Nurse Practitioner Restrictions

[travelNP]

I decided to become an ARNP because I knew it would be an empowering career. Although the work of an ARNP and Physician is similar, there are many differences. Physicians tend to use a scientific approach when addressing their patients, due to their rigorous science-based education. ARNPs approach the patient holistically. When I diagnose a patient with Diabetes Mellitus Type 2, I explain what this disorder is and the causes; I explain the treatment plan; I discuss nutrition and physical activity changes; I assess the patients comfort level with their treatment; I encourage the patient to discuss their feelings upon finding out they have this new chronic disorder; and I reassess the patient within a 2-4 week timeline. I am interested in making sure the patient understands their disorder and how they can manage it.

Unfortunately, in Florida there are some limitations on the ARNP that allows physicians to have more power. For example, Physicians can order home health treatment,controlled substances, and open their own practices without having a supervisory protocol. It is frustrating that Florida is one of the few states that has such strong limitations on ARNP scope of practice. For example, ARNPs cannot order durable medical equipment for Medicare patients in Florida. This means I cannot order a low back brace for my patient with chronic low back pain; I cannot order diabetic shoes for my patient with DM Type 2; I cannot order a cane for my patient with Parkinson's.

Moreover, ARNPs cannot prescribe controlled substances, including benzodiazepines that so many of my patients take for their anxiety or insomnia. Currently, I write out the prescription and my supervisory physician will sign the prescription. The only people suffering are my patients because this delays access to their medications. Recently,Tramadol was added to the controlled substance list. I had previously prescribed this medication frequently for my patients with chronic low backpain and severe osteoarthritis. I was not thrilled the day I received a phone call from the pharmacist telling me that tramadol was effectively now a controlled substance.

In addition, ARNPs cannot order home health treatment. This does not make sense to me since I am the primary care provider for many patients and oversee their medical care. So if I have a patient with history of a stroke and hemiparesis, I believe I should be able to order home health physical therapy for them. If I have a patient with dementia and uncontrolled hypertension, I believe I should be able to order home health blood pressuremonitoring for them.

Lastly, I do not like that ARNPs have to have a protocol with a supervising physician. It's as if the physician defines our scope of practice and not the state board of nursing. If I wanted to open up my own practice, I would need a physician to be the medical director. This means I would have to waste a few thousand dollars a month just to pay the physician for having their name on the wall of my clinic. I would be seeing the patients, overseeing the clinic, and reviewing charts, but would still have to pay my supervising physician to do nothing except 'supervise me'.

I am hoping with the Affordable Care Act and the abundance of new people seeking primary health care, that Florida will increase the scope of ARNPs. Working with the ANA, FNA, and other nursing organizations, I plan to fight for these rights. I see myself having my own practice where I see a variety of illnesses and ages. I hope that the care provided will not be based as much on cost as it is today. We already know ARNPs will be a forefront to help with the primary care shortage.

[travelNP]

Tramadol did not become a controlled substance until last year. And as a Florida NP we cannot prescribe controlled substances.

Another thing is that advanced practice nurses should always support each other instead of bringing each other down.

[Jules A, MSN]

I agree with your premise but the two things that really struck me are #1 that there is no mention of Florida's state NP organization which I would guess is kind of lame and imo the key to getting things done. Whats up with that? In my area NPAM is a force to be reckoned with, we work hard, spend money and get things done. I don't see any other way around it if you want more rights. Unfortunately there is a relatively small number of involved NPs who do the heavy lifting but still it is crucial to getting legislation changed. We don't even need an attestation agreement with a physician starting October 2015.

The second thing and this is a bit off topic but worth mentioning imo is if a large number of patients with anxiety or insomnia are being prescribed benzodiazepines that is concerning no matter who is prescribing especially in FL where I would guess a majority are geriatrics.

[honeykrown, MSN, NP]

I did not truly understand this frustration until I decided to move to a state with NP restrictions.

Moving from AZ to CO I was shocked that I would be needing provisional prescriptive authority till I get 3000hrs. I have always had the full prescriptive authority in AZ. Luckily for me, the CO governor just signed a law in March requiring less hrs of 1000 to receive full prescriptive authority. For this I am glad even if I still have to write a statement of safe prescribing to be signed by an APN or MD. It just shows the power of lobbying

[scottaprn]

I work in a tri-state area and practice in three states. It is amazing the difference that a couple miles makes in what I can do in practice. Luckily none of the three states are among the more restrictive nationwide but I don't believe in any restrictions that keep me from practicing at the limits of my education.

Lobby your state government. Your state senators and state representatives represent fewer people compared to our congress in Washington and it is much easier to meet and talk with your state representatives (who will ultimately be in charge of your state practice act).

Take your time to educate your state representatives. I deal with one state rep who always wanted to talk about the role of my "supervising doctor" and lump NPs and PAs together. I stopped him every time and reminded him that a PA signs a supervisory agreement with a doctor but I have not ever, nor will I ever sign a supervisory agreement.

Nurse practitioners sign a collaborative agreement with physicians because we are independent health care providers who work in collaboration with members of the healthcare team, including physicians, but the physician does not supervise me.

Focus on the fact that you want the state practice act to allow you to practice at the fullest level of your education. You are not asking the state legislature to turn you loose in the OR to do a CABG. You are asking them to let you put into practice the knowledge you have gained through structured education- Nothing more and nothing less.

Never concede that physicians are better equipped due to more hours of training. Anticipate that they will trot out the same story about how physicians have x amount of hours more training compared to x amount of training for an NP. Every time they bring it up ask them for the study that has shown the number of training hours necessary to be competent to be a practitioner. No such study exists. Does anyone think that the orthopedic surgeon I work for is a better orthopedic surgeon because of his rotation through the medical ICU as a resident? Give me a break.

Language matters when speaking to your patients as well. You are never "just a nurse practitioner" if someone says that (gently) correct them. You are a highly educated and skilled healthcare provider and not "just" anything.

OK off my soapbox now.

[PG2018]

Tramadol did not become a controlled substance until last year. And as a Florida NP we cannot prescribe controlled substances.

Another thing is that advanced practice nurses should always support each other instead of bringing each other down.

I know. But you should've known that too.

[automotiveRN67]

Yes this article was written prior to that. Luckily since then, the federal government mandated that APRNs can order DME. Prior to that all orders were rejected and suppliers were writing APRNs rude letters about reporting them to medicare. I think this shows how healthcare is changing, although slowly, for the best.

I guess my advice would be.

1) Don't post misinformation. Proof-read your work. People who stumble onto this and don't do due dilligence may believe what you have said. Misinformation will never help our cause. You may want to edit your post for accuracy.

2) Your writing style comes across as whiny, and without substance. I know you received a lot of likes, but if I handed this to physicians I work with, they would still say, "not seeing a need for change". Legislators will ask the same thing. Just because you want it, doesn't mean it's convincing to someone else.

3) Your information is kind of scattered and hard to understand. You may want to start with an outline next time. Remember those papers you wrote to get your degree? This reads like it was written by someone with a high-school education.

4) In my personal opinion, I am really afraid of your last statement. While there are many reasons why I feel NP's should be allowed more scope and less supervision, responding to a perceived need by making the regulatory requirements easier has never been a good idea, historically. In the article below, a Minnesota community started piloting a program to send paramedics to see the area's "sickest patients who might otherwise end up in the ER". Basically doing a house call. You read that right. There goal was to see sick patients, and try to keep them out of the ER. This would save money. And another article popped up in the WSJ this week on the same topic.

I don't know about you, but I am not convinced this is a good idea. "specialized training", does not equate to experience managing complex illness, and an advanced degree. I frequently see patients after home health nurses have been following them for weeks, or months, and find myself saying, "man, I sure wish they had called me and told me his BS has been 250 or more every day for the past six weeks".

So you have to think about this from the other side. What do we need to do to convince physicians we deserve a broader scope of practice. Even as an NP, I am concerned about opening the floodgates on patient care.

Instead of the ER: Paramedics making house calls to chronic patients - NBC News

Paramedics Aren't Just for Emergencies - WSJ

[Jules A, MSN]

4) In my personal opinion, I am really afraid of your last statement. While there are many reasons why I feel NP's should be allowed more scope and less supervision, responding to a perceived need by making the regulatory requirements easier has never been a good idea, historically. In the article below, a Minnesota community started piloting a program to send paramedics to see the area's "sickest patients who might otherwise end up in the ER". Basically doing a house call. You read that right. There goal was to see sick patients, and try to keep them out of the ER. This would save money. And another article popped up in the WSJ this week on the same topic.

I don't know about you, but I am not convinced this is a good idea. "specialized training", does not equate to experience managing complex illness, and an advanced degree. I frequently see patients after home health nurses have been following them for weeks, or months, and find myself saying, "man, I sure wish they had called me and told me his BS has been 250 or more every day for the past six weeks".

So you have to think about this from the other side. What do we need to do to convince physicians we deserve a broader scope of practice. Even as an NP, I am concerned about opening the floodgates on patient care.

Instead of the ER: Paramedics making house calls to chronic patientsÂ* - NBC News

Paramedics Aren't Just for Emergencies - WSJ

I agree and I'm also all for practicing to the full extent of our scope but as with anything we need to be properly trained and I disagree that any care is better than no care. The argument I often hear with regard to mental health care and unqualified providers be they FNPs or GPs "if I don't do it who will?" is borderline delusional which often times results in prolonging competent care and harm to vulnerable patients.

Another hint that I continue to come back to is the power of networking. Anytime a provider I have a relationship with calls me I will get their patient in for a medication evaluation within 10 days and frankly if a patient with mental health concerns can't wait 10 days they likely need an inpatient hospitalization not someone unqualified throwing inappropriate pills in their direction

[nursejoy1, ASN, RN]

From what I read, she states that she had "previously" prescribed Tramadol and at a later time received the call that it had just been made a controlled substance. Not that she prescribed it after it was controlled, not knowing that it had been changed.

[sailornurse]

I have to agree that your article is poorly written & biased as it is only discussing Florida which is known to be very restrictive. To my knowledge there are 22 states where NP's have independent practice. (see AANP website). I live in New Mexico where NPs have had independent practice for approximately 22 years. Almost everything you discuss are moot points. Currently in my city there are 8 NP's who have own clinics. We do not need collaborating or supervising MDs, have full prescriptive privileges, many have admitting privileges at local hospitals or work as hospitalists in those hospitals. I work in an Urgent Care owned by an NP, the providers are all FNP's, no physicians at all. As PPs have pointed out it requires organizing. The New Mexico Nurse Practitioner Council is our state wide organization and we support a paid lobbyist. Locally Southern New Mexico Advanced Practice Nurses (we have a Facebook page) we meet monthly, we talk to our legislators and we as a group maintain awareness of any pending bills in the legislature that may impact our practice. One of the NP's that has her own practice was instrumental in getting independent practice. As a student NP I was doing clinical both in New Mexico & Texas & in Texas I could not order cough med with codeine & that NP had to have her collaborating docs name on her script pads. Another NP with independent practice lives in El Paso but has her clinic in New Mexico due to the restrictions on NP practice in Texas. OP you are aware that Lyrica is Schedule V controlled substance yes?

[Conqueror+, BSN, RN]

I guess my advice would be.

1) Don't post misinformation. Proof-read your work. People who stumble onto this and don't do due dilligence may believe what you have said. Misinformation will never help our cause. You may want to edit your post for accuracy.

2) Your writing style comes across as whiny, and without substance. I know you received a lot of likes, but if I handed this to physicians I work with, they would still say, "not seeing a need for change". Legislators will ask the same thing. Just because you want it, doesn't mean it's convincing to someone else.

3) Your information is kind of scattered and hard to understand. You may want to start with an outline next time. Remember those papers you wrote to get your degree? This reads like it was written by someone with a high-school education.

4) In my personal opinion, I am really afraid of your last statement. While there are many reasons why I feel NP's should be allowed more scope and less supervision, responding to a perceived need by making the regulatory requirements easier has never been a good idea, historically. In the article below, a Minnesota community started piloting a program to send paramedics to see the area's "sickest patients who might otherwise end up in the ER". Basically doing a house call. You read that right. There goal was to see sick patients, and try to keep them out of the ER. This would save money. And another article popped up in the WSJ this week on the same topic.

I don't know about you, but I am not convinced this is a good idea. "specialized training", does not equate to experience managing complex illness, and an advanced degree. I frequently see patients after home health nurses have been following them for weeks, or months, and find myself saying, "man, I sure wish they had called me and told me his BS has been 250 or more every day for the past six weeks".

So you have to think about this from the other side. What do we need to do to convince physicians we deserve a broader scope of practice. Even as an NP, I am concerned about opening the floodgates on patient care.

Out of curiosity, why do advanced practice nurses need to convince physicians that they deserve anything ?

[BostonFNP, APRN]

Anytime a provider I have a relationship with calls me I will get their patient in for a medication evaluation within 10 days and frankly if a patient with mental health concerns can't wait 10 days they likely need an inpatient hospitalization not someone unqualified throwing inappropriate pills in their direction

It's great you do that. Do you think that's the norm though? I have networked with local psych provider in a 25 mile radius many of times both professionally and personally, and while I have some favors I can call in when needed, the truth is that out of those 20 providers in the area there is one group that takes MassHealth/Medicaid and there average wait time for an initial visit is 5 months; there is little I can do to get any patient in early, even an established patient. So I do my best to treat them, and the research supports that PCPs actually to a pretty decent job treating the majority of mental health issues. I don't do it because I want to, I do it because I have to.

Oh, and those local providers that will see our medicaid patients, they are allotted 7.5 minute visits. How do you treat a mental health issue in 7.5 minutes?

[Jules A, MSN]

It's great you do that. Do you think that's the norm though? I have networked with local psych provider in a 25 mile radius many of times both professionally and personally, and while I have some favors I can call in when needed, the truth is that out of those 20 providers in the area there is one group that takes MassHealth/Medicaid and there average wait time for an initial visit is 5 months; there is little I can do to get any patient in early, even an established patient. So I do my best to treat them, and the research supports that PCPs actually to a pretty decent job treating the majority of mental health issues. I don't do it because I want to, I do it because I have to.

Oh, and those local providers that will see our medicaid patients, they are allotted 7.5 minute visits. How do you treat a mental health issue in 7.5 minutes?

No clue how a 7.5 minute appointment appropriately treats anything. I can't speak about the availability of MassHealth/Medicaid providers and as I have said before I don't do too much with the insurance stuff but my understanding is that in Maryland our state insurance is one of the easier ones to get paid from and on an inpatient stay it pays longer than most other insurances.

The outpatient practice where I work part time is in an underserved area with more than a few lousy psychiatrists at other clinics so whenever a colleague calls if I can't help them over the phone with recommendations I will make adjustments to my schedule to get their patient seen asap. Even for patients who have no inside connections the very longest the wait is 2 months. Are you sure all 20 providers in the area are being contacted by your secretary for referral appointments? 5 months just seems like an excessive wait.

As for prescribing by PCPs of course I'm only seeing the not so successful cases either on the acute unit for hospitalization or the outpatient ones who have been "managed" by their PCP on Xanax and Ritalin and now months later need to see a specialist because their PCP realizes they have created a monster. I had an adolescent this week who's PCP had tried them on 2 SSRIs, not one taken up to a therapeutic dose, then went to Trazodone 150mg daily and finally a SSRI and SNRI together it was ridiculous. The parents think their child is untreatable because of all the medication "failures". It was all I could do not to say it was a provider failure not medication. On my adult unit I also had a patient with long term active addictions issues hospitalized for an intentional OD who was receiving Xanax and Adderall from the PCP. Really??? How is that even considered appropriate?

I guess the same can be said for any specialty but the horrific prescribing I see by PCPs do a disservice to the patients they are trying to help. Imo the patients absolutely would be better served by not being treated at all for several months rather than being mismanaged with some of these regimens.