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Knowing the Medical Staff Bylaws for your inpatient practice as an advanced practice nurse.

I would like to share some facts with you about how your practice maybe directed and/or decided before you even take a position in a hospital or other inpatient facility. My focus for this article is on advance practice registered nurses (APRNs) who practice in an inpatient setting. The information will also affect those of you who practice in both clinic and inpatient settings. This direction and possible limitation to your practice in the inpatient setting is spelled out in the Medical Staff Bylaws of your employing facility.

In order for you to understand the following discussion, I have to tell you a little secret seldom known by APRNs. Medical Staff Bylaws are a democratic governance set in place and mandated by The Joint Commission. I am sure it comes as no surprise that this democratic governance is usually directed, managed, and overseen by physicians. I have heard of a few smaller, more rural facilities having APRNs as medical staff officers and even part of the governing structure, but this situation appears to be atypical and not the norm.

The bylaws are set up to be a form of governance to provide organization, classification, and control of "citizenship" in a facility, as well as a framework for quality. They must provide a category for or definition of where each person involved in patient care fits in the medical staff. This category and definition must include a statement of the duties of each type of staff member and define that position's eligibility to vote on the bylaws as part of the medical staff. Often, these categories of citizenship are identified by such terms as full/active, ancillary, casual, honorary, and licensed independent providers (LIPs), among others. Since the 2010-2011 update from The Joint Commission, APRNs must be allowed recognition as a part of the medical staff and have a designation in the bylaws. On one hand, this is great news; unfortunately, it is also part of the problem.

Where Do APNs Belong?

I am sure many of you are asking where APRNs fit in the medical staff designations. What category are we? Unfortunately, the answer is not that simple.

The Joint Commission does not say how APRNs-note that the term also includes the certified registered nurse anesthetist (CRNA) and certified nurse midwife (CNM)-should be categorized or placed in the bylaws. It would be much easier if The Joint Commission had made the APRN position more clear-cut. But it did not, and this is where it gets challenging. Each state may have a different designation for APRNs with licensing, which makes it impossible for this type of article to provide information that can be applied across the board. As an example, let me tell you about Wisconsin since this is where I practice. I am licensed as an RN as well as an advanced practice nurse prescriber (APNP). I hold a separate license to prescribe in Wisconsin, but not as an APRN. One major difference in Wisconsin is that CNMs have a separate license from the board of nursing. The Medical Staff Bylaws at my place of employment have placed APNPs as ancillary staff and CNMs as LIPs. Is everyone with me so far? Clear as mud, right?

Why is this important? The categories of citizenship for the APNP and CNM define and delineate what they may do and how they may do it. In essence, LIPs may practice independently, ie, without the "attending physician" required for APRNs, who are considered ancillary staff members. When I began to learn more about this distinction, I had a very difficult time understanding why APRNs are being treated differently. It took me several years to really understand the intricacies. Every facility, no matter where it is located, has the right to be as strict with the delineation of medical staff privileges and control of citizenship as is deemed appropriate. Be cause being an APNP does not include a license to be a provider, other types of APRNs are placed differently than the CNM. I am sure that many APRNs have already run into this situation and are aware of the basic unfairness of our being segregated because of a state's arbitrary designation. Another part of this problem stems from a particular facility's corporate compliance office reading the rules, regulations, and laws in the state and determining how everyone should be placed based on the "letter of the law" alone.

However, there is a ripple effect, leading to far-reaching consequences. This lower designation for APRNs is likely to be part of the problem for those of you who are new to inpatient practice or who continue to meet resistance with medical records for some unidentified reason. All APRNs need to be aware of the Medical Staff Bylaws affecting their work environment. As part of the medical staff, each of you has a designation within the citizenship at your respective facility. As previously mentioned, your placement also affects your ability to vote as part of this democracy. My own personal experience and what I have been told by others indicate that unless you are a full/active member of the medical staff--which I am not--you do not have voting privileges.

As part of the medical staff, you have the right to see, read, and understand the institution's bylaws. Informal surveys of APRNs that I have conducted in the last few years suggest that many APRNS have neither heard of nor seen the bylaws that so profoundly affect their position. Following my talk on this topic, several APRNs have sent emails stating that they finally saw the bylaws for their facilities and were appalled at what they read. Some of them found the bylaws to contain errors and misinterpretations of state regulations. On the upside, I have seen a hopeful trend toward "loosening" the bylaws, especially in critical-access hospitals. I personally believe the existing limitations for APRNs are now being loosened to clear away some of the barriers to optimum practice, such as those requiring co-signatures, a physician on site, and an attending physician instead of an APRN be the clinician of record, just to name a few.

What Can You Do?

Whether you are a newly graduated APRN looking for your first job or a seasoned veteran seeking a new position, you need to be aware of the Medical Staff Bylaws that influence the way you are allowed to practice. Here are four steps that I recommend you take when considering a place of employment or shortly after being hired.

1. Ask for a copy of the bylaws; this can either be a paper copy or the electronic location if they are online or available on the hospital's intranet.

2. Identify the delineation in which APRNs have been placed.

3. Read and understand your delineation.

4. Be sure to network with other APRNs who work in your facility. I have found this to be essential in unifying APRNs for added influence and allowing all of you to gain a better understand of the bylaws.

But, what comes next? You have obtained a copy of the Medical Staff Bylaws. After reading them, you realize that the set of bylaws affecting your position is really incorrect or out of date. Is there anything you can do? Part of The Joint Commission regulations for Medical Staff Bylaws also state that there must be an annual or biannual period identified for correcting the bylaws. Every member of the medical staff has the ability to be heard on needed corrections; this right is not contingent on your citizenship designation. There should be a section in the bylaws that clearly outlines how additions or amendments can be accomplished.

My experience with editing and updating Medical Staff Bylaws was very lengthy. First, it took several peers and myself about 8 months to thoroughly review all 112 pages. Second, any proposed corrections to our bylaws had to be submitted 2-4 months before the annual meeting. Third, personnel in the medical staff office had to give copies of any purposed changes to the bylaws to the medical staff for review before the annual meeting. If cleared at that point, the corrections could be voted on at the annual meeting. Do you remember my earlier comment about voting? Since only full/active staff members can vote, proposed changes may fail to be voted into the bylaws because you, as ancillary staff, are not allowed to vote on them. And that is one important way that things always seem to stay the same. The bylaws are not updated to allow you to vote because you were not able to vote for the change. Can you feel the frustration? Of course, the exact conditions will be different in every facility.

So, how do we as APRNs accomplish anything if we cannot even vote on needed changes? I found that I had to "get to know" several people involved in this process so that everyone fully understood what the Medical Staff Bylaws actually say, what the APRN scope of practice states, and how the current bylaws maybe limiting our practice. I cannot overstress the importance of your getting to know the medical staff officers. Remember that the bylaws are a set of governance. There will always be officers, and, if your facility is large enough, you may have a specific medical staff officer, or MSO. I went out of my way to get to know these physicians. Much of my time was spent educating them on APRNs and our true scope of practice in accordance with the state.

Depending on each state and the current "mood" of the medical societies who have a place at the decision-making table, it may be difficult, even impossible, for you to get to know the people who wield the power. As fellow advocates for nursing and APRNs, we need a place at that table--especially now. As we move toward APRN licensing that is unified and consistent across all 50 states, bylaws will have to be changed. Our citizenship under those bylaws needs to be made more consistent with our vital role in inpatient care. Moving forward from here, it is essential for you to continue networking with peers, Facebook friends, co-workers, and even meeting attendees at your next conference. That is how we will find our spot at the table.

By Jeff Kobernusz, MS, RN, APNP, ACNP-BC

Secretary/Treasurer WNA APN Special Interest Group Board of Directors
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Title Annotation:APRN FORUM UPDATE
Author:Kobernusz, Jeff
Publication:STAT Bulletin
Date:Sep 1, 2012
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