Nurses need a more independent role, report argues

But doctors have repeatedly opposed the idea, citing potential safety risks

By Andrew Villegas and Mary Agnes Carey

Kaiser Health News

updated 10/5/2010 8:57:29 AM ET

A new report released today may give nurses with advanced degrees a potent weapon in their perennial battle to get the authority to practice without a doctor's oversight.

The Institute of Medicine report says nurses should take on a larger and more independent role in providing health care in America, something many doctors have repeatedly opposed, citing potential safety concerns. It calls for states and the federal government to remove barriers that restrict what care advanced practice nurses — those with a master's degree — provide and includes many examples of nurses taking on bigger responsibilities. “A qualified health care professional is a terrible thing to waste,” Cheryll Jones, a pediatric nurse practitioner in Ottumwa, Iowa, told the authors.

The report calls for elimination of "regulatory and institutional obstacles" including limits on nurses "scope of practice" -- which are state rules about what care people who are not physicians can provide.

The findings come from a committee on the future of nursing, a collaboration among nurses, doctors, health care business leaders and academicsthat studied the issue for two years.

Experts predict that more physicians, nurses and other medical professionals will be needed to care for the 32 million additional Americans who will get coverage beginning in 2014 under the sweeping new health law. Nurses' groups say that they can help ease a physician shortage. Last week, a report from the Association of American Medical Colleges said that in 2015, there will be a shortage of nearly 63,000 doctors across all specialties in America.

The new federal health care law provides more funding for nursing education and nurse-led clinics, but this study could also propel the nurses' argument for more authority to deliver care independently from physicians.

"We cannot get significant improvements in the quality of health care or coverage unless nurses are front and center in the health care system -- in leadership, in education and training, and in the design of the new health care system," said Donna Shalala, a former Health and Human Services secretary and chair of the IOM's committee on the future of nursing. "We can’t be fighting with each other if we really are going to have a high quality system that we can afford.”

For years advanced practice nurses — as well as a host of other caregivers such as chiropractors and physical therapists —have butted heads with doctors over "scope of practice" considerations. Doctors maintain that even with an advanced degree, these nurses do not have the same education that physicians get in medical school and residency programs and that patient safety could be compromised. They are also wary that their practices could see significant patient losses if the nurses were allowed to practice more independently.

In its recommendations, the committee said Medicare and Medicaid should reimburse advanced practice nurses the same as a physician for providing the same care. "When you do the same job you ought to be paid the same," Shalala said.

Dr. Rebecca J. Patchin, a former nurse who is now anesthesiologist and member of the American Medical Association’s Board of Trustees, said that physicians must be involved to help protect patients. “We think that care in the operating room or care in the office is best done with physician involvement and oversight,” Patchin said. “Due to that additional training that they have … when or if a complication occurs they are better equipped to handle it.”

The battle is being waged across the country. Colorado, for instance, recently became the 16th state to allow nurse anesthetists to work without a doctor's oversight. In Michigan, nurses are pushing for legislators there to allow advanced practice nurses to prescribe drugs. Other fights over scope of practice for registered nurses loom in Kentucky, North Carolina, Iowa and Minnesota.

But, Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, said the clashes between nurses and doctors scare the public. "It's exactly what people worry about when they worry about what health reform will bring," he said. "Patients and voters say 'If you're talking about taking the docs out of my health care, I want no part of it.'"

The report, which was sponsored by the Robert Wood Johnson Foundation, calls for nurses to be allowed to admit patients to the hospital or to a hospice and for the Federal Trade Commission and the Department of Justice to review existing scope of practice provisions for "anticompetitive" practices.

The Obama administration has signaled its commitment to increasing the number of primary care providers, including nurses. Late last month the Department of Health and Human Services announced $320 million in grants to strengthen the health care workforce. The grants include $31 million to 26 nursing schools to increase full-time enrollment in primary care nurse practitioner and nurse midwife programs and $14.8 million for nurse managed health clinics. In addition, a registered nurse heads the newly formed National Health Care Workforce Commission, which was set up under the new law to advise Congress on how to change the health care workforce to better fit America's needs.

While the report addresses a ongoing battle being played across state legislatures, it's not clear if the new report will have any impact on those battles. The panel is planning a meeting next month to discuss ways to implement its recommendations.

© 2010 This information was reprinted with permission from KHN. KHN is an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan health care policy organization that isn’t