Prescriptive authority.This is the eighth of a series of articles relating to WNA's 100th Anniversary.
Key factors came together within nursing, health care environment, public needs, and government to produce prescriptive authority for Wisconsin's Advanced Nurse Practitioner Prescribers (APNP). Although early there were persons who favored seeking prescriptive authority for all registered nurses, it soon was apparent that the initiative would focus on the nurses who were practicing in expanded roles which had been recognized since 1971. These nurses included Nurse Practitioners NPs), Clinical Nurse Specialists (CNS), Certified Nurse Midwives (CNM), and Certified Nurse Anesthetists (CRNA).
Also environmental factors included a shortage of physicians, rural and other areas, with a shortage of health care personnel, and issues with the lack of direct reimbursement of nurse practitioners and clinical nurse specialists. On November 11, 1991, Governor Tommy Thompson recognized the work of Wisconsin's 300 Nurse Practitioners.
There were some victories on the federal scene including updating and clarifying of Medicare Part B related to reimbursement of Nurse Practitioners. In Wisconsin, in the fall and winter of 1989, the fiscal intermediary revised supervision to require a doctor visit, require the doctor to make an individual evaluation and have a discussion with Physician Assistant (AP)/NP, and documentation at the point of doctor involvement, and doctor as well as nurse must sign. Only Wisconsin and New Mexico were enforcing rigidly. These requirements were unacceptable to WNA and in this successful effort to change, WNA worked with the NP Council, Wisconsin Physician's Services and Wisconsin Congressional delegation. The Rural Nursing Inclusion Act of 1990 provided that NPs and CNSs in rural communities could receive direct reimbursement under Medicare along with the Federal Employment Health Benefits Plan (FEHBP) including third party reimbursement. Under this act 40 million dollars for the funding year 1991, was allocated to the National Center for Nursing Research. The federal reconciliation spending bill in August 1997 provided for direct reimbursement of the NP and CNS.
The Wisconsin Department of Health and Social Services promulgated an emergency rule to comply with federal benefits with the addition of nurse practitioner services as a federally mandated Medical Assistance benefit. The 1993 Wisconsin Act 250 related to cost containment and a health insurance plan for small employers which "implements language recognizing the role of non-physician primary care providers and promotes access and funding for health care professionals in underserved areas." Also by March 1996, legislation was introduced to allow the APN to sign medical certification for clients to obtain disability sticker on license plates. Another victory occurred when WIAA changed its bylaws to permit pre-participation sports examinations to be performed and signed by the APNP. In 2004 Governor Doyle signed the provision for injured employees' access to APNP care and services.
Within WNA itself, the Board of Directors reaffirmed previous action defining the requirements for advanced practice nursing to be at least a Masters Degree in Nursing and national certification in agreement with the ANA position. Also a task force was appointed "to define comprehensive strategies to resolve the issues regarding the definition of Advanced Practice RN (APRN.)" WNA collaborated with other nursing organizations such as Tri-Council, Nursing Network, Wisconsin Nursing Coalition, and Primary Care Consortium at the state level. ANA direction and information as well as the experience in other state associations gave comparison data and some assessment of what had worked well or had produced problems in other states. There were already twenty six states which had some form of prescription authority. Two models of regulation produced choice; the substitutability (for physicians) approach and the complementary model in which the nurse prescribed only in collaboration with a supervising physician. WNA favored the independent model.
Studies began to demonstrate support for NP practice. A 1986 report by the Office of Technology and Assessment showed that the practice of NP, CNM and PA was comparable to that of physicians. In twelve of sixteen studies, the quality of nurse practitioner practice was higher based on number of diagnostic tests, effectiveness of interpersonal management, thoroughness of documentation, decreased symptoms, level of blood pressure control, weight reduction, pain reduction, level of activity limitation, and anxiety in chronic disease. In one of the studies, the care by the physician was better in the situation which required management of problems requiring technical solutions. The January 5, 2000 issue of JAMA reported that the NP provides quality of care on a par with that of physicians.
Early in 1993 there was an atmosphere of extensive discussion on prescriptive authority proposals and issues of defining advanced practice. Nurses in expanded roles needed to come to consensus on issues such as definition, preparation, grandfathering, supervision and liability. Physicians also had concerns about practice turf, supervision and their liability for the practice of NPs. The Pharmacy Board also raised issues. But the dialogue and negotiations continued.
AB756 Prescriptive Authority was introduced in November 1993 to authorize the Board of Nursing to certify advance practice nurses for independent prescriptive authority. Judy Pendergast declared: "Throughout discussions with the Governor and a bipartisan representation of legislators, we have emphasized that a key to a successful change in role is the removal of barriers to practice. The ability for nurses to independently prescribe medications will significantly increase the amount of primary care they can provide." (18) Speaking to the bill, she stated, "Wisconsin is in position to take a leadership role. The language in this bill is flexible and futuristic. By placing the details in administrative rules promulgated by the Board of Nursing, it will allow the state to efficiently respond to future changes in needs and delivery systems." (19) A WNA white paper on prescriptive authority was developed.
WNA conducted a 1973 survey of nurses in expanded roles sending out 800 surveys with 491 returned. At the time these Wisconsin nurses were practicing in one of the following fields: medical/surgical, gerontology, psychiatric/mental health, child and adolescent/pediatrics, school nursing, community health, general nursing practice, and maternal/child health.
Three hundred and seventy one respondents reported that they met the ANA definition, which was:
Nurses in advanced clinical nursing practice graduate degree in nursing. They conduct comprehensive health assessments, demonstrate a high level of autonomy and expert skill in the diagnosis and treatment of complex responses of individuals, families, and communities, to actual or potential health problems. They formulate clinical decisions to manage acute and chronic illness and promote wellness. Nurses in advanced practice integrate education, research, management, leadership, and collegial relationships with nursing peers, physicians, professionals and others who influence the health care environment.
Three hundred and fifty nine of these persons supported the definition. The state office of health care information finalized the APN Public Use Date File in June 1974.
Prescriptive authority for nurses bill was signed by Governor Tommy Thompson in 1994 to become Act138 of Wisconsin Statutes. The signing ceremony was held at the Capitol with many nurses present who were attending Day at the Capitol. WNA President Mary Jane Bloom reminded the group to remember the words of Elmer Davis in But We Were Born Free. He wrote "the first and great commandment is, don't let them scare you." She told the jubilant nurses: "... be pleased with the passage of the Prescriptive Authority for Nurses Legislation, which was written by a nurse (Senator Judy Robson), supported by nurses, received bi-partisan support and will alter existing laws governing nursing practice in this state."
A Prescriptive Authority Advisory Committee, as required by the legislation, was formed with representatives from nursing, pharmacy and medicine. Eight nurses served on that initial committee and ten nurses served on a second committee appointed in May 1994. The committee was to advise the Board of Nursing on administrative process for prescriptive authority.
In 1996, Psych/Mental Health and Maternal and Child Health Special Interest Group (SIG) supported an administrative rule change of APN prescribers for adequate professional liability insurance under shared limits policy.
A regulatory alert challenged nursing as the Board of Nursing defined APNP as having a narrow scope of practice and categorizing lab/x-ray/EKG as medically delegated acts. WNA used a collaborative approach teaming with Wisconsin Nurses Coalition to direct a letter to Tim Burns, Chair, Wisconsin Board of Nursing regarding APNP regulations. By April 2000, the Board of Nursing APNP rules had been rejected and the Senate Health Committee on a vote of 4 -2 approved new rules which defined collaboration and provided authority for an APNP to order in his/her name the lab, radiography and EKG appropriate to his/her area of expertise. Also at the state level, Robson's legislation delivered needed prescription drug revisions. (2001). It was a major victory for WNA advocacy and lobbying. In 2006, the APNP Statute Clean-up Bill (AB608) was signed by Governor Doyle.
The WNA Primary Care NP Council began Pharmacology Updates in 1987, a highly successful program which continues annually. Two WNA task forces were appointed in 1996, i.e. Direct Reimbursement for APN and Direct Reimbursement for NP.
In 1999, the Nurse Practitioner Forum began with Mary Schwanebeck presiding. A major activity in 2000 was seeking clarification of the rules pertaining to APNP authority to include ordering of labs, x-ray and EKGs. A second was to explore combining 2 special interest groups (NP and CNS) into an Advanced Practice Nurse Special Interest Group. Benefits anticipated were better communication, better networking opportunities, decreased fragmentation of APN practice, working together on APN Scope of Practice and Legislative Issues, broader involvement and topics at the Pharmacology Update and developing an APN directory. The APN online directory links with the Department of Health Services provider listing. Wisconsin APN Forum implemented Voter Voice, which allows electronic grass roots communication with legislators regarding bills which WNA advocates or opposes. Newsletters and brochures have been used to educate and advocate. Currently APN Forum is enhanced by information in STAT Bulletin and updates.
In 2009, Wisconsin had 74,000 RNs, 2,195 Advanced Practice Nurse Prescribers and 140 Certified Nurse Midwives. The achievement of independent prescription authority was a journey of strong support by Wisconsin Nurses, determined tenacity and collaborative problem solving and advocacy by advanced practice nurses and informed legislative decision making.
Joyce Esser Anderson, RN