WASHINGTON — A report released Tuesday may give nurses with advanced degrees a potent weapon in their perennial battle to get the authority to practice without a doctor's oversight.
The report, released by the Institute of Medicine and sponsored by the Robert Wood Johnson Foundation, says nurses should take on a larger and more independent role in providing health care in America, something many doctors have repeatedly opposed, citing potential safety concerns. It calls for states and the federal government to remove barriers that restrict what care advanced-practice nurses — those with a master's degree — can provide.
The report calls for elimination of "regulatory and institutional obstacles," including limits on nurses' "scope of practice" — which are state rules about what care people who are not physicians can provide.
The findings come from a committee on the future of nursing, a collaboration among nurses, doctors, health-care business leaders and academics that studied the issue for two years. While the report addresses an ongoing battle being played across state legislatures, it's not clear if the new report will have any impact on those battles. The panel is planning a meeting next month to discuss ways to implement its recommendations.
The new federal health-care law provides more funding for nursing education and nurse-led clinics, but this study could also propel the nurses' argument for more authority to deliver care independently from physicians.
"We cannot get significant improvements in the quality of health care or coverage unless nurses are front and center in the health-care system — in leadership, in education and training, and in the design of the new health-care system," said Donna Shalala, a former health and human services secretary and chair of the Institute of Medicine's committee on the future of nursing. "We can't be fighting with each other if we really are going to have a high-quality system that we can afford."
For years advanced-practice nurses — as well as a host of other caregivers such as chiropractors and physical therapists — have butted heads with doctors over "scope of practice" considerations. Doctors maintain that even with an advanced degree, these nurses do not have the same education that physicians get in medical school and residency programs and that patient safety could be compromised. They are also wary that their practices could see significant patient losses if the nurses were allowed to practice more independently.
In its recommendations, the committee said Medicare and Medicaid should reimburse advanced-practice nurses the same as a physician for providing the same care. "When you do the same job, you ought to be paid the same," Shalala said.
Also, the report calls for nurses to be allowed to admit patients to the hospital or to a hospice and for the Federal Trade Commission and the Department of Justice to review existing scope-of-practice provisions for "anticompetitive" practices.
The Obama administration has signaled its commitment to increasing the number of primary-care providers, including nurses. Late last month the Department of Health and Human Services announced $320 million in grants to strengthen the health-care work force. The grants include $31 million to 26 nursing schools to increase full-time enrollment in primary-care, nurse-practitioner and nurse-midwife programs and $14.8 million for nurse-managed health clinics. In addition, Peter Buerhaus, a registered nurse, heads the newly formed National Health Care Workforce Commission, which was set up under the new law to advise lawmakers on how to change the health-care work force to better fit America's needs.
Experts predict that more physicians, nurses and other medical professionals will be needed to care for the 32 million additional Americans who will get coverage beginning in 2014 under the sweeping health-care law. Nurses' groups say that they can help ease a physician shortage. The Association of American Medical Colleges said in a new report that in 2015, there will be a shortage of nearly 63,000 doctors across all specialties in America.
Dr. Rebecca J. Patchin, a former nurse who is now an anesthesiologist and a member of the American Medical Association's Board of Trustees, said physicians must be involved, to help protect patients. "We think that care in the operating room or care in the office is best done with physician involvement and oversight," Patchin said. "Due to that additional training that they have … when or if a complication occurs, they are better equipped to handle it."
The battle is being waged across the country. Colorado, for instance, recently became the 16th state to allow nurse anesthetists to work without a doctor's oversight. In Michigan, nurses are pushing for legislators there to allow advanced-practice nurses to prescribe drugs. Other fights over scope of practice for registered nurses loom in Kentucky, North Carolina, Iowa and Minnesota.
But Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, said the clashes between nurses and doctors scare the public. "It's exactly what people worry about when they worry about what health reform will bring," he said. "Patients and voters say, 'If you're talking about taking the docs out of my health care, I want no part of it.' "
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I think increasing the role of nurses for primary care is a step forward in alleviating the primary care shortage. However, I don't think this is the only way to go about it. By increasing nurse's scope of practice, you may cause confusion among patients as to who really are doctors. I've read stories about how some nurse practitioners asked patients to refer to them as "Dr. So and So" even if they didn't have any MD or PhD next to their name.
I'm curious as to how this may affect reimbursement rates for doctors. If insurance companies see that nurses are willing to provide a service for a reduced price (considering they don't pay malpractice fees), they may force doctors to accept less.
Anyways, I do feel nurses should be given more freedom in a primary care setting, but I don't think they should be paid the same, nor should they be allowed to treat patients the same. The person quoted that if you do the same job, you should get paid the same. That's a good point, but there is always the issue of quality of care, one that a doctor ideally should be more apt to provide.