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Challenges to ARNPs in Iowa.

A 2007 resolution of the American Medical Association is being played out in Iowa. That 2007 resolution (;mm/469/903i07.doc) contained sweeping statements that the treatment of pain should be handled only by physicians. In November 2007, the American Nurses Association sent a letter to the American Medical Association stating in part that "pain is the most common nursing diagnosis in all delivery-of-care models and management of pain is within the purview of every professional registered nurse. Pain is the primary symptom that drives patients to seek health care services."

In the spring of 2009, the Iowa Board of Medicine issued a draft policy statement that concludes that the practice of chronic interventional pain management is the practice of medicine and is not within the scope of practice of other health care professionals, including certified registered nurse anesthetists (CRNAs) under the broad umbrella of the Iowa Board of Nursing's regulation of advanced registered nurse practitioners(ARNPs).

The Iowa Administrative Rules Review Committee (ARRC) called the Iowa Board of Medicine to address the legislators on that committee on May 12. In discussion of the proposed policy statement, the Iowa Board of Medicine was advised that the "policy" was sufficiently substantive to warrant that it follow Iowa Code 17A- the Administrative Procedures Act and there would be further review at an upcoming ARRC meeting.

The Iowa Board of Nursing held a public hearing on ARNP supervision of fluoroscopy noticed rules on Wednesday, June 3. The rules and public comment were considered at their Board meeting on June 4 and adopted. The Board's rule addressed "supervision" (which infers the ordering and supervision of radiological technologists performing fluoroscopy) and specifies educational outcomes that ARNPs should meet.

The Board of Medicine and the Iowa Medical Society both expressed their objection to the Board of Nursing rule stating that there are no national standards to warrant proactive expansion of ARNPs into this area. The Board of Nursing maintained in a December 15, 2006 statement and reaffirmed on September 7, 2007 that the scope of practice for an ARNP does include the use of fluoroscopy. The request to limit fluoroscopy only to physicians (MDs & DOs) would also impact dentists, chiropractors, veterinarians and radiological technologists, as their associations have so indicated.

The Board of Nursing surveyed the ARNPs in Iowa and consulted with two nurse practitioner associations and the hospital association. Fluoroscopy has been used for more than two decades and in the following practice areas:

1. To locate foreign bodies in patients presenting themselves in emergency rooms.

2. To insert extended length IV lines.

3. To perform breast needle biopsies

4. To view swallowing studies.

5. To locate needles for chronic interventional pain management.

The Iowa Administrative Rules Review Committee met again on July 14 and reviewed the Board of Nursing adopted rules. It was noted that the rules had been worked on for the better part of three years to find agreement. Once again, the Board of Medicine, the Iowa Medical Society and the Iowa Society of Anesthesiologists expressed their opposition to final adoption of the rules; but most particularly in the area of use for chronic interventional pain management which is primarily been used by CRNAs to provide services to the elderly in rural areas of the state. There was a ninety-minute discussion by interested parties in this rule. The physician community requested a "Session Delay" and the vote was 6-3 which failed to move the rule to the legislative session for consideration since seven votes of the ARRC are needed to do so. A "General Referral" (needing only six votes) was passed to recommend the rule for consideration to the full Iowa General Assembly, but the rule goes into effect.

The Iowa Medical Society believes the rules are a scope of practice expansion while the nursing community believes it is a practice long in use in the state. The anesthesiologists are primarily opposed to the use of fluoroscopy for chronic interventional pain management (where CRNAs compete with them to provide health services). The Iowa Hospital Association supports the continuation of ARNPs to use fluoroscopy. In addition to physicians, dentists, dental hygienists, veterinarians, podiatrists and chiropractors all currently are authorized users of fluoroscopy, as are ARNPs in the neighboring Iowa states of Nebraska, Minnesota and Wisconsin.

The rule is only half of the needed clarity. The Iowa Department of Public Health (IDPH) needs to reflect that ARNPs are considered "licensed professionals" for regulations of the radiation machines and radioactive materials. These rules are still under consideration. In a July 21 phone call from IDPH Director Tom Newton to INA executive director, Linda Goeldner it was indicated that the Department of Public Health will use language similar to that of the Iowa Board of Nursing that will extend the rules of the Bureau of Radiological Health to all ARNPs, not just CRNAs. These rules will be coming before the Administrative Rules Committee later this summer/early fall and conversations with legislators are needed to explain how this will continue the patient care that is currently being delivered.

In response to a question asked by a Senator on the ARRC, an observation made by the Governor's Administrative Rules Coordinator, Jim Larew, was that in the discussion he heard only mention of hierarchical supervision and not horizontal "collaboration". Mr. Larew noted that he had been reading about airplane crashes and their cause. The highest probability of error occurred when the social hierarchy among airline pilots created a barrier to communication between all the members of the airline crew. A request was made for the health professionals involved to work together to address the number of Iowans in need of health care services.
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Publication:Iowa Nurse Reporter
Geographic Code:1U4IA
Date:Aug 1, 2009
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