“Our friend, Gale Adcock, FNP, joins us again for another guest blog titled Nurse Practitioner Regulation. This is part two of a three blog series by Representative Adcock. A big thank you again to Rep. Adcock for helping spread knowledge to our nurses and nurse practitioners throughout this great state.
Guest blogger series: Nurse Practitioner Regulation, Part 2 Representative Gale Adcock, FNP
In this second installment, we’re rolling back the clock more than 25 years to a period of significant advancement in the evolution of NP Rules.
Where we started
A mid-1970s amendment to the Medical Practice Act authorized nurse practitioner (NP) practice, conferred prescriptive authority and provided NP title protection (all great). But it also required physician supervision and joint regulation (necessary compromises that were not so great). Physician supervision and joint regulation as defined in the initial NP Rules were not huge obstacles to the small number of early NP pioneers. It would take almost 20 years before NPs became frustrated and vocal about certain Rule constraints.
The initial Rules required NPs to prescribe using a restrictive one-page formulary. NPs could order only a 30-day supply of meds from listed drug families and could order refills only for oral contraceptives, prenatal vitamins and fluoride. Controlled substances (CS) were expressly prohibited.
Listening to NPs voice concerns about the negative impacts of the prescriptive Rules led the Joint Subcommittee (JSC) in late 1992 to convene a task force to review them and suggest changes to facilitate patient care by NPs and certified nurse midwives (CNMs).
The magnificent seven
The task force had one representative each from the NC Nurses Association, NC Medical Society, NC BON and NC Medical Board, plus a practicing NP (me), a practicing CNM and a current supervising physician. Between January and August 1993, this 7-member task force met jointly four times and held additional subgroup meetings to create surveys and summarize the data collected.
The first survey was mailed to 20 state Boards of Nursing asking about their mechanisms for NP and CNM prescriptive authority. The survey had an impressive 85% return rate and these key findings:
- A majority of respondents implemented prescribing privileges through a physician—advanced practice nurse agreement instead of a standard formulary.
- CS could be prescribed in a majority of respondent states, with some restrictions.
- Except for CS, refills were most often limited to one year.
A second survey was mailed to the 685 NPs and CNMs currently approved to practice. With a 52% response rate, these were the areas of dissatisfaction:
- Restriction on refills.
- Restriction on allowed number of dosage units.
- Drugs/drug classes too narrow to meet patient needs in different practice settings
In preparing their report, the task force used the survey results and the experience of its members in active practice.
Taking the leap
The group focused on how to facilitate the delivery of safe, effective and efficient care in a way that acknowledged the diversity of NP/CNM practice settings. Other factors were also considered:
- Statutory language was clear that supervising physicians had ultimate responsibility and accountability to ensure appropriate prescribing by NPs and CNMs.
- It was inherently difficult to create one formulary to meet all NPs’ and CNMs’ patients’ needs.
- Recent changes in federal law allowed NPs, CNMs and PAs to apply for a DEA number (if permitted to prescribe CS by their state) and they would be held directly accountable for compliance with DEA regulations.
I recall our task force conversations as frank and lively. NPs did not get everything we wanted (for instance, no refill restrictions on Schedule II CS beyond those imposed by the DEA). Ultimately the task force made these recommendations to the JSC:
- Discontinue use of a formulary.
- Require NPs, CNMs and their supervising physicians to establish an agreement regarding drugs and devices that could be prescribed in each practice setting.
- Require that written standing protocols include a this agreement specific to the practice setting.
- Allow CS to be prescribed, ordered and dispensed by NPs/CNMs with a DEA number and as part of the (drug and device) agreement with these restrictions: dosage units limited to a one-week supply [changed to a 30-day supply based on public hearing comments]; no refills without a specific written or verbal order from the supervising physician; NP/CNM DEA number entered on each CS prescription.
- Allow refills of all meds except CS for period not to exceed one year.
First the JSC and then both Boards approved the recommendations. The proposed Rule changes made it successfully through the rulemaking process and the “new” prescriptive authority Rules became effective in 1994. With just a few tweaks to Schedules III, IV and V refills a few years later, these are the same Rules that NPs and CNMs use today, over 25 years later.
More to do
The task force’s one charge was to review and make recommendations about prescribing, although other Rules obviously needed evaluation and revision, such as a requirement that supervising physicians countersign all patient visits performed by NPs within 7 days.
Coming up in Part 3, how the successful 1993 task force model was used to advance discussions about APRN/physician collaboration and, ultimately, how this led to another revolutionary change in NP Rules—a new definition of physician supervision.