licensure, hospital privilege and professional society actions relating to quality of care by physicians and dentists. According to one source, proposed rules adding other practitioners, including nurses, were published in March 2007.

Query:  does anyone know if those “proposed rules” were ever made into final rules?

The full scope of the legislative history, the awarding of three grants to the National Council of State Boards of Nursing by Robert Wood Johnson Foundation (RWJF) in excess of $1,000,000 between 1990 and 1997, the commendable activities of the National Council of State Boards of Nursing over many years to get better control and surveillance of licensure and ‘fitness’ to practice for nurses are all topics well beyond the scope of this blog.

Research is underway by our firm to determine the current status of federal legislation in this area as well as a myriad of other related topics – for example, what states boards of nursing do not yet have an agreement with the National Council?  What are the current requirements for timely reporting of adverse actions against nurses?  What legislation, if any, is pending to address this situation?  What other sad stories like that reported by these investigative writers are out there?

All the hard work to establish reporting guidelines and a national network for avoidance of these types of tragedies can not go for naught due to provincial and/or political interests that can result in serious harm to the public.

If you have any information about the current status of legislation or stories like that reported by ProPublica and others, let us know.