Biggest obstacle, BON or BOM?

Trauma Columnist · Nov 9, 2011

Personally, Craig - I think the NCSBN Consensus Model (if accepted by all 50 states) will be a huge boon for all APNs.

I do agree that the differences in BON scopes of practices/rules is a hindrance to APN practice.

The AMA is luckily (NOT) based in Chicago so we in IL have a pretty strict practice act. Maybe....we can tell the docs to go south where its warmer...lol.

TX RN · Nov 9, 2011

In Texas the BOM is the biggest hinderance. APN's in TX have to practice under delegated rights to prescribe and diagnose. Because of the delegated oversight, any time scope of practice comes into question the BOM dictates what can and can't be done by APN's. It's really a pain.

For example:

Up until June of this year a NP in Texas could not sign for a new handicap parking placard. This was finally changed by state legislation. It seems like such a trivial thing, writing for a parking placard. But it really puts NP's in an awkward situation when you decline pt's request to write for one. I mean, you can diagnose them with a-fib, start them on coumadin, and order their advair for their worsening COPD. But guess what, you can't write for the parking placard. So instead of writing for the placard you instruct your patient to take a couple of puffs from their rescue inhaler when they park 1 block down from your clinic. Hopefully they'll make it to the door without passing out.

It undermines whatever credibility you have built with them.

The Texas BON is a whole other story. The one issue of concern I have is how they handle practice issues. Not too long ago I helped an attorney with a case that involved a NP and a complaint filed against them on a treatment issue. Bottom line was the treatment was appropriate, but the complaint came from a physician with a difference in treatment recommendation. The NP treatment was evidence based and reference from peer reviewed literature was submitted from several sources (3 or 4) to back the clinical decision from the NP.

The physician submitted a one paragraph statement. The BON found the allegations true and proceeded with taking disciplinary action on licensure.

Here's the part I have a real problem with. Texas BON investigators that reviewed the case were not APN's. They were not NP's, CNS's, Mid-wife's, CRNA's, etc. I have a real problem with that.

The nurse investigators are the party responsible for making recommendations to the boards attorney's on dropping the investigation or pursuing disciplinary action.

If an NP's clinical decision is questioned and investigated, it should be a NP of the same type specialty to review the case. Period.

Advanced Practice Columnist / Guide · Nov 9, 2011

Although I had previously decided not to pursue my NP and travel down the academic RN pathway, I've recently started thinking about it again. The CNS route isn't working out in the area's I'm working in. As I look back at the reasons I choose to drop out of the NP program, I'm giving a bit more detailed examination to some of the reasons.
One of the reasons was BON. Boards of Nursing in a lot of cases, are nurses worst enemies. Some of the BON's determination of who can work were and take care of what patients, is outside of any other medical profession. For those of you practicing NP's out there. In your opinion, which organization is more of a hinderance to your practice today. The Board of Medicine or the Board of Nursing? the example that I use for the BON being stupid is a rule from my staff nurse days. It was in my scope of practice to pull PA catheters, but I couldn't cut the suture that the introducer was secured with. Or the I can no longer put PICC's in because the PICC has a wire inside it and it's now a Modified Seldinger technique and that is outside the scope of practice. Even though the wire is is just a stiffening tool for the PICC to help it advance. Not something I'm threading in and then threading the PICC over. I don't have any recent advanced practice examples but it always concerned me that there were as many stupid rules for APRN's as RN's.

I personally welcome regulation when it protects the public from inadequately trained healthcare providers. What healthcare professional are allowed to do are not only determined by the practice act in one's state of jurisdiction but also by institutional policy. Both should be consistent with national standards established through research evidence. Your RN examples are a bit odd to me maybe because I'm lucky enough to have worked in two states where those restrictions to RN practice do not exist. As someone who routinely places PICC's (as an NP), it is a Modified Seldinger Technique in that you do thread a guidewire through a peripheral vein you cannulate with a finder needle via ultrasound guidance. Once you dilate the vein, you then take out the guidewire and thread a PICC with another guidewire built in to the PICC itself (which acts as a "stiffening" tool as you said or in some instances as a catheter tip locator).

However, bedside PICC placement by nurses have been shown to be safe when the nurse is adequately trained to place them -- this is consistent with national standards set forth by a nursing-related organization, the Infusion Nursing Society. In the same manner, central line removal including PA catheters are routinely done by critical care nurses who deal with all types of central lines on a day to day basis. Suture removal is also a nursing role in many institutions. This is consistent with national standards set forth by another nursing organization, the American Association of Critical Care Nurses. I would have to say that a BON that puts the restrictions you just mentioned are just plain behind the times. These rules are not consistent with national standards and the evidence that shows that nurses are able to perfrom them safely with adequate training.

As a nurse practitioner, I have mixed feelings about limitations in scope practice. I must first say that I've never practiced in a state where NP's are fully independent. Second, I must also mention that I'm in California where we NP's seem to have a modest amount of restrictions placed on us in terms of practice. The fact that we have a requirement for a Standardized Procedure document arranged with a "supervising" physician and a separate Furnishing License in addition to our NP License in order to "prescribe" can be off-putting. However, I find that as a non-physician provider working for a hospital in a critical care service, these requirements do protect me from risks to my license. Institutional policy in terms of credentialing and priviledging already impose restrictions on who can do what anyway and that is independent of BON regulations.

To explain further, I find that because we are required to have a Standardized Procedure for all the things we do on a day to day basis (Central Venous Line Placements, Aterial Line Placements, Intubations, Procedural Sedation, etc), ensures that the institution provides me with the training I need to be proficient in those procedures and makes sure that a mechanism is in place for a named supervising physician to be consulted should I run across problems. The fact that we are required to have a minimum number of annual cases for each procedure included in our Standardized Procedure document to be deemed competent only ensures that I maintain a high level of skill in performing these procedures. So in that sense, I welcome the regulation or restriction however you wish to view them.

Trauma Columnist · Nov 9, 2011

Juan - that is the way it is in IL too: you have to have a list of procedures at each hospital where an APN is credentialed, then you also have to show that you have done x-amt of those procedures each credentialing period (1-2-3 years depending on the institution).

You also must show evidence that you are not doing something outside the scope of specialty practice of your supervising MD. For instance, I work in nephrology, so it would be out of my scope to prescribe birth control or OB care since my MDs do not provide this.

However, when I worked in the ER few procedures were outside my scope r/t emergency medical care.

It all goes back to being totally aware of the rules/restrictions/scope of practice placed upon you by your governing body, be that the BOM, AMA, BON, hospital credentialing committee.

CraigB-RN, MSN, RN · Nov 9, 2011

I've been putting PICC lines in for 10-12 years as an RN not an NP. I started doing them when we switched from interacts to the PICC's, before there were break away needs. We had been putting the PICC's with wires in for 2-3 years before the BON made their ruling. We never found out how it came to their attention. They also wanted to make it outside my scope of practice to use ultrasound to ID the vessels. I know were that came from, the Radiologist wanted another revenue stream. But this point wasn't about starting PICC's.

This post wasn't about PICC or the Infusion Nurse Society it's about BON obstacles to practice. Those were just two examples of BON's making rulings that didn't make any sense. I can come up with a pretty long list of those things. We read about the ruling about NP's not being allowed to take care of inpatients because their initial clinical didn't cover it. And that ruling came from a BON. I know it's a stretch, but if you use that as a base then anytime a new procedure comes up, then NPs shouldn't be able to do it because it wasn't covered in their basic education.

I'm all for protecting the public, but neither BON's or BOM have shown a good track record in doing that. There are always cases out there eof people RN's NP.MD's etc that are still practicing when they shouldn't be. Whether due to politics, or in your states case, just to over worked to adequately supervise all those providers. As a CNS, in one state I can put in central lines, and do other invasive procedures, even prescribe meds. But I go across a state line and a CNS is a job description and RN's with BSN's are doing the job, Not a level of certification.

I'm also not addressing credentialing. That is a whole other can of worms. The hosp I just left had never had an ACNP and wouldn't credential them. Allowed PA's to advance PA catheters but the ACNP couldn't and a few other things like that. Would only credential the FNP's.

Trauma - what kind of time line are you seeing for the consensus model.

I'm at the point now that if I win the lottery, I'll either go to CRNA school or PA school. Which isn't going to happen anytime soon. I get confused with moles and mili-moles so CRNA isn't for me.

Advanced Practice Columnist / Guide · Nov 10, 2011

I've been putting PICC lines in for 10-12 years as an RN not an NP. I started doing them when we switched from interacts to the PICC's, before there were break away needs. We had been putting the PICC's with wires in for 2-3 years before the BON made their ruling. We never found out how it came to their attention. They also wanted to make it outside my scope of practice to use ultrasound to ID the vessels. I know were that came from, the Radiologist wanted another revenue stream. But this point wasn't about starting PICC's.
This post wasn't about PICC or the Infusion Nurse Society it's about BON obstacles to practice. Those were just two examples of BON's making rulings that didn't make any sense.

I only mentioned the Infusion Nursing Society to point out how ridiculous that BON rule you mentioned is. While I'm lucky I have not worked in a state where such rules exist, I likely would move somewhere else if I happen to live in such a state. I find it odd that you think Radiologists have an impact on how BON regulations are decided on. Those BON members are sell-outs if that's the case. Radiologists have no sole possession of ultrasound guided vessel identification technique. Ultrasound utilization at the bedside is now taught in some med schools and numerous other specialty boards in medicine have CME's that teach these techniques (SCCM, ACEP, ASA, etc.). Ultrasound isn't such a huge revenue generator in the grand scheme of things when you look at many other high-cost IR procedures Radiologists can charge for.

I can come up with a pretty long list of those things. We read about the ruling about NP's not being allowed to take care of inpatients because their initial clinical didn't cover it. And that ruling came from a BON. I know it's a stretch, but if you use that as a base then anytime a new procedure comes up, then NPs shouldn't be able to do it because it wasn't covered in their basic education.

I am firm believer that NP's should practice under the specialty track they trained under. I don't see the point of going through a nurse practitioner program if the provider is going to draw solely from their RN experience and hope to learn stuff on the job. It defeats the purpose of training to be an NP. As far as learning new procedures that come up, then that comes with the nature of healthcare. New and improved treatment modalities emerge at a rapid speed in medicine no matter what specialty you fall under. If one's specialty is in acute care, then one needs to update oneself of new developments in the field of acute care. Same goes for someone trained in primary care.

I'm all for protecting the public, but neither BON's or BOM have shown a good track record in doing that. There are always cases out there eof people RN's NP.MD's etc that are still practicing when they shouldn't be. Whether due to politics, or in your states case, just to over worked to adequately supervise all those providers. As a CNS, in one state I can put in central lines, and do other invasive procedures, even prescribe meds. But I go across a state line and a CNS is a job description and RN's with BSN's are doing the job, Not a level of certification.

Hopefully the consensus model addresses these variances. It is slated for implementation in 2015.

I'm also not addressing credentialing. That is a whole other can of worms. The hosp I just left had never had an ACNP and wouldn't credential them. Allowed PA's to advance PA catheters but the ACNP couldn't and a few other things like that. Would only credential the FNP's.

Though you're not addressing this issue, not credentialing ACNP is plainly due to ignorance on the hospital credentialing board's part. I have not worked in a hospital where this is even happening luckily. I've worked in critical care in 3 different hospitals in 2 states and have not had difficulty getting credentialed for invasive procedures. I have received adequate training including being provided with all the tools I need to perform these procedures in all the places I've worked in and have maintained competence by making sure I actually get to do these procedures regularly. Sure you can pull anecdotal data on an RN that could do these somewhere but RN's can not bill for procedures. It's all about finding a supportive environment. I would never work in a hospital where my potential as an ACNP is not realized. These horrible practice settings do exist, but there are good places out there as well.

Advanced Practice Columnist / Guide · Nov 10, 2011

Juan - that is the way it is in IL too: you have to have a list of procedures at each hospital where an APN is credentialed, then you also have to show that you have done x-amt of those procedures each credentialing period (1-2-3 years depending on the institution).
You also must show evidence that you are not doing something outside the scope of specialty practice of your supervising MD. For instance, I work in nephrology, so it would be out of my scope to prescribe birth control or OB care since my MDs do not provide this.
However, when I worked in the ER few procedures were outside my scope r/t emergency medical care.
It all goes back to being totally aware of the rules/restrictions/scope of practice placed upon you by your governing body, be that the BOM, AMA, BON, hospital credentialing committee.

I totally agree. I am all for making sure one knows what the state practice act is and how institutional policy can affect one's practice. There can be a good amount of autonomy for NP's even in states where independent practice is not written in the law. More importantly, a supportive practice environment goes a long way in making sure NP's are happy in their practice settings.

Trauma Columnist · Nov 10, 2011

Yes indeed Juan.