Elimination of Barriers to RN Scope of Practice Essay
If you could envision a preferred future for registered nurses (RNs), what would that look like? Would you want an RN’s voice heard, honored, and considered essential at every healthcare decision-making table? Would you want every RN energized to begin work each day; to experience a continuous journey of professional growth and improvement; to be acknowledged and recognized appropriately for their optimal contribution? Have you pondered how this preferred future could be realized?Elimination of Barriers to RN Scope of Practice Essay
When the Institute of Medicine’s original report on the future of nursing was released (IOM, 2011), it outlined a future full of opportunity and with the challenge for all nurses to practice to the full extent of their education and scope. Over the last several decades, much has occurred to elevate the practice and value of the RN. Patient needs have become more complex and quality and patient safety are now the front and center of reimbursement and regulatory landscapes. Nurses have adapted to these changes by expanding their skill sets and knowledge of science, securing their places as linchpins to provision of improved health outcomes in the era of healthcare reform (IOM, 2011).
Still, there is much to be done. Experts agree that the ability of RNs to practice to the fullest extent of their education and scope has not yet been achieved in most healthcare settings (IOM, 2015). In response to this problem, the American Nurses Association (ANA) established a Professional Issues Panel—the Barriers to RN Scope of Practice Panel (Panel)—to explore factors that both promote and inhibit nurses ability to practice to the top of their licensure. The Panel was established as a think tank to create an environment for RNs to consider and identify some barriers to RNs’ ability to practice to the full extent of their education, experience, and scope of practice.Elimination of Barriers to RN Scope of Practice Essay
Five of the six introductory articles in this OJIN topic are based on the work of the ANA panel and written by members of the panel steering committee. These articles include evidence-based recommendations to address some of the barriers identified by the panel that prevent RN practice to the full extent of education and scope. The first four articles are organized in this OJIN topic based on key roles of RNs that emerged from the panel work and demonstrate RN value to the healthcare delivery system: RN as professional, RN as advocate, RN as innovator, and RN as collaborative leader. The fifth article provides an executive summary of the panel work. The sixth article discusses a research study that considered several variables important to full scope of practice, such as nurse educational level and organizational factors.Elimination of Barriers to RN Scope of Practice Essay
The first article, “Registered Nurses as Professionals: Accountability for Education and Practice,” focuses on several key messages. Authors Zittel, O’Sullivan, Siek and Moss write that to ensure the highest possible patient outcomes, preparation of RNs at the BSN level is essential. This can be accomplished either through initial education or through educational progression. To achieve this, individuals, organizations, policy makers, and educators must make policy decisions based on this core message. Seamless academic progression models must be developed to support nurses educational advancement (BSN or higher). This article also focuses on individual level nurse responsibility to practice at the fullest extent of scope of practice and remain accountable for their own educational progression. The article considers timing related to achieving specialty certification and recommendations for basic nursing education and continuing education content related to scope of practice, standards, and competencies, and for individual RN responsibility to obtain a BSN degree upon entrance to the nursing profession. To achieve this goal, it will be critical for academia and practice environments to provide appropriate mentoring and guidance toward that goal.Elimination of Barriers to RN Scope of Practice Essay
The second article, “Registered Nurses as Caregivers: Influencing the System as Patient Advocates,” outlines multiple steps at the stakeholder level to support the RN. It includes forward thinking suggestions for organizations to adopt a model of privileging and credentialing RNs and comprehensive methods to assess nurse competency. Authors Lucatorto, Thomas, and Siek also recommend that organizations maximize the use of nurse-initiated protocols in concert with specific, validated nurse competencies. The article proposes academic and practice setting collaboration to define, research, validate, and measure the evaluation of nursing care and use these data to expand comprehensive nurse quality indicators. Lastly, the article challenges nurses to engage in measuring the effectiveness of nursing care and articulate the value they add to patient care. The article challenges hospitals and healthcare systems to evaluate available data and make data-based decisions to determine and quantify the value of the RN.Elimination of Barriers to RN Scope of Practice Essay
The article entitled “Registered Nurses Leading Innovative Changes,” considers strategies to position nurses in all roles and settings to drive innovative changes in policy and procedures. The purpose of these changes is to advance the National Quality Strategy (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, 2016) and the goals of the Institute for Healthcare Improvement (n.d.) Triple Aim. Authors Thomas, Seifert, and Joyner describe the concept of innovation and examine ways that nurses are creating new knowledge through innovations in areas such as primary care, quality improvement, healthcare policy, health information technology, simulation training, and delegation. The authors describe efforts to create environments that foster innovation and consider characteristics and attributes of nurses who score higher on an innovation scale. They also discuss skillsets that may play an important role is nurse innovation, including leadership skills, self-awareness, resilience, financial management skills, and critical thinking skills. The article concludes with a series of recommendations to empower all nurses to lead innovation and encourage nurse managers and nurse leaders to create environments where innovation can thrive.Elimination of Barriers to RN Scope of Practice Essay
Article four, “Registered Nurses as Interprofessional Collaborative Partners: Creating Value-Based Outcomes,” describes programs to maximize RN contribution and minimize barriers to practice, including transition programs, nurse residencies, student nurse externships, preceptorship, and the creation of healthy work environments for RNs. Moss, Seifert, Lucatorto and O’Sullivan identify recommendations to advance nurse-led initiatives in culturally competent care; describe recommendations to create and foster interprofessional environments; and highlight evidence-based programs to support RN transition-to-practice environments. The authors suggest specific recommendations related to the required minimum level of education for preceptors; development and evaluation of transition programs; and partnerships for academic and practice environments for development of collaborative interdisciplinary practice models. They also highlight the importance of culturally competent care and a nursing workforce that reflects the community being served.Elimination of Barriers to RN Scope of Practice Essay
The fifth article related to the effort of the panel, “Registered Nurses as Professionals, Advocates, Innovators, and Collaborative Leaders: Executive Summary,” offers a synthesis of the panel work process, findings, and recommendations. Panel members, led by Williams and Baker, work together to describe their methodology, succinctly recapitulate the four role definitions and recommendations that emerged from their effort and offer recommendations for RNs at the individual level to remove barriers and practice to the full extent of their scope. The authors conclude with considerations for future work.Elimination of Barriers to RN Scope of Practice Essay
The final article, “Enhancing Patient Safety: Factors Influencing Medical Error Recovery among Medical-Surgical Nurses,” presents a view on RN scope of practice external to the work of the panel. Authors Gaffney, Hatcher, Milligan and Trickey have conducted research that examined the potential relationships between nurse characteristics, organizational factors, and recovery of medical errors among medical-surgical nurses in hospitals. Several variables in their study, such as educational level and organizational policy, were also found important by the members of the ANA panel. The study authors suggest that improving patient safety within the healthcare system requires nurses who are able to fully use their education, and expertise.Elimination of Barriers to RN Scope of Practice Essay
Acknowledging change is incredibly difficult. Because change is difficult, nurses must create a guiding vision, take incremental steps toward that vision, and not lose heart when faced with obstacles. Nurses must embrace revolutionary ideas that are implemented in an evolutionary manner. Nurses must not forget that they are part of a community of care providers and may need to help others embrace this vision and their role in actualizing it. Through that process, nurses can eliminate limits and barriers to their current practice and deliver on the promise of their potential.
If a future is created where nurses practice to the full extent of their education and scope, the entire healthcare delivery system will benefit. In the opinion of the panel members, there are many significant potential outcomes to such an effort. The healthcare delivery team will be fueled by mutual respect and an improved sense of interdisciplinary collaboration. Financial stewardship will be achieved by implementing proactive strategies to attain high-value patient outcomes as opposed to reactive mitigation of system inefficiency. Nurses will have a high level of job satisfaction that can translate to improved care of the patient at the bedside.Elimination of Barriers to RN Scope of Practice Essay
Recommendations set forth in these OJIN articles demonstrate that this preferred future is within our power to achieve. The journal editors invite you to share your response to this OJIN topic addressing Barriers to RN Scope of Practice either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
Portions of the research for this article were performed by an American Nurses Association (ANA) Professional Issues Panel entitled “Barriers to RN Scope of Practice.” The panel was composed of volunteers from a variety of nursing backgrounds who contributed through participation on the Panel’s Steering Committee and Advisory Committee. While the articles were generated by authors participating in a Professional Issues Panel convened by ANA, the conclusions and recommendations articulated by any author do not necessarily reflect those of the Association.Elimination of Barriers to RN Scope of Practice Essay
Kathy Baker, PhD, RN, NE-BC
Kathy Baker is a nurse leader with strategic, operational experience in multiple healthcare settings as well as specific expertise in workforce development, financial management, and optimization of personnel resources and work environments to achieve high value patient centered outcomes. She earned Master’s and PhD degrees from Virginia Commonwealth University with a focus on Nursing Systems. She currently holds a Nursing Director position at the Virginia Commonwealth University Health System (VCUHS) in Emergency Services, Critical Care Transport, Resource Management and Patient Care Support. She is also a nurse scientist at VCUHS with a research focus in work environments and patient safety. Her clinical background includes critical care, cardiovascular and emergency nursing with experience in both adult and pediatric populations. Dr. Baker holds an affiliate faculty position at the VCU School of Nursing where she teaches in the Graduate Nursing Leadership program.
Tracy E. Williams, DNP, RN, FNAP
Tracy Williams has served as Senior Vice President and System Chief Nursing Officer with Norton Healthcare since 2005. She has oversight of all care functions for Norton Healthcare’s five owned, seven affiliate hospitals, Cancer Institute and Medical Group. Williams earned her BSN degree from Old Dominion University; an MS in nursing from Medical College of Virginia/Virginia Commonwealth University; and a DNP in Executive Leadership from Rush University. Her doctoral work resulted, in part, in Norton Healthcare receiving the 2011 National Quality Forum’s (NQF) National Quality Award; the 2011 Kentucky Hospital Association Quality Award; and being a top five finalist for the 2012 AHA McKesson Quest for Quality Prize. Williams is the Executive Associate Dean for the Norton Academic Practice Partnership and Professor with the University of Kentucky College of Nursing and is an Assistant Professor, (Adjunct), at Rush University, College of Nursing. Williams serves as chairperson of the Jefferson Community and Technical College Foundation Board of Directors and is a graduate of the class of 2008 for Leadership Louisville. She has been recognized as a Business First Partner in Health Care from 2007 through 2016; received the HCPro Nursing Image Award in 2011; was named Medistar Nurse of the Year in 2014; and selected as a Fellow in the National Academies of Practice in 2016.Elimination of Barriers to RN Scope of Practice Essay
The ability of frontline RNs to practice to the fullest extent of their education and training is imperative in promoting patient safety, increasing nurse satisfaction and improving access to care for all patients These outcomes are achieved by optimizing the care delivery model at the frontline level. Empirically, we know the variables that must be present in the individual nurse, within the interdisciplinary team and within the organization to achieve this goal. The roadmap that is necessary to address these issues however, remains underdeveloped and not fully or widely embraced. Conclusion & Significance: There are tangible steps that the nursing profession can take to support the ability of frontline RNs to practice to the fullest extent of their education and training. First, we must promote education progression and provide the support for all nurses to achieve a B.S. in Nursing. Second, we must from a regulatory perspective ensure that scope of practice is maximized and increase the use of protocols based on evidenced based practice principles to provide options for nurses to respond to patient needs. Third, RNs must be participants and leaders in interdisciplinary teams to drive innovative change. Fourth, RNs must have the skills to measure their contributions and demonstrate the value they bring to patient care. Lastly, RNs must have the leadership skills to work collaboratively as part of the interdisciplinary team. To implement these important steps, nursing practice, nursing academia and professional organizations must incorporate these five principles into their strategic initiatives and lay the foundation to achieve the future for nursing that is deserved, needed and will enhance the health of our communities.Elimination of Barriers to RN Scope of Practice Essay
The existing primary care system faces imminent challenges as more Americans gain insurance
coverage under the Patient Protection and Affordable Care Act (ACA). Current scope-of-practice
laws may restrict the use of Nurse Practitioners (NPs) as a means of limiting the burden in this field.
This policy analysis provides three recommendations to remove restrictive scope-of-practice laws to
approach this problem. This analysis finds that the most politically and technically feasible option is
to expand coverage of NP services in public insurance.
The existing primary care system has been facing strains. One study found that in Massachusetts the
average wait time for new patient appointments with primary care physicians is around 39 days and
only about half or less of primary care physicians are seeing new patients in 2013.1 With the average
length of a primary care visit around 15 minutes, patients and physicians feel the pressure under time
constraint.Elimination of Barriers to RN Scope of Practice Essay
2 Short visits strain the doctor-patient relationship, which is essential for quality care. For
example, studies show that less dialogue between patient and doctor increases the odds patients will
leave the office frustrated.2
This problem may worsen as millions of consumers who gained health coverage through the ACA
begin to seek care—some of whom may have seen doctors rarely, if at all, and have a slew of
untreated problems.2 This increased coverage may not translate to increased access to services. If
health care providers are already at or near capacity, this expansion of public coverage may simply
result in longer wait times without actually increasing the amount of health care services patients
receive.3 However, evidence shows that if health care providers are able to increase the amount of
care they supply, either by increasing their labor supply or changing the way they practice, these
negative spillover effects may be at least partially mitigated.3
Expanding the role of NPs in primary care may be a key component of addressing the primary care
workforce shortage. According to the American Association of Nurse Practitioners:
NPs are trained to provide a full range of primary, acute and specialty health care services,
including diagnostic, treatment, and prescription services. All NPs must complete a master’s
or doctoral degree program, and have advanced clinical training beyond their initial
professional registered nurse preparation.
Upon completion of the graduate program, an NP must become board certified by an accrediting
body such as the American Nurses Credentialing Center or American Association of Colleges of
State scope-of-practice (SOP) laws determine the range of services NPs can provide and the extent
to which they can practice independently.
5 These laws, which vary state to state, govern the clinical
role of NPs by defining the level of required physician oversight. Some states allow NPs to practice
independently, while others limit NPs’ authority to diagnose, treat and prescribe medications to
patients without supervision.5 Currently, 22 states and the District of Columbia permit NPs to
practice independently, while others require some level of physician oversight.7 Two-thirds of states
with a shortage of primary care physicians also have restrictive SOP laws, which may be a barrier to
increasing access to primary care services through NPs.7
Payer policies indirectly influence the services provided by NPs. Such policies include whether NPs
are recognized as primary care providers and included by health plans in provider networks and
whether NPs can bill and be paid directly.5 Medicare, for example, does not permit NPs to conduct
assessments to admit the patients to skilled nursing facilities or provide the initial certification for
hospice care even though it does authorize them to order skilled nursing care and to serve as
attending providers and recertify patients’ eligibility.6 Medicare indirectly recognizes NPs to certify
patients for home health care services by authorizing them to conduct the required face-to-face
documentary examinations but still requires a physician to document that the NP completed the
certification evaluation Elimination of Barriers to RN Scope of Practice Essay
Restrictive SOP laws in conjunction with strict payer policies limit NPs to working as employees of
physician practices, hospitals or other entities rather than in their own independent practices.5 Given
that NPs gain the necessary skills and qualifications to act similarly to a Primary Care Provider, and
because they command lower salaries and can be trained more quickly and at lower cost than
, removing some of the barriers that restrict NPs’ scope of practice may address some of
the growing concerns about access to primary care services. Shifting SOP may give rise to concerns
over quality of care. Increasing access to primary care services in the form or reduced wait times will
require thoughtful policy changes to protect the quality of care provided.
The literature used to inform this memo were found using searches for key words such as “scopeof-practice” “primary care shortage” and “nurse practitioner scope” on Google Scholar and
PubMed as well as keeping up-to-date with news sources such as Politico.
Problems arise in the context of societal values, and currently, the ACA places an emphasis on
access and quality of health care. According to the Congressional Budget Office, as a result of the
ACA, roughly 30 million more people are expected to gain both public and private health insurance
coverage by 2015.5 Unless there is adequate provider capacity to meet new demand, these coverage
expansions will not be equivalent to providing access to services.3 This concern is especially acute
for primary and preventive care, as over 57 million Americans live in areas that are deemed by the
Centers for Medicare and Medicaid Services to be “primary care health professional shortage areas”.Elimination of Barriers to RN Scope of Practice Essay
According to the Health Resources and Services Administration, to meet a target of one provider
for every 2,000 patients, an additional 17,722 primary care practitioners are already needed in
shortage areas across the country.7 Additionally, an analysis of the aging U.S. population found that
another 35,000 to 44,000 adult primary care providers may be needed by 2025.
Studies show that increased insurance coverage expansions cause wait times to increase modestly.3
However, this effect varies significantly across states with different policies towards the provision of
non-physician caregivers, with increased wait time concentrated in states with relatively restrictive
scope of practice laws.3 In an already strained environment, increased demand for primary care will
further restrict access in the form of longer wait times for appointments if the supply of primary
care providers response is not great enough to match.
This policy analysis provides three recommendations to remove restrictive scope-of-practice laws to
approach this problem. It considers expanding coverage of NP services in public insurance, creating
a licensing process to remove SOP barriers, and eliminating SOP laws all together.
Expand Reimbursement of Public Insurance to Cover NP Primary Care Services
Currently, NP reimbursement varies under Medicare and Medicaid. In Rural Health Clinics, NPs are
recognized as primary care providers, operate with an expanded scope of practice and are paid the
same rate as physicians.5 On the other hand, as previously described, NP service reimbursement
under Medicare varies greatly. Revising state regulation of Medicaid managed care plans and federal
regulation of Medicare plans may be a more immediate and politically feasible way to expand Elimination of Barriers to RN Scope of Practice Essay
effective utilization of NPs in primary care.5
Public payers can recognize NPs as primary care providers nationally to set a precedent and increase
access to services for populations in greatest need of these services. Expanding payment of NPs
under Medicaid and Medicare will provide coverage for the millions of Americans living in “primary
care professional shortage areas”.3 With more Americans gaining coverage under Medicaid in
particular, increasing the supply of providers and reducing SOP laws under public coverage may
translate to increased access of services for this population.
Create a Licensing Process to Experienced Veteran NPs to Practice without Restrictions
Unlike physicians, NPs do not undergo a residency program before entering their practice.
Generally, NPs are trained to provide services similar to primary care physicians, though they do not
complete a post-graduate residency training program.5 However, even in restrictive SOP states, most
NPs describe having latitude to make clinical decisions, although with a greater level of documented
supervision.5 Moreover, individual practitioner traits, such as years at the organization or level of
experience seem to play an important role in determining everyday practice style and the level of
autonomy NPs experience.5
Creating a licensing process for experienced NPs to practice without the restrictions of SOP laws
can be viewed as a similar training mechanism as physician residency programs. After a set number
of years under supervised practice—between 3 and 5 years—an NP will be able to take a licensing
exam, similar to primary care physician licensing exams. Passing this exam will give the NP an
unrestricted SOP. This mechanism restricts the practicing barriers of NP while still ensuring that
they receive adequate supervised training, and therefore may ensure the quality of their care.
Creating an additional licensing exam for NPs on top of their board certification does not
completely remove the barrier restricting their scope of practice. It merely adds another hurdle that
NPs must pass in order to practice what their training already prepares them to do.
Recognize NPs as Primary Care Providers in All Health Care Plans and Programs6
In their training, NPs are given the diagnostic, treatment, and prescribing tools necessary to provide
quality care to patients. Therefore, restrictive SOP laws should be completely removed and payers
should recognize NPs as primary care providers in all programs and settings.6 Given the supply of
NPs currently delivering primary care and the shorter time frame required for training new entrants,
broadening SOP laws for NPs is a possible avenue to expand primary care capacity more rapidly.7 22
states have already allowed NPs to practice independently while others require some physician
oversight for certain services.7 Policy should be changed to remove SOP laws in all states.
Restrictive SOP laws are not the only barriers NPs face in practice. Variation in payer coverage of
NP services indirectly impacts their ability to provide certain types of care. Eliminating the barrier of
SOP laws without addressing the payer issue will not completely address this issue, and since payer
practices vary by plan and by state, this option may be less politically and technically feasible.Elimination of Barriers to RN Scope of Practice Essay
Expand Reimbursement of Public Insurance to Cover NP Primary Care Services
Studies suggest that by increasing the ability of providers to meet increased demand, more liberal
scope of practice laws mitigate the negative spillover effects associated with large public coverage
expansions.3 The positive relationship between coverage expansions and wait times is driven by
practices in states where non-physician caregivers cannot directly bill Medicaid.3 In contrast, states
where these providers can bill Medicaid directly experience no significant increase in wait time for an
appointment.3 These results provide compelling evidence to remove restrictive SOP laws for NPs
practicing primary care in order to increase access to these services.
Federal policies mandating recognition of NPs as primary care providers in Medicare plans and State
policies mandating recognition of NPs as primary care providers in Medicaid managed care
networks could encourage broader and more efficient use of NPs in primary care settings.5
Expanding their role in government-regulated services may be more politically and technically
feasible, especially in regards to implementation across the nation.
It is recommended that the following actions be taken:
• Expand Medicare reimbursement for NP services provided in primary care settings,
providing them with the ability to obtain reimbursement for diagnosing, treating, and writing
prescriptions for these patients.
• Expand Medicaid Managed Care reimbursement for NP services provided in primary care
settings, providing them with the ability to obtain reimbursement for diagnosing, treating,
and writing prescriptions for these patients.
• Provide beneficiaries with information and justification of the policy change.
• Monitor metrics surrounding access and quality as NP scope of practice increases within
As millions of people gain health coverage under health reform and provider shortages worsen, this
policy recommendation has the ability to set a precedent. Previously, Medicare policy changes have
acted as a model for change in the private insurance market.2 The success of this policy has the
ability to spark future discussions to remove these barriers in the private insurance market as well.
The Obama administration and the interest groups that worked to enact the Patient Protection and
Affordable Care Act are hopeful that it will help salvage the country’s broken healthcare system,
provide more consumer-friendly insurance coverage for all or some of the nearly fifty million
Americans who are currently uninsured, and reduce the rate of increase in healthcare costs, if not the
total amount expended.
Many aspects of healthcare reform, including insurance coverage, portability, and mandates, are being
addressed at the federal level. Nonetheless, there are at least two elements (scope of practice and
continuing competence) that must be addressed by the states because the legal authority resides in
state-based health professional licensing laws. Although stronger continuing competence Elimination of Barriers to RN Scope of Practice Essay
requirements at the state level could significantly enhance healthcare quality, that aspect of reform is
beyond the scope of this paper.1
Here, we concentrate on scope of practice regulations, which directly
impact the composition and productivity of the healthcare workforce. Depending on how they are
written and implemented, scope of practice laws can either limit or promote access to care, thereby
affecting the quality and cost of services.
By covering a significant number of the currently uninsured, federal health care reform will increase
demand for healthcare services and thereby compound already worrisome shortages of healthcare
personnel, especially among primary care physicians and nurses practicing in all settings. Paradoxically,
having an overtaxed healthcare workforce is an incentive for policymakers to take a fresh look at the
subject of this paper: the scope of practice regulations that specify which services various healthcare
professions are permitted to provide to whom in what settings. It is increasingly recognized that scope
of practice restrictions often prevent professionals other than physicians from practicing to the full
extent of their training and skills.
In testimony before the House Committee on Energy and Commerce Subcommittee on Health, James
R. Bean, MD, President, American Association of Neurological Surgeons put it this way:
To the degree that the clinical care workforce as a whole needs more providers to address the
changing needs of the population, a strong strategy of support for nurse practitioners and
physician assistants should be adopted. The increased use of PAs and NPs should not be limited
to the primary care section. Both professions have demonstrated excellent functionality as team
members in all aspects of medical practice… Nurse practitioners and physician assistants are
trained more quickly, at less expense than physicians, cost less in practice, and are not, on their
own, drivers of ancillary clinical tests and services. Moreover, they represent a highly flexible
workforce – an important asset generally lacking in the physician workforce… NPs and PAs
provide a well-proven quality, clinical workforce that can interdigitate with all aspects of physician
practice and whose pipeline can be turned up or down as needed to assist in addressing emerging
or changing clinical needs.Elimination of Barriers to RN Scope of Practice Essay
Swankin, D., LeBuhn, R., Morrison, R., Implementing Continuing Competence Requirements for Health Care
Practitioners, AARP Public Policy Institute, #2006 – 2016, July 2006.
Bean, James R., MD, Testimony before the House Committee on Energy and Commerce Subcommittee on
Health, March 14, 2006.
Further, changing scope of practice laws represents an important way to control long-term health care
costs. The Engelberg Center for Health Care Reform, at Brookings Institution in the report, Bending the
Curve: Effective Steps to Address Long-Term Health Care Spending Growth, among its
recommendations, points out the need to:
Create incentives for states to amend the scope of practice laws to allow for greater use of nurse
practitioners, pharmacists, physician assistants, and community health workers.3
While it might make sense to address scope of practice on a national level,4
the authors of this paper
chose to accept the existing legal framework and concede the difficulty of cracking the ingrained
tradition of state-level professional regulation. Scope of practice reform is more likely to get attention
at the state level than it is to find its way into an already complex and contentious federal healthcare
reform initiative. So, the premise of this paper is that states should be encouraged to experiment with
new approaches to scope of practice as part of healthcare reform. From this experimentation, there
may emerge a model so compelling that it eventually will be widely adopted as a best practice.
This paper explores three aspects of the relationship between scope of practice reform and healthcare
reform more broadly:Elimination of Barriers to RN Scope of Practice Essay
The contribution of scope of practice reform to access, affordability and quality of care;
The case for consumer involvement and leadership in reforming state scope of practice laws
and their implementation by state licensing boards;
Alternative institutional methods for making scope of practice decisions.
The productivity of the U.S. healthcare system is constrained by an inability to make full and
appropriate use of its professional workforce. Artificial scope of practice restrictions prevent
healthcare professionals from performing the full range of skills for which they have been trained, limit
consumer access to care and choice of providers, and inflate the cost of healthcare. These problems
are greatest in times, as now, of workforce shortages, and they especially impact already underserved
rural areas. Two looming developments will only compound healthcare workforce challenges. These
are the aging of the Baby Boomers (including many physicians and nurses of that generation, whose
retirement will compound workforce shortages) and the surge in the number of insured Americans as a
result of healthcare reform.
State licensing laws define the permissible scope of practice for the healthcare professions. The stated
purpose is to ensure consumers that healthcare workers conduct their practices in areas for which they
are properly trained. However, as a number of prestigious groups have reported, scope of practice
Engelberg Center for Health Care Reform, Brookings Institution, Bending the Curve: Effective Steps to Address
Long-Term Health Care Spending Growth, August 2009.
Students of professional regulation, including the Pew Health Professions Commission and the Center for the
Health Professions at the University of California, San Francisco, and workforce advocates, including the
Association of Academic Health Centers, argue that it is inefficient and irrational to have state legislatures define
health professional scopes of practice fifty times over. These experts would like to see the creation of a national Elimination of Barriers to RN Scope of Practice Essay
body to establish scope of practice guidelines. To do so, they argue, would correct the crazy-quilt situation
where nurses, to cite one example, who share an identical education encounter different scope of practice
parameters in different states. National scope of practice standards, they point out also would eliminate the
unjustifiable state-by-state differences in access and choice available to consumers of healthcare services. Why,
for example, should consumers in some states, but not others, be entitled to make an appointment directly with
a physical therapist?
laws too often protect the economic interests of healthcare professionals by unnecessarily restricting
other professions from providing competent, affordable, and accessible care. The first practice acts
were written at a time when there were only a few healthcare professions. Now, there may be as
many as 30 different practice acts in any given state, a totally different environment, yet still governed
by the old regulations.
Nearly fifteen years ago in 1995, the Pew Health Professions Commission’s Report of the Task Force on
Health Care Workforce Regulation proposed changes in scope of practice regulation in its publication,
Strengthening Consumer Protection: Priorities for Health Care Workforce Regulation. Recognizing that
advances in technology and workforce innovations have blurred traditional boundaries between
professional scopes of practice, the task force called for increased regulatory flexibility. They wrote:
The varying objectives and levels of specificity found in different professions’ scopes of practice
are more than frustrating; they have encouraged a system that treats practice acts as rewards for
the professions rather than as rational mechanisms for cost-effective, high quality and accessible
service delivery by competent practitioners.5
The task force proposed some policy options to advance the following recommendation, which is just
as relevant today as it was in 1995:
States should base practice acts on demonstrated initial and continuing competence. This process
must allow and expect different professions to share overlapping scopes of practice. States
should explore pathways to allow all professionals to provide services to the full extent of their
current knowledge, training, experience and skills.6
More recently, in February 2007 six associations7
representing licensing boards and a certification body
in a variety of professions published a document intended to guide state legislators and regulatory
bodies in their decisions related to scope of practice. In the section entitled, “Assumptions Related to
Scope of Practice,” the authors elaborate on what they believe to be five ground rules about scope of
The purpose of regulation – public protection – should have top priority in scope of practice
decisions, rather than professional self-interest.
Changes in scope of practice are inherent in our current healthcare system.
Collaboration between healthcare providers should be the professional norm.
Overlap among professions is necessary.
Practice acts should require licensees to demonstrate that they have the requisite training and
competence to provide a service.Elimination of Barriers to RN Scope of Practice Essay
In May 2009, the National Council of State Boards of Nursing urged the Obama administration and
Congressional authors of healthcare reform legislation to consider several policy priorities, including
maximizing the use of all licensed healthcare providers by supporting overlapping scopes of practice:
Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century, Report of the
Taskforce on Health Care Workforce Regulation, December, 1995, p. 10.
Taskforce, p. 9.
Association of Social Work Boards (ASWB), Federation of State Boards of Physical Therapy (FSBPT), Federation
of State Medical Boards (FSMB), National Board for Certification in Occupational Therapy (NBCOT), National
Council of State Boards of Nursing (NCSBN), and National Association of Boards of Pharmacy (NABP).
Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations, 2007, pp 8 – 10.
As scopes of practice evolve, they should be supported, provided care can be delivered in a safe,
effective and efficient manner. For example, advanced practice registered nurses (APRNs) can
safely and effectively deliver primary care, anesthesia and midwifery services.9
A few classic scope of practice debates demonstrate that restrictive scopes can unjustifiably prevent
some healthcare professionals from using their full range of skills and limit consumers’ choice and
access to affordable care. One has to do with whether dental hygienists should be permitted to
practice independently so that they might, for example, visit long term care facilities to clean residents’
teeth without a dentist being physically present. Similarly, many states wrestle with whether advanced
practice nurses need direct supervision by physicians and, if so, how much. Further, regulatory and
business practice restrictions relating to optometry and opticianry interfere with consumer access to
affordable eye care services, typically less costly than those offered by ophthalmologists. The battle
between physicians and podiatrists over whether a foot ends above or below the ankle would be
laughable, if it did not represent a highly questionable limitation on practice.Elimination of Barriers to RN Scope of Practice Essay
Other recently proposed or enacted scope of practice expansions in the states demonstrate that
disputes over scopes of practice can occur anywhere and involve just about any profession. For
example, Utah’s medical association recently opposed an effort to add direct-entry midwives to the list
of professions overseen by the Division of Occupation and Professional Licensing; the Board of
Examiners for Registered Nurses in West Virginia threatened to revoke the licenses of school nurses
who prescribed or dispensed any type of medication without a doctor’s order; West Virginia speech
therapists were angry with the Board of Education for permitting speech/language assistants to treat
public school children if no speech/language therapists were available; and doctors and advanced
practice nurses in Florida have battled over whether a physician must be present when a nurse
anesthetist administers anesthesia, whether advanced practice nurses can prescribe controlled pain
medications, and whether new patients must be seen by a dermatologist or may be seen by an
advanced practice nurse.
Traditionally, competing claims to a scope of practice have been characterized as “turf battles” over
control, prestige, and the all-important right to receive direct reimbursement from third party payers.
Few state level policy makers have begun to see scope of practice as a tool to promote the goals of
healthcare reform: improved access, quality care and lowered costs. The most notable exception to be
discussed in detail below is Pennsylvania where Governor Ed Rendell linked scope of practice changes
to healthcare reform in general.
Most States Are Approaching Healthcare Reform and Scope of Practice in a
Several states (MA, ME, VT, CA, IL, HI, WI, NM, CO, AK, MN, PA and others) have enacted healthcare
reform legislation in recent years, focusing primarily on reining in costs and expanding insurance
coverage. The State Coverage Initiatives (SCI) program sponsored by the Robert Wood Johnson
Foundation and administered by Academy Health observed that:
Finding ways to expand coverage to the uninsured continued to dominate state policy agendas in
2008. The year saw a multitude of state efforts aimed at developing, legislating, and
implementing reforms. While forecasters projected that 2009 would bring renewed energy Elimination of Barriers to RN Scope of Practice Essay
NCSBN Weighs in on Health Care Reform, NCSBN Press Release, May 13, 2009.
many states’ coverage efforts, the nation’s serious economic ills are causing an about-face such
that state officials are now concerned whether progress by states can continue to be made.10
States have undertaken a variety of worthwhile initiatives, including such things as increased Medicaid
spending, and other measures to expand insurance coverage and access to care; advancements in
health information technology infrastructure, evidence-based care, and other delivery improvements;
and promoting wellness and illness prevention.
Public/private partnerships are operating in at least ten states with the goal of improving healthcare
quality, expanding access and containing costs. A summary of the activities underway in the ten states
(CO, KS, ME, MA, MN, OR, PA, RI, VT, and WA) confirms that only in Pennsylvania is scope of practice
reform a central part of healthcare quality improvement efforts. Quality Improvement Partnership
accomplishments in the other nine states include infrastructure development, public reporting of
quality indicators, experimentation with the medical home concept, adoption of payment efficiencies,
data gathering to support evidence-based treatment decisions, chronic care disease management, and
nosocomial infection control.11
Largely unrelated to healthcare reform, legislative initiatives in a variety of states have sought scope of
practice expansions for various non-physician professions. There is nothing new or unusual about
these initiatives, a number of which are described later in this paper. State legislatures have been
fielding requests for scope of practice changes for decades. Medical societies, dental societies, and
other interests who feel threatened by another profession’s scope expansion typically push back.
Case Study: Pennsylvania
“Prescription for Pennsylvania” was announced by the Governor in 2007 and almost completely
enacted by the legislature as of 2009. The goals of the scope of practice plank of the Prescription are
to relieve shortages of primary care providers; ensure access to cost-effective healthcare for citizens of
all racial, ethnic, and language backgrounds; improve access to healthcare services in evenings and
weekends; and, increase the diversity of the healthcare workforce. These goals are reflected in
legislation intended to remove unnecessary restrictions that prevent licensed healthcare providers –
including nurses, advanced nurse practitioners, and physician assistants, social workers, midwives,
pharmacists and dental hygienists – from practicing to the fullest extent of their education and
training.Elimination of Barriers to RN Scope of Practice Essay
The original legislation introduced in 2007 was an omnibus bill (HB 700) calling for comprehensive
healthcare reform. It included provisions related to access to insurance and insurance rates, charitable
care institutions, price transparency at drug stores, hospitals and outpatient clinics, the use of health
information technology, patient safety, the creation of a Center for Health Careers and a Health
Careers Leadership Council, health professional education and training, as well as scope of practice
expansions for a variety of professions. Shortly after it was introduced, HB 700 was broken up into
more manageable pieces with the scope of practice issues separated out by profession Elimination of Barriers to RN Scope of Practice Essay
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