NURS 4
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CHAPTER4GovernmentResponse-Regulation7.docxConclusion
The capacity to adapt is crucial in an era of rapid change. Today’s politically astute nurses have many opportunities to shape public policy, by working in coalition together and with other health professionals and consumers, and to advocate for state and federal health policies and regulations that will allow the public greater access to affordable, quality health care. The window of opportunity that opened with the enactment of the comprehensive ACA will look somewhat different as we move forward. It is essential for nurses and APRNs to develop skills to capitalize on the chaos present in the healthcare and political environments and to create opportunities to advance the profession as a whole. Familiarity with the regulatory process will give nurses and APRNs the tools needed to navigate this dynamic environment with confidence. Knowing how to monitor the status of critical issues involving scopes of practice, licensure, and reimbursement will allow APRNs to influence the outcomes of debates on those issues. Participation in specialty professional nurse organizations is especially advantageous. Participation builds a membership base, providing the foundation for strong coalition building and a power base from which to effect change in the political and regulatory arenas. Participation also gives members ready access to a network of colleagues, legislative affairs information, and professional and educational opportunities. Although supporting the profession through participation is central, it is equally important to remember that each professional nurse has the ability to make a difference.
Discussion Points
Compare and contrast the legislative and regulatory processes. Describe the major methods of credentialing. List the benefits and weaknesses of each method from the standpoint of public protection and protection of the professional scope of practice. Discuss the role of state BONs in regulating professional practice. Obtain a copy of a proposed or recently promulgated regulation. Using the questions in Exhibit 4-1, analyze the regulation for its impact on nursing practice. Describe the federal government’s role in the regulation of health professions. To what extent do you believe this role will increase or decrease over time? Explain your rationale. Analyze the pros and cons of multistate regulation (choose multistate regulation of RNs, APRNs, or a combination). Based on your analysis, develop and defend a position either for or against multistate regulation. Prepare written testimony for a public hearing defending or opposing the need for a second license for APRNs. Contrast the BON and the national or state nurses association vis-à-vis mission, membership, authority, functions, and source of funding. Identify a proposed regulation. Discuss the current phase of the process, identify methods for offering comments, and submit written comments to the administrative agency. Evaluate the APRN section of the nurse practice act in your state using the NCSBN Model Act (NCSBN, 2012) or regulations using the NCSBN Model Rules (NCSBN, 2014a). Identify the states that have implemented nurse-staffing ratios. List some of the obstacles one of the states has encountered in the implementation phase.
CASE STUDY 4-1: Delegation of Medication Administration by APRNs
The authority to administer medications in one state is restricted and specific. The NPA allows RNs to delegate medication administration only to BON-certified medication aides in nursing homes and residential care facilities. Otherwise, unlicensed persons may only assist an individual with self-administration of certain medications, may give oral medication or apply topical medication in accordance with the laws and regulations of the Department of Disabilities, and may administer prescribed medication to a student if the RN is employed by a board of education or charter school if those medication administration procedures are in accordance with the laws regulating boards of education. However, with the exception of these special instances, RNs and APRNs are not permitted to delegate medication administration to non-nurses, including medical assistants. This restriction is problematic for APRNs, particularly NPs and CNSs who function in primary care settings. Patients in primary care settings frequently need immunizations, tuberculosis skin tests, and routine medications. Because the current law largely prohibits APRNs from delegating medication administration to unlicensed personnel, the flow of patient care must be interrupted. APRNs must perform all medication administration and associated tasks themselves, unless there is another RN who is available to administer the medication. This prohibition is a significant barrier to productivity and efficiency. APRNs and stakeholder nurse associations approached a legislator who has been a friend to nursing and is interested in improving healthcare delivery in the state. This member of the state House of Representatives sponsored a bill to allow APRNs to delegate medication administration to a trained, unlicensed person, such as a medical assistant, so long as certain conditions are met. These conditions include (1) the APRN has assessed the patient prior to administration to determine appropriateness; (2) the APRN has determined the unlicensed person has completed the requisite education and has the knowledge, skills, and ability to administer the drug safely; and (3) delegation is in accordance with rules that are established by the BON. Additional safeguards include (1) the drug must be within the formulary established by the BON for APRNs, is not a controlled substance, and is not to be administered intravenously; (2) the employer has given the APRN access to employment records documenting the unlicensed person’s education, knowledge, ability, and skills with regard to medication administration; and (3) the APRN must be physically present at the location where the drug is administered by the unlicensed person. Language in the bill clarifies that the APRN delegating authority would not affect or change the current law governing delegation authority in certain facilities, including nursing homes and residential care facilities. This legislation received four hearings in the House Health Committee and was reported out with two sponsor amendments. One amendment added ambulatory surgical facilities to the list of sites where an APRN cannot delegate medication administration, and the other moved the rule authority language to the general rule authority of the nurse practice act. Although this second amendment is technical, it is beneficial to APRNs in that it will authorize the BON to promulgate rules without the advice and counsel of its multidisciplinary Committee on Prescriptive Governance. One state nursing association and one APRN testified on behalf of nursing as proponents for the bill. The state medical association remained neutral throughout the process.
Discussion Points
Identify ways to increase the likelihood that the legislation will pass. Determine a complete list of possible stakeholders. In addition to state nurses associations, which other associations or organizations might have an interest? Discuss the position of neutrality on the part of the state medical association. Would you expect this? Why or why not? Could this organization’s position change? Why or why not? If so, what could you do in anticipation to assure its continued neutrality or future support for the bill? Although a number of state nurses’ associations have an interest in this bill, only one formally provided proponent testimony for the record. In addition, one adult NP, who represented herself as a single practitioner, provided testimony. What are the implications of limited proponent testimony? What does a small turnout, or silence, say to legislators? What might be done differently, or in addition, when the bill reaches the Senate?
CASE STUDY 4-2: Evidence Versus Stakeholder Interests in Rule Making
