2. Designs and Editing by Joseph A. Rodriguez | 2
THE PROBLEM
Arizona Supports Nursing - Highlights from the #NursesCare4AZ Campaign to Update APRN Scope of Practice
Patient demand for healthcare in Arizona has
never been greater. The immense challenge of
delivering accessible, high-quality, fiscally
responsible care to nearly 7 million Arizona
citizens requires every healthcare team member
to be operating at the top of their game.
Policy actions at the state and federal level have
brought hundreds of thousands of Arizonans and
tens of millions of Americans into the traditional
health care system - not to mention physician
shortages in primary care.
Meeting Arizona's
Healthcare Demands
That's why the Arizona Nurse's
Association and groups representing
nearly 7,000 Advanced Practice
Registered Nurses (APRNs) have banded
together with patients, therapists, and
physicians representing 30 different
specialities to support updating the
scope of practice for APRNs.
A truly unprecedented level of support
for this legislation exists. With thousands
of citizens represented, our coalition also
has bound together with over 170
physicians, as well as community groups
like AARP and the Goldwater Institute.
Included in this publication are letters
from all over the state: from leaders,
physicians, administrators, patients,
business owners, and of course, APRNs
themselves. Also included is notable
summaries of research and recent
editorials in local publications.
It's our pleasure to present these
testimonies of quality APRN care. It's
past time to let APRNs give the high-
quality care they are educated
to provide.
APRNs can meet the challenge - and they have the
support of the public, patients, and physicians.
A R I Z O N A H E A L T H C A R E
THE SOLUTION
Ali J. Baghai, a Midwestern University graduate, is a
Certified Registered Nurse Anesthetist, Chief of
Anesthesia at Tempe St. Luke’s Hospital, and is
president of the Arizona Association of Nurse
Anesthetists. Learn more at aprnAZ.org
DID YOU KNOW?
Ali J. Baghai, CRNA, President, AZANA
40 years of Independent,
3rd-party research
has repeatedly
confirmed the safety
and quality of APRN care.
8. ANESTHSIOLOGISTS SUPPORT
"Anesthesia providers do not work in a
vacuum; we work in a team with the
surgeon. The new language will
enhance the team with clarity - I fully
support the proposed legislation."
"The outdated language does
not make any sense and in my
opinion does not offer any
patient saftey. I am completely
comfortable with the update
proposed by CRNAs."
Dr. Ned Sciortino, DO Anesthesiologist,
Director of Anesthesiology, IASIS Healthcare
Phoenix, Arizona
Dr. David Beauchamp MD Anesthesiologist,
Phoenix, Arizona
9. CRNA SCOPE OF PRACTICE
"I support CRNAs being able
to practice to the fullest
extent of their education,
training, and ability."
"'Direction and presence' creates confusion."
"Surgeons, by virtue of their
training and experience, are not
qualified to direct the
anesthesiologist or CRNA while
providing anesthesia care to
patients."
Dr. David Vertullo, MD, Cardiovascular Anesthesiologist
Former Board Examiner, American Board of Anesthesiology
Phoenix, Arizona
10. Much has changed since the
1920s
So has healthcare.
It's Time to Update Scope of Practice.
18. INDEPENDENT, 3rd PARTY RESEARCH
Medicine
The Institute of
A Division of the National Academies of Science
19. RESEARCH
CRNA-ANESTHESIA OUTCOMESAPRNAZ.ORG
A P R E P O N D E R A N C E O F E V I D E N C E
COMPILED & COMPRESSED BY JOSEPH A RODRIGUEZ
"There simply is no ignoring 40 years of research
pointing toward one conclusion.
For the benefit and welfare of Arizona's citizens,
Arizona legislators should recognize CRNA Full Practice Authority."
Justin B. McBride, CRNA
Chief of Anesthesia, Phoenix St. Lukes Hospital
28. 9.29.2015
FROM
Dr. Ned Sciortino, DO
Anesthesioloigst and Medical Director, Mountain Vista Medical Center,
Phoenix St. Luke’s Hospital, Tempe St. Luke’s Hospital.
Director of Medical Education and Residency, Mountain Vista Medical Center
TO
Mr. Pete Werheim
Executive Director, Arizona Osteopathic Medical Association
Sent to: pwertheim@az-osteo.org
CC:
Arizona Senate and House Health Committees
Dear Mr. Werheim:
Hello, my name is Dr Ned Sciortino DO. I am the director of anesthesia for
over 30 Certified Registered Nurse Anesthetists (CRNAs) at 3 hospitals in the
Phoenix area. I have worked with my team of CRNAs for over 5 years now. I
am very familiar with their practice and level of professionalism. I am also
aware of the challenges they face with their current scope of practice
language and the legislation they are proposing this year in efforts to amend
that language.
The team I work with at these 3 facilities are exceptional anesthesia providers.
The CRNAs current scope states that they must work under the direction of
and in the presence of a physician, which in our facilities and many others in
the state means that the operating surgeon/physician is present and directing
them. I would agree with the CRNAs, that this creates a unique challenge as
operating surgeons/physicians can mean orthopedic surgeon, vascular
surgeon, general surgeon, gastroenterologist, dentist, interventional
radiologist, etc.... And although these physicians are excellent at what they
do, they are not anesthesia experts nor are they credentialed to practice
anesthesia. For them to "direct" and be "present" for a CRNA to practice does
not make any sense and in my opinion does not offer any patient safety. It can
29. also create a concern for some surgeons that perceive this language to mean
they are more liable for the actions of a CRNA. I am completely comfortable
with their efforts to remove the direction and presence language from their
current scope of practice.
The CRNAs that I work with are also very competent in providing our patients
preoperative and postoperative pain/nerve blocks. One of our CRNAs in fact
has brought over 10 years of pain management experience to our group which
has been extremely helpful for us. The surgeons at our 3 facilities have been
very pleased with our anesthesia group and the service we provide which is
the ultimate reason we have held these contracts for nearly 10 years now.
Please feel free to contact me if I can be of any further assistance.
Dr Ned Sciortino DO, Director Anesthesia
onofrio3@gmail.com
480-544-6446
or contact;
Justin McBride CRNA Chief, Phoenix St. Lukes Hospital
mcbanesthesia@gmail.com
602-370-3103
32. Frank Joseph Fara, M.D., FACOG
19191 North Palermo Street
Surprise, AZ 85374
October 20, 2015
Govenor Ducey and the Arizona Legislature
Dear Legislators:
I am writing today to add clarity to and support for the issues surrounding CRNA practice in Arizona.
As a practicing Obstetrician and Gynecologist, I have had the pleasure of practicing with CRNAs in many settings over the 33
years of my career and have continually been impressed with their knowledge, expertise and professionalism. In several of
these settings, CRNAs were the only anaesthesia providers serving my patients, and they did so uniformly with a high degree
of success. Of interest, my most recent experience with CRNAs happened as they began to practice at my home hospital,
Banner Del E. Webb Medical Center in Sun City West. As they joined our medical staff, several of my colleagues who had
never practiced with these dedicated clinicians questioned their qualification and capacity in the provision of care to the
surgical patient. Gratifyingly, and to no surprise to me, each of these skeptical colleagues were rapidly impressed with the
quality of service they have delivered, and are now very supportive of the CRNA service at Del Webb. This has been
especially notable in our Labor and Delivery unit, where they do their job with aplomb, to the benefit of doctors, nursing staff,
and patients alike.
When CRNAs are administering anaesthesia, they are managing the anaesthesia and are thus responsible for the anaesthetic
portion of the procedure. The surgeon does not assist the CRNA in providing anaesthesia, the choice of medication, airway
management, and so on. In this capacity, the CRNA makes numerous second-to-second decisions which ultimately allow the
surgeon to perform the operation with the secure knowledge that the patient is being well cared for. The outdated language
that, in some sources, require the “presence and direction” of the surgeon in the provision of anaesthetic service was written
in the start of the 20th century, and in no way currently contributes to patient safety or anaesthetic outcome.
What this outdated language does accomplish, however, is the perpetuation of misperceptions about who is liable for
anaesthetic outcomes. Let me be clear: the CRNA is a highly trained, experienced medical professional, licensed by the state
and credentialed by their professional board to provide anaesthesia, while the surgeon is similarly licensed and credentialed to
perform the surgical procedure itself. This current and contemporary relationship between CRNA and surgeon must be
supported by the medical team, and also by any legislative action that may seek to more carefully define such relationships.
I also strongly support the provision of DEA credential to CRNAs and the allowance of focused prescriptive authority that
will allow them to practice to their fullest and most effective level of education and training. This is especially important in
systems such as the Veteran’s Administration, where DEA certification is required for employment, but also in situations in
which preoperative and postoperative prescribing is necessary to provide adequately for conditions involving significant
preoperative anxiety and the control of postoperative nausea, vomiting and pain.
Arizonans deserve to have every member of the surgical team functioning at his/her highest levels of expertise. Physicians
and surgeons have enough liability and enough work without adding to it this burdensome and ambiguous regulation which
slows down our health care system and fosters inefficiency. Further, this legislative action is in close accord with
recommendations from the universally recognized and respected Institutes of Medicine. Please work to remove this confusing
language from the statue and allow all members of the surgical team to get back to doing what we seek to do best: the expert
care of our patients.
Sincerely,
Frank Joseph Fara, M.D., FACOG
(Electronically Signed)
33. Dr. Frank Joseph Fara, MD,FACOG
Obstetrician and Gynecologist, Phoenix AZ
Fellow, American College of OBGYNs
"CRNAs were the
They performed with a uniformly
only anesthesia
providers...
high degree
of success"
42. Vijay Swarup, MD, FACC, FHRS
500 W Thomas Rd #750 — Phoenix, AZ 85248— Phone: 480-227-4563
E-Mail: vswarup@azheartrhythm.com Web: azheartrhythm.com
October 8, 2015
Senate Health and Human Services Committee
Chairwoman: Nancy Barto
Members: David Bradley, Katie Hobbs, Debbie Lesko, Lynne Pancrazi, Kelli Ward (Vice Chair,
Kimberly Yee
House Health Committee
Chairwoman: Heather Carter
Members: Paul Boyer, Regina Cobb (Vice Chair), Randall Friese, Jay Lawrence, Eric Meyer
Dear Legislators:
I am writing today to add clarity to issue of CRNA practice in Arizona.
The anesthesia care that my patients receive from the Certified Registered Nurse Anesthetists
is second to none. The CRNAs that I work with function independently at an incredibly high
level, managing without oversight or supervision all aspects of the anesthetic. This is how it
should be, since they are trained for (and able to provide) the independent provision and
management of anesthesia; I am not. In my experience, CRNA’s are often my preferred
anesthesia provider for my cases due to their attentiveness, focus, skill, and ongoing
education. Actually, the only anesthesia provider in the state (and country) who is a certified
cardiac device specialist and fellow of the heart rhythm society is a nurse anesthetist! It
benefits my practice and the patient when he is able to practice to the full scope of his
training without hindrance or confusion, which the current law could create.
Thus the century-old language requiring physician “presence and direction” is unnecessary,
practically meaningless, and does not enhance patient safety. In fact, it only serves to
confuse. When I practice with a CRNA I am the physician “present” offering “direction.”
However, the presence of the CRNA provides for safe anesthetic, and I am not qualified nor
should I actually direct in any way. The provision of anesthesia should be (and in the reality of
21st century practice is) left in the hands of those trained to provide anesthesia. Thus the
current law’s language is confusing and does not reflect current practice. I support the
updates to the law that the CRNA’s are proposing. Unfortunately, I am not able to attend the
Sunrise Hearing in person, but please accept this letter as my support for the proposed
legislative changes.
43. 2
When CRNAs are administering anesthesia, they are managing the anesthetic and are
responsible for the anesthetic portion of the procedure. The surgeon/physician/proceduralist
performing the procedure do not and should not assist CRNAs in providing anesthesia,
choosing medications, airway management, and so on. CRNAs make numerous second-to-
second decisions which allow me to perform the procedure knowing the patient is cared for; I
do not direct the CRNA how to perform the anesthetic as this is not my specialty. The
outdated language requiring physician “presence and direction” was written at the start of
the 20th century, and does nothing to enhance patient safety.
What this language does, however, is create misperceptions about who is liable
for anesthesia outcomes. Let me be clear: CRNAs are anesthesia professionals, trained,
licensed and credentialed to practice anesthesia, while I am the surgeon/proceduralist
trained, licensed, and credentialed to perform the procedure which the anesthesia is
facilitating.
I also support CRNAs having DEA numbers and allowing them the focused prescriptive
authority they need to practice to their full education and training. This is especially
important in systems like the Veteran’s Administration (where DEA numbers are required for
employment), but also essential in situations where pre-op and post-op prescriptions are
needed which are directly related to my procedure such as preoperative anxiety, post-
operative pain management, and post-operative nausea and vomiting. I believe that the
current restriction on CRNA’s keeping them from being employed at the VA may actually be
keeping the best quality care away from our state’s and nation’s veterans.
Arizonans deserve every member of their team functioning at the highest levels. Surgeons
and Physicians have both enough liability and enough work without dealing with this
burdensome and ambiguous regulation which slows down our health care system. Further,
this update is in line with recommendations from the universally recognized and respected
Institute of Medicine Please remove this confusing language. It does nothing to enhance
patient safety but rather only creates confusion and potential inappropriate liability and
inappropriate limits on practice.
Sincerely,
Vijendra Swarup, MD, FACC, FHRS
45. Arizona's Advanced Practice Registered Nurses
(APRNs) are the VERY BEST.
IT'S TIME TO LET
THEM DO THEIR
JOBS
Update Scope of Practice, Lawmakers.
#NursesCare4AZ
46. La Paz Regional Hospital
M. Victoria Clark, Chief Executive Officer
1200 W. Mohave Road, Parker, AZ 85344
(928) 669-7300 FAX (928) 669-7417
info@lapazhospital.org
November 30, 2015
TO: Arizona Senate and House Health Committees and All Interested
Arizona Legislators
Dear Legislators:
As the Chief Executive Officer of La Paz Regional Hospital, I am writing today to ask for your
help in updating the legislative statutes regarding Certified Registered Nurse Anesthetists
(CRNAs) and their ability to direct the care of the patients they serve.
At La Paz Regional, anesthesia is administered only by Certified Registered Nurse Anesthetists
(CRNAs) and has been for many years. I have been very pleased with their expertise and
professionalism. CRNAs are extremely competent and they manage all phases of anesthesia for
our patients, which range from healthy-low risk patients to high-risk patients with severe
comorbidities. CRNAs cover our entire hospital from the Emergency Department to the Surgery
Department for difficult airway access, central line insertion, lumbar punctures, emergency and
difficult airway access, as well as trauma surgery. Without these anesthesia services, our
community would be drastically limited in our ability to provide healthcare and patients would
suffer from lack of access to proper medical care.
The current statute is outdated and does not reflect real practice. Language requiring physician/
surgeon “presence and direction” creates a false concern for surgeons of liability and does not
enhance patient care or safety. The language creates misperceptions about who is liable
for anesthesia. CRNAs are responsible for the anesthetic management, and surgeons are
responsible for their surgery. Surgeons are not trained or credentialed in anesthesia or to direct
anesthesia from a CRNA. CRNAs are not trained to be directed. When we bring in new
surgeons we have to educate them on this issue and let them know that they are not liable for the
actions of the CRNAs they are working with any more than they would be with an
anesthesiologist - a fact has been borne out in decades of case law and research.
This language has been a barrier in our community, with some surgeons unwilling to practice
here due to their unfounded idea that they would be liable for anesthesia care, even as we show
them the case law that proves they are not liable.
47. Open Letter to Arizona Legislators
November 30, 2015
Page !2
I have been informed that some are stating that removing this language would be “breaking up
the team.” However, nothing could be further from the truth. In reality removing the outdated
language enhances the team by making statute reflect practice, removing confusion about roles,
and removing a perception of liability that does not exist. The proposed language from CRNAs,
which still ensures CRNAs work as part of a healthcare team helps create a safe, accessible, and
cost-effective healthcare system.
I also support CRNAs having DEA numbers and allowing them the focused prescriptive
authority they need to practice to their full education and training. This is especially important in
systems like the VA where DEA numbers are required for employment, but also essential in
situations where pre-op and post-op prescriptions are needed which are directly related to the
procedure such as preoperative anxiety, post-operative pain management, and post-operative
nausea and vomiting.
Last, I also want to voice support for the CRNAs providing Chronic Pain Management. While
CRNAs in nearly every state including Arizona practice interventional pain management
currently, CRNAs are proposing a “gold standard” approach to pain certification, and would be
the only healthcare providers in the United States to require pain certification. CRNAs can
provide this highly-valued service to patients who suffer from chronic pain and an accessible
option for treatments close to home. Their interventions offer an adjunct to medication-only pain
management, thus decreasing potential for opioid addiction, a problem which is a plague for our
communities. I urge you to embrace these upgrades to Arizona’s pain management services.
According to the universally respected Institute of Medicine of the National Academies, CRNAs
and other Advanced Practice Nurses “have the opportunity to play a central role in transforming
the health care system to create a more accessible, high-quality, and value-driven environment
for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated
policies, regulations, and cultural barriers, including those related to scope of practice, will have
to be lifted.”
Current statistics and research demonstrates that nurse practitioners, physician assistants and
nurse anesthetists will have a greater and greater role in healthcare in the future, as the number of
doctors in practice falls far short of the number needed. Arizonans deserve every member of
their team functioning at the highest levels. Surgeons and Physicians have both enough liability
and enough work without dealing with this burdensome and ambiguous regulation which slows
down our health care system. Please remove this confusing language and allow all members of
the healthcare team to get back to the work we want to do: taking care of our patients.
Sincerely,
M. Victoria Clark
Chief Executive Officer
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48. "Educating future Certified
Registered Nurse Anesthetists
(CRNAs) remains strong. The
rigorous training at Midwestern
exceeds requirements, and its track
record of excellence is evidenced by
success of 185 graduates who
provide anesthesia care that meets
the healthcare needs of society."
#NursesCare4AZ
Photo: Dan Lovinaria
Dr. Shari Burns, EdD, CRNA,
Program Director, Midwestern
University, Glendale Arizona
53. November 27, 2015
To: Arizona State Legislature:
I am the president of the American Association of Nurse Anesthetists (AANA), which
represents more than 49,000 nurse anesthetists (including Certified Registered Nurse
Anesthetists (CRNAs) and student nurse anesthetists) nationwide. The AANA submits
the following comments in support of Sunrise Application for expanded scope of
practice, submitted by Arizona Nurses Association, the Arizona Association of Nurse
Anesthetists, the Arizona Affiliate of the American College of Nurse-Midwives and the
Arizona Nurse Practitioner Council, which would allow for more independent practice for
advanced practice nurses in Arizona.
Potential Impact of the amendment to Title 32, Chapter 15 in Arizona:
CRNAs have been providing high quality, cost effective anesthesia care to the citizens
of Arizona and this country for over 150 years. This amendment would help to improve
quality of health care and reduce costs by eliminating the outdated physician oversight
requirements and allowing residents of Arizona to have improved access to the services
provided by CRNAs. The amendment will remove the outdated requirements of
direction and presence of a physician or surgeon for CRNAs. The amendment will also
allow CRNAs ability to obtain certification for prescribing authority. By removing the
above barriers to CRNA practice, this will improve access to care, promote competition
and decreaseFeF health care costs to the residents of Arizona.
National Trend
In recent years, the national trend has been toward removal of the barriers to practice
and toward allowing advanced practice nurses, including CRNAs, to practice to the full
extent of their education and training. 32 states and the District of Columbia have no
supervision or direction requirement concerning nurse anesthetists in nurse practice
acts, board of nursing rules/regulations, medical practice acts, board of medicine
rules/regulations, or their generic equivalents. Further, 17 states have opted-out of the
federal physician supervision requirement for CRNAs, with the most recent being
Kentucky in April 2012.
CRNA Scope of Practice
As healthcare professionals, CRNAs practice according to their expertise, state statutes
and regulations, and institutional policy. The AANA supports the full scope of CRNA
practice as set forth in the AANA’s “Scope Nurse Anesthesia Practice” and “Standards
for Nurse Anesthesia Practice” (at
54. 2
http://www.aana.com/resources2/professionalpractice/Pages/Professional-Practice-
Manual.aspx).
Practice by CRNAs and other APRNs to the full extent of their education and training is
also supported by the 2010 Institute of Medicine (IOM) report titled, The Future of
Nursing: Leading Change, Advancing Health (the IOM report, at
http://www.nap.edu/catalog.php?record_id=12956). The IOM report includes the “key
message” that: “Nurses should practice to the full extent of their education and
training.” [page 3-1] The IOM report further indicates “…regulations in many states
result in APRNs not being able to give care they were trained to provide. The
committee believes all health professionals should practice to the full extent of their
education and training so that more patients may benefit.” [page 3-10]
CRNAs Provide High Quality, Cost-Effective Care
There is overwhelming evidence, most recently documented in studies released in
2010, that CRNAs provide superb, cost-effective anesthesia care. Nurse anesthetists
have been, since their inception, professionals who are acknowledged by the surgeons
with whom they practice to be experts regarding anesthesia.
The excellent safety record of CRNAs is reflected in a study titled, “No Harm Found
When Nurse Anesthetists Work without Supervision by Physicians,” which was
published in the August 2010 issue of Health Affairs, the nation’s leading health policy
journal. (The study is available at http://www.aana.com/optoutstudy/.) In that study,
which was conducted by Jerry Cromwell, a senior fellow in health economics at the
Research Triangle Institute (“RTI”) and Brian Dulisse, a health economist at RTI, the
authors analyzed nearly 500,000 hospitalizations in 14 opt-out states (i.e., the 14 states
that, at the time of the study, had opted out of the federal physician supervision
requirement for CRNAs; there are now a total of 17 opt-out states) and concluded that
allowing CRNAs to administer anesthesia services without physician supervision does
not put patients at risk. In fact, the authors found no increase in the odds of a patient
dying or experiencing complications in states that had opted out. The study also
compared outcomes by provider type and found that there are no differences in patient
outcomes of anesthesia services delivered by solo CRNAs, by solo anesthesiologists,
or by CRNAs being supervised by anesthesiologists.
An article that appeared in the May-June 2010 issue of the Journal of Nursing
Economic$ titled, “Cost Effectiveness Analysis of Anesthesia Providers” had similar
findings regarding the quality of CRNA care. (The article is available at
http://www.aana.com/advocacy/federalgovernmentaffairs/Documents/Value%20of%20C
RNA%20Care%20Study.pdf .)That article, which was written by a group of researchers
for The Lewin Group, an Ingenix company which is, in turn, a wholly-owned subsidiary
of UnitedHealth Group, analyzed the cost-effectiveness of various anesthesia models.
This article also concluded that CRNAs can perform the same set of anesthesia
services as anesthesiologists and said that research studies have found “no significant
differences in rates of anesthesia complications or mortality between CRNAs and
55. 3
anesthesiologists or among delivery models for anesthesia that involve CRNAs,
anesthesiologists, or both after controlling for other pertinent factors.…” The article
further noted that “[g]iven the low incidence of adverse anesthesia-related complications
and anesthesia-related mortality rates in general, it is not surprising that there are no
studies that show a significant difference between CRNAs and anesthesiologists in
patient outcomes.”
In addition, the Lewin Group article analyzed the cost-effectiveness of various
anesthesia models and concluded that “CRNAs acting independently provide
anesthesia services at the lowest economic cost.…” The article also concluded that
models that require physician oversight of CRNA practice are inefficient in areas of low
demand such as rural communities. In such communities, CRNAs acting independently
is the only model likely to result in positive net revenue.
For additional information regarding anesthesia quality of care studies, see the AANA
publication titled Quality of Care in Anesthesia. (Available at
http://www.aana.com/resources2/professionalpractice/Pages/Professional-Practice-
Manual.aspx under Quality of Care in Anesthesia.) The Quality of Care synopsis
includes evidence that documents the high quality of anesthesia care that CRNAs
deliver.
Based on the foregoing, the AANA would like to express our support for this
amendment and encourage you to continue advocating for solutions that improve the
quality of health care and reduce costs. Please do not hesitate to contact Anna Polyak,
RN, JD, the AANA’s Senior Director, State Government Affairs, at 847-655-1131 or
apolyak@aana.com if you have any questions or require further information.
Sincerely,
Juan F. Quintana CRNA, DNP, MHS
AANA President
60. JEFFERY KIVAT MD
jefnjoy@gmail.com, 85086
December 1, 2015
VIA EMAIL
Members of the Arizona Legislature committee of reference:
Advanced practice registered nurses (APRN) are a vital part of the health system of the United States.
They are registered nurses educated at Masters or Doctoral level for practice in a specific role and with
a defined patient population to provide basic and specialty healthcare services in a wide variety of
settings. APRNs are prepared by education and certification to assess, diagnose, and manage patient
problems, order and interpret tests and consult with other members of the healthcare team as the
condition of a patient requires. Where APRNs have received appropriate education and training, and
qualified through certification, they should have consistent prescriptive authority aligned with their
scope of practice.
A large body of published research conducted by expert panels and government agencies has
consistently demonstrated that the care provided by APRNs meets or exceeds established standards for
quality. It has been my experience that APRNs provide safe and effective health care to my family in
our community.
In the report of the Committee on the Robert Wood Johnson Foundation Initiative on the Future of
Nursing at the Institute of Medicine of the National Academies (The Future of Nursing: Leading
Change, Advancing Health), “Nurses have the opportunity to play a central role in transforming the
health care system to create a more accessible, high-quality, and value-driven environment for patients.
If the system is to capitalize on this opportunity, however, the constraints of outdated policies,
regulations, and cultural barriers, including those related to scope of practice, will have to be lifted,
most notably for advanced practice registered nurses.”
I agree that APRNs represent a pool of qualified professionals ready and able to meet the increasing
demand in Arizona for timely access to preventive and restorative healthcare services. I value and
support legislation that will permit APRNs to practice to the full extent of their education and training.
As a retired physician who started practice in 1976, I have witnessed an explosion of knowledge in the
various medical subspecialties. This has created a need, not adequately met at this time, for large
numbers of general practitioners who can handle basic medical needs and make appropriate referrals to
sub-specialists. I do not believe that this role requires an MD degree. I have seen it performed well by
APRN's, NP's and PA's. Giving them prescriptive authority is a must, if society is to get the full benefit
of their abilities.
Respectfully,
Jeffrey Kiviat MD (sent electronically)
62. Advanced Practice Nurses can bridge
Arizona’s health gap
By: Guest Opinion December 17, 2015 , 3:58 pm
Patient demand for health care in Arizona has never been greater.
As front-line health care professionals working in both metro Phoenix and the White Mountains,
we see it every day. Graying members of the Baby Boomer generation require more care with each
passing year. And policy actions at the state and federal level have brought hundreds of thousands
of Arizonans and tens of millions of Americans into the traditional health care system.
Meanwhile, the Association of American Medical Colleges projects that the U.S. faces a shortage
of up to 31,000 primary-care physicians by 2025.
Who is going to meet our growing health care needs? In Arizona, we believe that Advanced
Practice Nurses can help bridge the gap.
That is why the Arizona Nurses Association and groups representing our state’s nearly 6,500
Advanced Practice Nurses have banded together under the banner of the Arizona Coalition of
Advanced Practice Nurses. What the Coalition seeks is an update of Arizona’s Scope of Practice
for the four Advanced Practice Nursing groups: Nurse Practitioners, Nurse Midwives, Certified
Registered Nurse Anesthetists (CRNAs) and Clinical Nurse Specialists.
As supporters of this effort, we are grateful a joint state committee of House and Senate legislators
recently gave a positive recommendation to this Scope of Practice expansion. We are also mindful
this was but the first step in the legislative process that lies ahead.
Advanced Practice Nurses have graduate-level education, advanced clinical knowledge and
specialized focus. They work in areas like family practice, pediatrics, geriatrics, psychiatric/mental
health and women’s health.
Some sections of the existing statutes governing Advanced Practice Nurses are antiquated, dating
back decades or more. Other provisions are confusing or misleading, such as a provision requiring
CRNAs to provide anesthetics “under the direction of and in the presence of a physician or
surgeon.”
What does “under the direction of” mean? The statute doesn’t define it and there is no case law.
Additionally, requiring that CRNAs operate “in the presence” of a physician is both unnecessary
and, frankly, impossible in rural and other settings where the physician is likely scrubbing in,
reviewing test results in another room, assisting another patient or conducting any of a thousand
other tasks necessary in today’s busy health care world.
Here’s a reality check: a lack of area anesthesiologists means CRNAs are safely and securely
providing virtually all anesthetic services to patients in the White Mountains.
63. F R E S H S T A R T
G O O D N E S S I N O N E H I T
Vitamin C+
VITAMINFRESH.NET
64. Tanya R. Sorrell, PhD, Psychiatric Nurse Practitioner, Yuma
Karen Watts, MSN, Family Nurse Practitioner, Yuma
Annette Casey, MSN, Certified Nurse Midwife, Yuma
"Advanced Practice
Nurses have graduate-
level education. It has
been over 10 years since
we practiced under
physician supervision."
#NursesCare4AZ
65. Guest Column: Critical
nursing legislation offers
changes
By Tanya R. Sorrell, PhD, PMHNP-BC, Psychiatric Nurse
Practitioner, Yuma Karen Watts, MSN, FNP, Family Nurse Practitioner, Yuma Annette Casey, MSN, CNM, Certified
Nurse Midwife, Yuma. December, 2015.
As Yuma health professionals, we are concerned Yuma Sun readers may have been misled
by Dr. Uribe’s recent letter to the editor (“Option could compromise quality of health care,”
Dec. 14, 2015). We write to correct the record.
Dr. Uribe’s letter conjures up century-old concepts in which the nurse was subservient to the doctor. To
put it mildly, those ideas are not relevant to the approximately 6,500 Advanced Practice Registered
Nurses across Arizona providing world-class healthcare to patients every day.
Here are the facts: Advanced Practice Nurses have elevated (at least graduate-level) education and
specialized training. It has been more than a decade since Arizona required that we practice under the
“supervision” of a physician.
Advanced Practice Nurses safely deliver babies, diagnose and treat illnesses (yes, Dr. Uribe, even
patients with diabetes and cancer), provide anesthetic care for pain management and provide the kind
of quality care our patients expect and deserve. We serve in communities both urban and rural. And we
are increasingly relied upon within a healthcare system in which physician shortages are chronic and
patient demand is surging.
The good news? There are a number of studies and a multitude of research that demonstrate the high
quality of care provided by Advanced Practice Nurses.
One such report, jointly issued in 2010 by the Institute of Medicine and Robert Wood Johnson
Foundation, stated: “Now is the time to eliminate the outdated regulations and organizational and
cultural barriers that limit the ability of nurses to practice to the full extent of their education, training,
and competence. The current conflicts between what (Advanced Practice Nurses) can do based on their
education and training and what they may do according to state and federal regulations must be
resolved so that they are better able to provide seamless, affordable, and quality care.”
In the coming months, a coalition representing Nurse Practitioners, Certified Nurse Midwives, Clinical
Nurse Specialists and Certified Registered Nurse Anesthetists will seek legislation updating the
regulations governing Advanced Practice Nurses in Arizona. The changes are modest and common
sense — clarifying sections of existing law that have been the source of confusion and granting greater
autonomy so that Advanced Practice Nurses like us can provide care in accordance with our elevated
education, training and experience.
Contrary to Dr. Uribe’s assertions, nobody seeks to replace the role of your doctor in your health care.
More than 700 Arizona nurses, patients and healthcare advocates have signed letters in support of this
critical nursing legislation. So have approximately 70 physicians from every corner of our state.
Anyone who would like to learn more may visit AZnurse.org for more information.
66. AChapter of the American PhysicalTherapyAssociation
President
Linda Duke, PT
Gilbert
ldukept@msn.com
Vice President
Sara Demeure, PT, MSPT, OCS
Scottsdale
sara@desertpt.com
Secretary
Staci Whitman, PT, DPT
Flagstaff
4whits@npgcable.com
Treasurer
Justin Dunaway, PT, DPT, OCS
Gilbert
jdunawaydpt@gmail.com
Chief Delegate
John Heick, PT, DPT, NCS, OCS
Gilbert
jheick@atsu.edu
PTA Caucus Representative
Jane Jackson, PTA
Tempe
j.jacksonpta@gmail.com
District 1 - Western Maricopa
Kyle Guidry, PT, DPT, ATC
Surprise
kguidry@guidryphysicaltherapy.com
District 2 - Central Maricopa
Tabitha Kuehn, PT, DPT
Scottsdale
tabithakuehn@gmail.com
District 3 – Eastern Maricopa
Katie Larson, PT, DPT, OCS
Gilbert
klarsondpt@gmail.com
District 4 - Southern Arizona
Joni Raneri, PT, DPT
Tucson
joni.raneri@yahoo.com
District 5 - Northern Arizona
Lorie Kroneberger, PT, DPT, GCS
Flagstaff
lorie.kroneberger@nau.edu
Executive Director
Catherine Langley, CAE
1055 N. Fairfax St., Suite 205
Alexandria, VA 22314
602.569.9101
info@aptaaz.org
Arizona Physical Therapy Association
1055 N. Fairfax St., Suite 205
Alexandria, VA 22314
www.aptaaz.org
To the Honorable members of Arizona Senate and House Health Committee:
We believe advanced practice registered nurses (APRN) are a vital part of the
health care delivery system of the United States. These are registered nurses,
educated at a Masters or Doctoral level for specific practice with a defined patient
population to provide basic and specialty health services across a variety of
settings. APRNs are prepared by both education and certification to assess,
diagnose, and manage health concerns, order and interpret tests, and collaborate
with other team members as each patient condition requires. In areas where
APRNs have received appropriate education and training, qualified through
certification, they should have consistent prescriptive authority in alliance with
their scope of practice.
Published research conducted by expert panels and government agencies has
consistently demonstrated that the care provided by APRNs meets or exceeds
established standards for quality. We know that APRNs provide safe and effective
health care to persons treated in collaboration with our respective physical
therapy practices, across various settings, and for ourselves and our families.
One published example of this is in the Committee on the Robert Wood Johnson
Foundation Initiative on the Future of Nursing at the Institute of Medicine of the
National Academies (The Future of Nursing: Leading Change, Advancing Health)
report which states: “Nurses have the opportunity to play a central role in
transforming the health care system to create a more accessible, high-quality, and
value-driven environment for patients. If the system is to capitalize on this
opportunity, however, the constraints of outdated policies, regulations, and
cultural barriers, including those related to scope of practice, will have to be lifted,
most notably for advanced practice registered nurses.”
We have discussed this legislation and our respective viewpoints based on
personal and professional relationships, and agree that APRNs represent a pool of
qualified professionals ready and able to meet increasing demand in Arizona for
timely access to preventive and restorative healthcare services. We value and
support legislation that will permit APRNs to practice to the full extent of their
education and training.
Respectfully,
Dr. Linda Duke, PT, DPT
President AZPTA
70. Date: October 15, 2015
Dear Members of the Arizona Legislature Committee of Reference:
The National Association of Pediatric Nurse Practitioners (NAPNAP) has been the leading voice for pediatric nurse
practitioners in America for over 40 years. As a division of this organization, the Arizona Chapter of NAPNAP works
collectively to support advanced practice registered nurses (APRN) and improve the health of infants, children and
adolescents in Arizona.
I am writing of behalf of the leadership team from the Arizona Chapter of NAPNAP to support that advanced practice
registered nurses (APRN) are a vital part of the health system of the United States. They are registered nurses educated at
Masters or Doctoral level for practice in a specific role and with a defined patient population to provide basic and specialty
healthcare services in a wide variety of settings. APRNs are prepared by education and certification to assess, diagnose, and
manage patient problems, order and interpret tests and consult with other members of the healthcare team, as the condition
of a patient requires. Where APRNs have received appropriate education and training, and qualified through certification,
they should have consistent prescriptive authority aligned with their scope of practice.
A large body of published research conducted by expert panels and government agencies has consistently demonstrated that
the care provided by APRNs meets or exceeds established standards for quality. It has been our experience that APRNs
provide safe and effective health care to children across our state.
In the report of the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute
of Medicine of the National Academies (The Future of Nursing: Leading Change, Advancing Health), “Nurses have the
opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-
driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated
policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for
advanced practice registered nurses.”
We agree that APRNs represent a pool of qualified professionals ready and able to meet the increasing demand in Arizona
for timely access to preventive and restorative healthcare services for children. We value and support legislation that will
permit APRNs to practice to the full extent of their education and training.
Sincerely,
Daniel Crawford, DNP, RN, CPNP
Legislative Chair
Arizona Chapter of the National Association of Pediatric Nurse Practitioners
71. Arizona Chapter of the National Association
of Pediatric Nurse Practitioners
Dr. Daniel Crawford, DNP, RN, CPNP
"We agree that APRNs represent
a pool of qualified professionals
ready and able to meet the
increasing demand in Arizona
for timely access to preventive
and restorative healthcare
services for children."
72.
73.
74. November 17, 2015
Dear Committee of Record,
As advanced practice nurses and advanced practice nursing faculty, we are urging the Health
Committee of Reference as well as the entire legislature to approve the Sunrise Application that
amends Title 32-3106 Chapter 15 of Arizona Revised Statutes. This application aims to enlarge
the scope of practice of advanced practice registered nurses (APRNs) in Arizona. In 2008,
through the work of the APRN Consensus Work Group & the National Council of State Boards
of Nursing APRN Advisory Committee the Consensus Model for APRN regulation was
developed. This document came about due to the fact that each state independently determines
each APRN specialty’s legal scope of practice, the roles recognized, the criteria for entry-into
advanced practice and the certification examinations accepted for entry-level competence
assessment. This inconsistency of state laws creates a significant barrier for APRNs to easily
move from state to state and has led to decreased access to care for patients. Furthermore, in
2010, the Institute of Medicine of the National Academies published a report entitled The Future
of Nursing Leading Change, Advancing Health. This report listed 8 recommendations which
include removing scope-of-practice-barriers, expanding opportunities for nurses to collaborative
improvement efforts, and prepare and enable nurses to lead change to advance health.
Shortly after the publication of the Future of Nursing report, the Robert Wood Johnson
Foundation and AARP began a Campaign for Action to the promote recommendations in these
reports. The National Council on State Boards of Nursing (NCSBN) also created the Campaign
for Consensus, an initiative to create uniformity in the laws of all states to permit advanced
practice nurses to practice to the full extent of their education and training.
As advanced practice nursing educators/practitioners at the University of Arizona, we adhere to
the goal that all of the advanced practice nursing specialties prepare advanced practice nurses
at the doctoral level of education. This level of education education includes hundreds of hours
of supervised practice in the clinical setting as well as 3 years of didactic preparation. In
addition, we are responsible for preparing all advanced practice nursing students to successfully
complete a certification exam in their specialty which psychometrically demonstrates
competency as an advanced practice nurse.
The quality and cost-effectiveness of APRN delivered care has been studied repeatedly and
shown to be of high quality and at lower cost. As a result, it is crucial that in today’s healthcare
environment that APRNs be able to have practice barriers removed which will then enable
state’s to improve access to care to quality care at lower health care costs. This Sunrise
application to enlarge scope of practice of advanced practice nurses will undoubtedly be of
great benefit to the residents of Arizona.
Sincerely,
Allen V. Prettyman, Ph.D., FNP-BC, FAANP
Clinical Associate Professor
Director of Practice Innovations
FNP Specialty Coordinator
apretty@email.arizona.edu
1305 North Martin Avenue
P.O. Box 210203
Tucson, AZ 85721-0203
Tel: (520) 626-6152
Fax: (520) 626-2669
www.nursing.arizona.edu
75. "As Advanced Practice
Nursing Faculty, it is
crucial that APRNs be
able to have practice
barriers removed which
will then enable Arizona
to improve access to care"
#NursesCare4AZ
Dr. Allen V. Prettyman, Ph.D., FNP-BC
Fellow, American Academy of Nurse Practitioners
University of Arizona College of Nursing
Director of Practice Innovations
76.
77.
78. 10/14/15
From:
Kelly M. McCormick
Arizona Anesthesia Solutions (AzAS)
Practice Administrator
To:
Senate Health and Human Services Committee
Chairwoman: Nancy Barto
Members: David Bradley, Katie Hobbs, Debbie Lesko, Lynne Pancrazi, Kelli Ward (Vice Chair), Kimberly Yee
House Health Committee
Chairwoman: Heather Carter
Members: Paul Boyer, Dr. Regina Cobb (Vice Chair), Dr. Randall Friese, Jay Lawrence, Eric Meyer
All Interested Legislators in Arizona
Dear Legislators,
I’m writing to you today as the administrator of an anesthesia business that services facilities, surgeons, and dentists
throughout Arizona. Our anesthesia staff consists of both Certified Registered Nurse Anesthetists (CRNAs) as well
as board-certified physician anesthesiologists. While both of these professions deliver excellent anesthesia care,
the statute concerning CRNAs is not only outdated, it also affects my business’s ability to give anesthesia care in a
safe and accessible fashion.
The current language is obsolete to the delivery of anesthesia. When an anesthesia provider is delivering the
anesthetic, they are the only person in the operating suite with any formal training and education in the field of
anesthesia. The same is true of all our our anesthesia providers – neither our CRNAs or our anesthesiologists are
“directed” by the surgeon, nor could the relationship between CRNAs and surgeons in any way be construed as
“direction.” CRNAs and anesthesiologists possess a similar knowledge base and act in the same role when
delivering anesthesia – they are the sole expert in anesthesia management, airway management, and hemodynamic
control. The surgeon is the expert in their procedure, and while we are responsible for the same patient, our areas
of expertise are very different.
When surgeons are approached on this issue and read the current statute, their reaction is one of shock. That’s
because anyone with surgical or anesthesia experiences realizes that no surgeon “direction” ever occurs, and they
recognize that this language does not protect the public in any fashion, but rather, creates confusion about liability
and responsibility for anesthesia and hinders access to care.
The risks to patient care posed by keeping this outdated language are not theoretical. My company was recently
approached by a Phoenix urology group to administer anesthesia for in-office procedures. Due to this statute, a
two-week delay occurred before the surgeons and my anesthesia group could go into the office and deliver care.
This statute is not just a patient care issue but also an economic one. My company has lost business because of the
confusing, outdated, ambiguous language. Multiple studies have demonstrated the economic boon that results
when reducing unproven, unneeded regulations for providers such as CRNAs. Free-market solutions, with
reasonable restrictions and guidelines, are what will drive healthcare costs down for patients while ensuring they
receive the highest quality of care.
CRNA care is not a new phenomenon as CRNAs have been administering anesthesia since the late 1800’s. Their
skill on the battle field is well-known among the armed forces, where CRNAs are the only providers of anesthesia
care in forward-surgical hospitals, and often are required to administer two simultaneous anesthetics to patients
with severe trauma. Taking that skill into the civilian sector, CRNA outcomes have been researched exhaustively
and have been found, like their anesthesiologist colleagues, to have an outstanding record of safety.
86. December 4, 2015
Arizona Legislature
Arizona Senate and House Health Committees
Capitol Complex
1700 West Washington
Phoenix, AZ 85007-2890
Re: Advanced Practice Registered Nurse Sunrise Review
Dear Members of the Arizona Senate and House Health Committee:
On behalf of the American Association of Nurse Practitioners (AANP), our Arizona members, and the patients served by
our membership, AANP welcomes the opportunity to provide comment during the Senate and House Health
Committees’ sunrise review process for Advanced Practice Registered Nurses (APRNs), a group of health care providers
to which Nurse Practitioners (NPs) belong.
Nurse Practitioners in Arizona are currently licensed to provide a range of health care services. Existing statute
authorizes nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage
treatments, and prescribe medications. This scope of service is regulated under the exclusive licensure authority of the
Arizona Board of Nursing, and has benefited the people of Arizona significantly.
In the years since the last licensure update for NPs, the state has seen tremendous growth in the number of NPs
providing care across the state. In fact, the 2002 licensure changes resulted in a substantial increase of the NP
workforce. According to the Arizona Rural Health Workforce Trend Analysis study produced by the Arizona Rural Health
Office, there was a 52% increase in the number of nurse practitioners working in the state between 2002 and 2006,
with the largest area of NP workforce growth according in rural counties. 1
Arizona’s Full Practice Authority practice
environment for NPs continues to serve as an incentive for NP provider recruitment to the state. During the 2015
Colorado legislative session, the Colorado legislature noted that NPs from Colorado were relocating to Arizona because
the state’s licensure laws were more closely aligned with NP education, national certification, and the National Council
of State Boards of Nursing Consensus Model for Advanced Practice Registered Nursing regulation. 2
The American Association of Nurse Practitioners supports the APRN sunrise proposal as it will not alter the existing
scope of services, scope of practice, or regulatory oversight for nurse practitioners in the state. The purpose of this
proposal is to align language with the national consensus model for nurse practitioner licensure. Adopting the
standardized language will help Arizona remain competitive in recruiting NP providers to the state, especially as more
states adopt the Consensus Model framework and compete for provider workforce resources.
87. Additionally, there is compelling evidence to support the growth of Arizona’s NP workforce and ensure that patients
continue to receive full and direct access to nurse practitioner services. Recent studies have underscored that states
with licensure frameworks consistent with the Consensus Model have better access to health care services, improved
health outcomes, lower hospital readmission rates, and lower costs of care. 3,4,5,6
Adopting the sunrise proposal to align
language with the Consensus Model will help cultivate the state’s health care workforce and maintain the safe, high
quality of care nurse practitioners have been providing to Arizonans.
The American Association of Nurse Practitioners, along with our Arizona membership, respectfully asks that the Arizona
Senate and House Health Committee move forward the sunrise proposal to adopt the Consensus Model for nurse
practitioners. We appreciate the opportunity to provide comment on this process and its implication to care delivery. If
there are any questions regarding AANP’s comments, please contact our office at (512) 442-4262.
Sincerely,
Cindy Cooke, DNP, FNP-C, FAANP
President
American Association of Nurse Practitioners
1. Arizona Rural Health Workforce Trend Analysis. Retrieved February 3, 2012 from
http://crh.arizona.edu/sites/crh.arizona.edu/files/pdf/publications/Final_AHEC_WorkforceReport.pdf
2. Hearing on Colorado Senate Bill 15-197, Colorado State Senate Health and Human Services Committee, 2015 Regular Session (March
12, 2015)
3. Oliver GM, Pennington L, Revelle S, Rantz M. Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients.
Nursing Outlook. 2014 Nov-Dec;62(6):440-7.
4. Kuo, Y., Chen, N., Baillargeon, J., Raji, M. A., & Goodwin, J. S. (2015). Potentially Preventable Hospitalizations in Medicare Patients With
Diabetes: A Comparison of Primary Care Provided by Nurse Practitioners Versus Physicians. Medical Care, 53(9), 776-783.
5. Yong-Fang Kuo, Figaro L. Loresto, Jr., Linda R. Rounds and James S. Goodwin. States With The Least Restrictive Regulations Experienced
The Largest Increase In Patients Seen By Nurse Practitioners. Health Affairs, 32, no.7 (2013):1236-1243
6. Richards, M.R., & Polsyk, D. (2015) Influence of provider mix and regulation on primary care services supplied to US patients. Health
Economics, Policy and Law, 2015 Oct;(7):1-21.
91. It's past time to update scope of practice laws for
Arizona's APRNs.
LESS
BUREAUCRACY.
MORE PATIENT
CARE.
#NursesCare4AZ
Photo: Dan Lovinaria
92. 8403 Colesville Road, Suite 1550, Silver Spring, MD 20910-6374 240.485.1800 fax: 240.485.1818 www.midwife.org
November 25, 2015
TO:
Members of the Committee of Reference and All Interested Legislators in Arizona
I am writing on behalf of the American College of Nurse-Midwives (ACNM), the national
professional organization representing the interests of certified nurse-midwives (CNM) and
certified midwives (CM) practicing in the United States, to express support for legislation that
will allow CNMs and other Advanced Practice Registered Nurses (APRNs) to practice to the full
extent of their education and training. The sunrise application currently under consideration
presents sound policy initiatives that will increase access to quality health care providers, control
health care costs, and align advanced practice regulation with recommended national standards.
Nurse-midwives are highly trained providers who earn graduate degrees and must pass a national
certification examination to demonstrate mastery of ACNM's core competencies, which meet or
exceed international recommendations for midwifery care. Nurse-midwifery practice
encompasses a full range of primary healthcare services for women from adolescence to beyond
menopause. Midwifery services are provided in partnership with women and families in diverse
settings such as ambulatory care clinics, private offices, community and public health systems,
homes, hospitals and birth centers.
Decades of research indicate that services provided by nurse-midwives compare favorably to
those provided by physicians. For example, in a recent systematic review of studies comparing
midwifery care to physician care, researchers concluded that women cared for by CNMs
compared to women of the same risk status cared for by physicians had lower rates of cesarean
birth, lower rates of labor induction and augmentation, a significant reduction in the incidence of
third and fourth degree perineal tears, and higher rates of breastfeeding.1
Moreover, a 2012 meta-
analysis of midwifery outcomes as compared to labor and delivery care provided by physicians
concluded that there was no difference in CNM versus MD care and, for some variables, that
midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe
and effective" and urged that midwives "should be better utilized to address the projected health
care workforce shortages."2
Importantly, the midwifery model of care also results in significant savings in health care
spending by appropriate use of expensive technology and reducing cesarean rates. This is
particularly important to the state, given that Arizona’s Medicaid program covers approximately
1
Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nursing outcomes 1990-2008: a systematic
review. Nurs Econ. 2011;29(5):1-22.
2
Johantgen M et al. Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives
and Physicians: A Systematic Review, 1990 to 2008. Women's Health Issues 22-1 (2012) e73–e81.
93. 53 percent of all births in the state. ACNM estimates that in 2013 alone, if CNMs had attended
all Arizona births to low risk women, the savings from reduced cesarean births alone would have
amounted to nearly $6.4 million for Arizona’s Medicaid program and nearly $12 million for
individuals with commercial insurance or paying out of their own pocket.3
A robust midwifery
workforce would greatly improve the delivery of and access to women’s health care in Arizona
while reducing the state’s health care expenditures. A modernization of the regulation of nurse-
midwives would likely yield an increase in the midwifery workforce, as “the single best
predictor” of the distribution of nurse-midwives has been shown to be the degree to which state
policies “facilitated or restricted” practice.4
The proposals expressed in the sunrise application are vitally important policy initiatives with
positive, far-reaching implications for Arizona’s health care workforce, maternal-child health
outcomes, and health care expenditures. Now more than ever, the high quality care and lower
costs associated with midwifery care matters. And perhaps more importantly, midwives matter
to the mothers and babies of Arizona.
Respectfully,
Jesse Bushman
Director, Advocacy and Government Affairs
3
Estimate based on the cost of vaginal and cesarean births in “The Cost of Having a Baby in the United States,”
available at: http://transform.childbirthconnection.org/reports/cost/ (cost figures inflated to 2013 dollars by the
Medicare Economic Index). Estimate takes into account the percent of births covered by Medicaid, commercial and
self-pay, as reported by the CDC at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm. Estimate
assumes 80% of women are appropriate for midwifery care.
4
Eugene Declerq et al, “State Regulation, Payment Policies, and Nurse-Midwife Services,” Health Affairs 17
(1998): 190-200.
98. National Association of Clinical Nurse Specialists
100 N. 20th St., Suite 400 Philadelphia, PA 19103
www.nacns.org info@nacns.org
November 25, 2015
To members of the Arizona Legislature:
On behalf of the National Association of Clinical Nurse Specialists (NACNS) and the millions of
patients who receive care from and supervised by Clinical Nurse Specialists (CNSs), I strongly
encourage you to enlarge the scope of practice for Advanced Practice Registered Nurses
(APRNs), including CNSs, that is consistent with their education and training, as outlined in the
Sunrise Application submitted by the Arizona Nurses Association, the Arizona Association of
Nurse Anesthetists, the Arizona Affiliate of the American College of Nurse-Midwives and the
Arizona Nurse Practitioner Council.
APRNs, including CNSs are a vital part of the United States health system. We are registered
nurses educated at the master’s or doctoral level to practice in a specific role and with a defined
patient population to provide basic and specialty healthcare services in a wide variety of settings.
APRNs are educated and certified to assess, diagnose, and manage patient problems, order and
interpret tests and consult with other members of the healthcare team as needed. Where APRNs
have received appropriate education and training, and qualified through certification, they should
have consistent prescriptive authority aligned with their scope of practice.
A large body of published research has consistently demonstrated that the care provided by
APRNs meets or exceeds established standards for quality. In its 2010 landmark report, The
Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine noted, “Nurses
have the opportunity to play a central role in transforming the health care system to create a more
accessible, high-quality, and value-driven environment for patients. If the system is to capitalize
on this opportunity, however, the constraints of outdated policies, regulations, and cultural
barriers, including those related to scope of practice, will have to be lifted, most notably for
advanced practice registered nurses.”
APRNs represent a pool of qualified professionals ready and able to meet the increasing demand
in Arizona for timely access to preventive and restorative healthcare services. NACNS strongly
supports legislation that will permit APRNs to practice to the full extent of their education and
training.
Respectfully,
Peggy Barksdale, MSN, RN, OCNS-C, CNS-BC
President
National Association of Clinical Nurse Specialists
99. August 10, 2015
Esteemed Members of the Arizona Legislature,
On behalf of the National Association of Hispanic Nurses, Phoenix Chapter, we strongly ask
for your support of allowing Advanced Practice Registered Nurses (APRNs) to practice to
their full scope of education and practice, in order to meet the health care needs of patients
and their families throughout our state. The need for more primary care providers is
especially critical in underserved and rural Arizona communities and this is a gap in health
care that APRNs can fill.
As you know, APRNs are a vital part of the health system of the United States. They are
registered nurses educated at Masters or Doctoral level for practice in a specific role and
with a defined patient population to provide basic and specialty healthcare services in a
wide variety of settings. APRNs are prepared by education and certification to assess,
diagnose, and manage patient problems, order and interpret tests and consult with other
members of the healthcare team as the condition of a patient requires. Where APRNs have
received appropriate education and training, and qualified through certification, they
should have consistent prescriptive authority aligned with their scope of practice.
A large body of published research conducted by expert panels and government agencies
has consistently demonstrated that the care provided by APRNs meets or exceeds
established standards for quality. It has been by experience that APRNs provide safe and
effective health care to our patients and communities that we serve as a non-profit,
professional organization.
In the report of the Committee on the Robert Wood Johnson Foundation Initiative on the
Future of Nursing at the Institute of Medicine of the National Academies (The Future of
Nursing: Leading Change, Advancing Health), “Nurses have the opportunity to play a
central role in transforming the health care system to create a more accessible, high-
quality, and value-driven environment for patients. If the system is to capitalize on this
opportunity, however, the constraints of outdated policies, regulations, and cultural
barriers, including those related to scope of practice, will have to be lifted, most notably for
advanced practice registered nurses.”
We agree that APRNs represent a pool of qualified professionals ready and able to meet the
increasing demand in Arizona for timely access to preventive and restorative healthcare
services. We value, need and support legislation that will permit APRNs to practice to the
full extent of their education and training.
Respectfully,
Adriana Perez, PhD, ANP-BC, FAAN
President, Phoenix Chapter
National Association of Hispanic Nurses
100.
101.
102. FROM: Aaron Ketcher, DNP, CRNA, President of Anesthesia Consultants of Arizona
TO: Senate and House Health Committee Members
My name is Dr. Aaron Ketcher. I am writing to encourage you to please support Arizona Nurses Associations
Sunrise application, which will allow all Advanced Practice Registered Nurses (APRNs) to practice to the full
extent of their education and training. Arizona’s current statutes and regulations are outdated and
unnecessary. The Nurses Association is proposing a reasonable update that will increase access to affordable
care to all of Arizona, but especially to the underserved rural communities.
I currently have extended family spread across Arizona’s rural communities. They rely on these APRNs to give
them the health care they need. In the Phoenix and Tucson metro areas if it were not for the large number of
APRNs not only would patients have long weight times to get needed care but also health care prices would be
drastically higher.
I am a Certified Registered Nurse Anesthetist (CRNA) and I own and operate my own anesthesia company. I
provide anesthesia services throughout Arizona in both medical and dental offices, surgery centers, and
hospitals. Many of the procedures that I provide anesthesia services for are not covered by health insurance.
If it were not for the affordable care I provide, these patients simply would not be able to receive the care they
need.
One obstruction that I have in growing my business is that many physicians are concerned that they are
somehow liable for my services because of outdated statutes that state they must direct the anesthesia. None
of the operating practitioners I work with (surgeons, dentists, or physicians) have any formal training in
anesthesia. It does not make sense that any physician, untrained in anesthesia, would required to direct
another provider who is an expertly trained anesthesia provider.
It is important, as we continue to grapple with fixing this country’s health care problem, that we use every
member of the health care team to their fullest potential. In Arizona we are handcuffing APRNs of all
specialties and not allowing them to provide the care they are trained to provide. Let me assure you that all
APRNs function as part of a health care team, but within that team they should be able to utilize all of their
training. Every increase in scope of practice that the Nurses Association is asking for is already a standard
practice in multiple states across the country. In those states, APRNs are functioning safely within these
capacities, and have for decades.
I ask you to support the Nurses that Care for Arizona, and remove this harmful and outdate verbiage. Thank
you for your service to our beautiful state, and for your time.
Respectfully and Professionally,
Aaron Ketcher, DNP, CRNA
President, Anesthesia Consultants of Arizona
