What was envisioned as a 3-part series will actually be more. There is a lot more history to share. Click here for Gale’s last installment in this series.
To recap Part 2, in 1992 the Joint Subcommittee (JSC) appointed a task force to review prescribing regulations for nurse practitioners (NPs) and certified nurse midwives. From this group’s work, major rule revisions for prescriptive authority were implemented in March 1994.
Stakeholders for change
The same task force was reconvened in July 1994 to review NP rules in their entirety and propose revisions to the JSC for consideration. The task force received a lot of input:
- The NCNA NP Council wanted revisions to the definition of supervision and primary/backup supervising physician; approval to practice not tied to practice site; “inactive” approval status; addition of an NP scope of practice (SOP); and approval to practice renewal linked to continuing education.
- NPs employed in hospitals, long-term care facilities, hospice and dialysis centers requested a more realistic physician co-signature timeframe based on their special patient populations.
- The NPs on the task force wanted to increase consistency between NP Rules and physician assistant (PA) Rules wherever it was advantageous to do so.
At the request of the task force, a special work group was appointed by the JSC to review the NP education program requirements and approval process. Suggestions from that special work group were incorporated into the task force’s final Rules revision recommendations.
Progress made
Although some compromises were inevitable in the process (example: some of the original SOP language was deleted), additional significant changes were made in NP Rules as a result of the task force’s additional work.
The JSC accepted the final task force report, made some minor changes and submitted the proposed Rule revisions for adoption by both the Board of Nursing (BON) and the Medical Board in July 1995. The formal Rules revision process was completed in December 1995 and the new NP Rules became effective January 1, 1996.
Impact
Tangible results of the new Rules included a shorter application and a streamlined application process that decreased time from application to approval. Because approval to practice was no longer tied to an NP’s practice site (instead it was linked to the primary supervising physician), it was less complicated for NPs with locum tenems assignments and NPs with multiple practice settings to obtain additional approvals to practice. Adding a backup supervising physician became as simple as keeping a signed and dated agreement at the practice site.
The new ability to prescribe a 30-day supply of specific drugs for the treatment of ADD/ADHD was an improvement in the day-to-day practice of many nurse practitioners, especially those in pediatrics.
More philosophical gains were the recognition of the independent accountability of NPs and the acknowledgment that there was an NP SOP rather than the implication that NPs practiced solely at physicians’ direction.
Conclusion
Although it was understood that NP Rules would require additional scrutiny and revision over time, this did not diminish task force members’ appreciation for the power of the process or the utility of the results.
The NP Rules that went into effect January 1, 1996 included:
- A definition of supervision which clarified the physician’s role in overseeing “medical acts” only (not nursing acts or other nursing functions).
- Clearer definitions of primary supervising physician and backup supervising physician.
- A definition of NP which included this statement: “It is understood that the nurse practitioner by virtue of RN licensure is independently accountable for those nursing tasks which he or she may perform”.
- Inclusion of an NP scope of practice (for the first time).
- Clarification of content and contact hours for core curriculum in NP education programs; required evidence of course content in diagnostic reasoning, pathophysiology and pharmacology; and national certification in lieu of NP education program approval which was important for NPs who graduated from out-of-state programs.
- Clarification of the approval to practice process that delineated each Board’s responsibility, with the BON given full responsibility for reviewing and approving NP education programs and recognizing national credentialing bodies that certified NPs and/or approved NP continuing education.
- Approval to practice linked to the primary supervising physician instead of the practice site.
- A process for adding backup supervising physicians that eliminated the previous requirement for Board notification, an application and an application fee.
- Inactive status that could be requested by previously approved to practice NPs not currently employed as NPs.
- An increase in the fee for initial approval to practice (to $100).
- A requirement for 30 hours of CE every two years to renew approval to practice, three hours of which had to be the study of medical and social effects of substance abuse, including abuse of prescription drugs, control substances and illicit drugs.
- The ability to write 30-day prescriptions for certain Schedule II CS (dextroamphetamine, methylphenidate and Pemoline) for the treatment of ADD/ADHD.
- Change in the time internal for physician co-signature of patient visits for NPs employed in hospitals, long-term care facilities and community-based programs like dialysis and hospice, consistent with institutional or care program rules and regulations.
Coming up next
“Collaboration” becomes a hot topic of conversation among North Carolina’s advanced practice registered nurses (APRNs) and physicians.
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Gale Adcock is an FNP and member of the NC House of Representatives. Contact the author at galeadcock@gmail.com.