Nebraska nurse practitioners seeking more independence in patient care have bumped up against a powerful dissenting opinion — the state's chief medical officer's.
Two panels earlier this year endorsed autonomous practice privileges similar to those of nurse practitioners in Iowa, Colorado and 15 other states.
But Dr. Joseph Acierno reached a different conclusion. Acierno, director of Nebraska's division of public health, wrote early this month that the state law requiring nurse practitioners to have a practice agreement with a physician should remain in place for now.
Some new graduates without prior nursing experience “lack sufficient clinical experience to practice independently,” he wrote. “The risks of the (nurse practitioners') proposal outweigh the benefits that might arrive from passing it.”
Acierno's finding may be a blow to Nebraska Nurse Practitioners' hopes of getting a bill passed in the Nebraska Legislature next year to remove the required practice agreement from state law.
Nurse practitioners and another group of clinicians, physician assistants, are recognized as increasingly important players in health care. This is especially true as the nation confronts a physician shortage at the same time as the Affordable Care Act is expected to provide health insurance to millions of more Americans.
Nurse practitioners are seen more frequently in clinics than ever before. Nationwide, their numbers increased 31 percent over five years, from 120,000 in 2007 to 157,000 in 2012. Iowa had about 1,615 nurse practitioners last year and Nebraska had about 1,100.
They play a big role, for instance, in the care provided at OneWorld Community Health Centers in Omaha and Plattsmouth. The centers for low-income and uninsured people employ nine nurse practitioners, five certified nurse midwives, 10 physician assistants and 12 physicians.
OneWorld CEO Andrea Skolkin said the centers' nurse practitioners work well as teammates and are overseen by a physician medical director. They handle a large chunk of primary care at OneWorld, she said.
“We wouldn't be able to care for all the patients without them,” Skolkin said. “They're very good at what they do.”
Nurse practitioners, who have master's degrees or doctorates, generally argue that they should be allowed to practice to the full scope of their education and training. That means diagnosing and treating such problems as colds, asthma, sprains and simple broken bones and referring more complex or severe cases to physician specialists, they say. Nurse practitioners tend to provide primary care but may also work in specialty clinics, directly under specialists.
Seventeen states and Washington, D.C., don't require nurse practitioners to have practice agreements with physicians.
The Nebraska Nurse Practitioners goal of adding Nebraska to that group of states had been bolstered by the findings of a technical review committee and those of the Nebraska Board of Health, both of which recommended that nurse practitioners have “full practice authority” and not be tethered to a supervising physician.
Kathy Hoebelheinrich, executive secretary of Nebraska Nurse Practitioners, a 500-member association, said the notion that nurse practitioners simply want “independent practice” privileges isn't accurate. “We're educated to consult, collaborate and refer,” said Hoebelheinrich, a Lincoln nurse practitioner. “We're very well prepared to work in teams and work in collaboration with others.”
Cora Schrader, a lobbyist for Nebraska Nurse Practitioners, said nurse practitioners are meeting with state senators and looking forward to introducing legislation in the next session, which opens in January.
Schrader said she hasn't identified a senator to introduce the legislation, “but we're hopeful that we'll identify the right person for carrying the issue” through the Legislature. Similar nurse practitioner proposals have gone to legislative committees before and stalled, as recently as five years ago, Hoebelheinrich said.
Nurse practitioners argue that in some cases, finding a partnering physician can be difficult. When a physician leaves or retires, that interrupts the nurse practitioner's ability to treat patients. Hoebelheinrich said Nebraska loses some nurse practitioner graduates to states such as Iowa that don't require the integrated practice agreement.
The relationship between the nurse practitioner and the physician partner varies. In many cases they work closely in the same clinic, but in rural areas, miles might separate them. Nurse practitioners confer with their physician partner, and the physician may review some or all of the nurse practitioners' charts.
Schrader said some physicians perform this service at no charge to nurse practitioners. Others charge a little and, in rare instances, doctors charge thousands of dollars, she said.
At Nebraska Nurse Practitioners' request, the nurse practitioners profession this year underwent a formal scope of practice review overseen by the Nebraska Department of Health and Human Services. The results of that review will serve as advisory information to the Legislature's Health and Human Services Committee.
Information provided to the technical review panel indicated that nurse practitioner training subjects students to 500 to 1,000 hours of clinical training, compared with physicians' 12,000 to 16,000 hours.
Pat Coyle-Rogers, Clarkson College's director of graduate nursing, said nurse practitioner students “have plenty of experience” working with patients to be able to focus on primary care problems when they graduate.
Nurse practitioners “always send patients that are above their scope to physicians” who specialize in those patients' problems, she said in an interview.
Dr. Rick Blatny of Fairbury, Neb., president-elect of the Nebraska Medical Association, said nurse practitioners are “a valuable member of the team” but shouldn't practice independently. Some symptoms are subtle and vague, he said, and can stem from cancers, kidney problems and heart diseases that nurse practitioners might miss initially.
“We want to work with them,” Blatny said, “but we just believe they should be part of a team.”
The seven-person technical review committee appointed by the state medical director recommended this year that nurse practitioners “be permitted to practice without having a collaborative agreement with a physician.” The committee added that there should be “some form of supervision or mentorship for new nurse practitioners. ”
The Nebraska State Board of Health, the second panel to examine the issue, reached a similar conclusion. The board added: “Additional measures of ongoing competency, above and beyond current continuing education, should be developed” for nurse practitioners.
Acierno, however, didn't agree with those panels. He declined to give an interview. He wrote in a two-page report that the current system “has not worked as intended.” Nurse practitioners find it burdensome and doctors fear liability for “the actions of persons over whom they have little or no control.”
He wrote, though, that he found no evidence that the public suffers in the current situation or that many nurse practitioners can't find a doctor willing to sign a practice agreement.
Acierno went on to suggest that the practice agreement might be unnecessary if nurse practitioner graduates underwent training similar to a physician's residency training. He also suggested that the practice agreement might be limited to new and inexperienced nurse practitioners.