Alabama APRN Update: Prescribing 1Running head: ALABAMA APRN UPDATE: PRESCRIBING Alabama Advanced Practice Registered Nurses Practice Update: Prescribing Privileges Lori Lioce, MSN, FNP-BC, NP-C, RDH Samford University, Ida V. Moffett, School of Nursing May 7, 2010
Alabama APRN Update: Prescribing 2 AbstractThe Advanced Practice Registered Nurses (APRNs) scope of practice was defined in 1996, instatute in the Code of Alabama. Since 1996, there have been no changes in these statues, despitethe immense growth and evolution of the APRNs role throughout Alabama in providing primaryand specialty care. Recent legislative efforts to decrease barriers in delivering patient care haveyielded no positive results. Alabama is 1 of 2 states in the U.S. unauthorized to prescribecontrolled substances. This project describes APRN practice in Alabama, identifies barriers,describes the need for controlled substance prescription privileges, and the process of seekingthose privileges. The project also details lessons learned from the process and presents a changeplan for accomplishing future legislative goals. The purpose of the project is to improve thequality of health care by helping nurse practitioners develop, plan, educate, and implement achange plan. This change plan can be used to add controlled substance prescriptive privileges tothe APRN Scope of Practice.
Alabama APRN Update: Prescribing 3List of FiguresFigure 1: Lioce Advanced Practice Nursing Legislative Change Model……………….8
Alabama APRN Update: Prescribing 6 Table of ContentsAbstract......................................................................................................2Background........................................................................................................................9 Definitions...................................................................................................10Problem...........................................................................................................................12 Intended improvement ...............................................................................12Significance of the problem..............................................................................................20 Patient Care................................................................................................20Nursing practice.........................................................................................21Project Purpose..........................................................................................22Theoretical Framework...............................................................................22 Related Concepts.......................................................................................22 Definition of Project Terms .........................................................................23 Specific Theories Related to Capstone Project...........................................23 Relationship of Concepts and Theories......................................................25Assumptions or Presuppositions....................................................................27Relevant Variables......................................................................................28Review of the Literature..............................................................................30Setting.......................................................................................................35 Institution and Unit .....................................................................................35Purpose.....................................................................................................35
Alabama APRN Update: Prescribing 7 True Leaders..............................................................................................36 Population..................................................................................................37 Detailed Plan for Project..............................................................................37 Resources...................................................................................................38 Budget.......................................................................................................39 Timeline....................................................................................................39 Evaluation Plan..........................................................................................40 Results.......................................................................................................41 Evaluation of the timeline for the project shows the revisions, in orange, for the time line. Thelegislative drafts took longer than expected due to the ongoing negotiations. Bill sponsors were unwilling tocommit their support for a bill that was not fully supported by MASA. Introduction of the bill was delayeddue to inadequate sponsorship and support in the legislature. .....................................................42 .........................................................................................................................................42 Lessons Learned..............................................................................................................44 Limitations......................................................................................................................45 Plans for Dissemination...................................................................................................50 Recommendations for Future Research............................................................................50 Conclusion.................................................................................................51 References..................................................................................................52 Appendices54
Alabama APRN Update: Prescribing 9 Alabama Advanced Practice Registered Nurses Practice Update: Prescribing Privileges How can Advanced Practice Registered Nurses (APRNs) in Alabama effect legislationthat will change the scope of practice laws in Alabama? The answer to this question has provendifficult for APRNs as a result of multiple practice barriers. Despite the growing number ofAPRNs in the state and the rapid evolution of their professional role, limitations in scope ofpractice and the scope’s absence in the Code of Alabama have created barriers to delivering carein Alabama. APRNs are educated and nationally certified to provide primary care. This capstoneproject describes current APRN practice and the state of prescribing for APRNs. Further, afocused change plan is developed to expand prescribing privileges to include controlledsubstances, specifically, limited schedule II through V, regulated by the Alabama Board ofNursing (ABON). Background There are approximately 157,782 APRNs practicing in the United States today. Thenumber of APRNs has doubled since 1999 from 76,306 APRNs. This ranks Alabama as one ofthe three slowest growing states for the profession with a rate of 47% growth (Pearson, 2010).APRNs have been educated and trained to provide primary care across the country since 1965(American Academy of Nurse Practitioners (AANP), 2009). Ninety-two percent of APRNsmaintain national certification (AANP, 2009a). APRNs have prescriptive authority in all 50states and write over 513 million prescriptions each year (AANP, 2009a). Presently, 48 statesauthorize APRNs to prescribe controlled substances. Alabama and Florida are the only two statesin the country restricted from providing these prescriptions for their patients’ care (AANP,
Alabama APRN Update: Prescribing 102009a; Pearson, 2009). Moreover, 15 states and D.C. require no physician involvement in anyaspect of prescribing (Pearson, 2009, map 2). This capstone project proposes expansion of the APRN prescribing privileges to includelimited controlled substances in schedule II and schedules III-V. The change plan eliminates oneof the barriers to delivering appropriate care, increases access to care when the physician is notin the office, decrease the wait time for patients for pain relief, and provides increased quality ofcare for the patients in Alabama. APRNs currently have controlled substance prescribingschedules II-V, with varying rules, in 40 states (AANP. 2009).Definitions An advanced practice registered nurse (APRN) has completed a master’s degree or higherin the field of nursing. They have received additional educational preparation in advancedpharmacology, advanced pathophysiology, and advanced health assessment. They have had over600 post-baccalaureate hours of supervised clinical practice that includes the above skills. APNs conduct comprehensive health assessments aimed at health promotion and disease prevention. They also diagnose and manage common acute illnesses, with referral as appropriate, and manage stable chronic conditions in a variety of settings. APNs titles include Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, and Certified Nurse Anesthetist. Independent practitioners are capable of solo practice with clinically competent skills and are legally approved to provide a defined set of services without assistance or supervision of another professional (Sherwood, Brown, Fay & Wardell (1997). APRNs, for the purpose of this study, include nurse practitioners and certified nurse-midwives. Under existing law in Alabama, APRNs are titled as Certified Registered NursePractitioners (CRNP), when in collaborative practice.
Alabama APRN Update: Prescribing 11 A controlled substance is legally defined as: A drug, which has been declared by federal or state law to be illegal for sale or use, but may be dispensed under a… prescription. The basis for control and regulation is the danger of addiction, abuse, physical and mental harm (including death), the trafficking by illegal means, and the dangers from actions of those who have used the substances (The People’s Law Dictionary, 2005, n.p.). Drugs are assigned to one of five schedules by the Drug Enforcement Agency (DEA).The DEA is “the federal agency responsible for enforcing laws and regulations governingnarcotics and controlled substances; their goal is to immobilize drug trafficking organizations”(The Peoples Law 2005, n.p.). Their mission is to “enforcement of the provisions of theControlled Substances Act as they pertain to the manufacture, distribution, and dispensing oflegally produced controlled substances (U.S. Drug Enforcement Administration, 2010, p.8)” A certifying board “promulgates rules and charge reasonable fees to defray expensesincurred in registration and administration of the provisions of this article in regard to themanufacture, dispensing or distribution of controlled substances within the state” (Code ofAlabama, 1975, Sec. 20-2-50). Certifying boards currently include: The State Board of MedicalExaminers, the State Board of Health, the State Board of Pharmacy, the State Board of DentalExaminers, the State Board of Podiatry, and the State Board of Veterinary Medical Examiners(Sec. 20-2-2). The certifying board is responsible for granting and withdrawing the QualifiedAlabama Controlled Substances Certificate (QACSC). The process for both is defined in therules and regulations of the administrative code by the certifying body and should include, fees,monitoring, investigating complaints and abuse, and discipline. A Qualified Alabama Controlled Substances Certificate is required from the applicant’s
Alabama APRN Update: Prescribing 12regulatory board in the state of Alabama before application can be made to the DEA for acontrolled substance prescribing number. The BME rules for physician assistant prescribing,adopted in December 1, 2009 are found in Appendix A. Problem Under existing law, a CRNP may prescribe legend drugs. Legend drugs are defined as“any drug, medicine, chemical, or poison bearing on the label the words, caution, federal lawprohibits dispensing without prescription," or similar wording indicating that such drug,medicine, chemical, or poison may be sold or dispensed only upon the prescription ofa licensed medical practitioner” (Code of Alabama, 1975, Sec 34-23-1). Legend drugs includemedications such as attention deficit disorder (ADD) stimulants, antibiotics, diabetic insulin,heart, cholesterol, and blood pressure medications. Patients’ treatment should not be delayed orundertreated when qualified providers are providing their care. The significant underutilization of Advanced Practice Nurses (APRNs) continues to limitpatient care. Numerous gaps in policy and the healthcare system have been identified in theliterature and unnecessary restrictions on APRNs limit access to care for patients who areunderserved or receive no medical care at all (Institute Of Medicine (IOM), 2001; Safriet, 1994).Intended improvement The proposed legislative change expands APRN prescribing privileges by addingcontrolled substance, schedules II-V, to the scope of practice. This practice change increases thequality of care delivered to patients. Concurrently, it eliminates one of the current barriers forAPRNS to practice in Alabama. National Alabama is ranked 51st in country for restrictive APRN regulation, consumer choice andpractice environment (study included the District of Columbia). The ranking of 51st earns
Alabama APRN Update: Prescribing 13Alabama an “F” for severely limiting patient’s choice. Alabama received the lowest number ofpoints in the United States, 5 out of 30, for patient’s access to prescriptions (Lugo, O’Grady,Hodnicki & Hanson, 2007). Scopes of practice restrictions are barriers to increased quality of care (IOM, 2001;Safriet, 1994). With shortages of physicians expected to reach 200,000 in 15 years, states arelooking to expanding scopes of practice for APRNs to provide primary care (ACP, 2009;Cooper, 2004). Scope of practice barriers decrease access to care for Alabama citizens and rankAlabama in the bottom ten states for healthcare access in the United States (America’s HealthRankings, 2007). The American College of Physicians (ACP) released a policy monograph in 2009recognizing nurse practitioners as primary care providers, equal in safety to physiciancounterparts, and endorsed efforts to support healthcare collaboration. The monograph’sexecutive summary supports that APRNs be regulated and certified solely by boards of nursing.Further, the ACP stated “anticipated and actual shortages of primary care physicians have ledpolicy makers to consider the roles of nurse practitioners in improving access to primary carehealth care services” (American College of Physicians (ACP), 2009, p. 2). According to the American Academy of Nurse Practitioners, 48 states authorize APRNS toprescribe controlled substances and recognized by the DEA. Only six states are restricted toschedules III-V, and two states, Alabama and Florida restricted to legend drugs only, as shownon the map in Appendix B (2009a). These facts negate any reasonable explanation formaintaining the current statutory or regulatory barriers in Alabama that may limit prescribingprivileges for APRNs. The facts support the need for legislative change. The Pearson report utilizes a national map to display the state of nurse practitioner
Alabama APRN Update: Prescribing 14prescriptive practice. The map summary clearly shows 15 states with “absolutely no requirementfor any physician involvement” and 38 states with a written requirement for physicianinvolvement. (Pearson, 2010, maps 2). The American College of Emergency Physicians (American College of EmergencyMedicine (ACEM), 2008) report card ranks Alabama 38th with a “D-” for access to emergencycare. This ranking included the following areas of study: quality and patient environment, accessto care, liability, public health and prevention and disaster preparedness. Alabama received thelowest ranking as 44th with an “F” in the public health and injury prevention study (Appendix C).The study further recommends Alabama improve “access to care by expanding its health careworkforce (ACEM, 2008, p.17).” The AANP’s national position statement on nurse practitioner prescriptive privilegesstates: Four decades of research conclude that nurse practitioners provide safe, cost-effective, high-quality healthcare. Prescribing medications and devices is essential to the nurse practitioners practice. Restrictions on prescriptive authority limit the ability of the nurse practitioners to provide comprehensive health care services (AANP. 2009b, n.p.).Further research suggests state boards of nursing should be the sole regulatory authority for nursepractitioner practice and prescriptive privileges (AANP, 2009b; ACP, 2009; NCSBN, 2009). Regional Alabama and Florida remain the only two states without controlled substance privileges.There have been no regional studies identified in this literature search. The search included thefollowing key words: nurse practitioner, advanced practice nurse, Alabama, southern regional,prescriptive privileges, prescriptive authority, prescribing. In Mississippi, the 2009 legislative session removed the joint regulation/promulgation of
Alabama APRN Update: Prescribing 15nurse practitioners recognizing the Board of Nursing as the sole regulatory authority (AppendixD). Mississippi is now the 48th state under sole regulatory authority of the state Board of Nursing.House Bill 1260 eliminated the Board of Medical Licensure and the requirement for supervisionby a physician for insurance reimbursement. Mississippi APRNs are “authorized for controlledsubstance prescribing privileges, schedules II-V, as separately approved by the BON” (Medscape,2009, n.p.). In Georgia, “authority to prescribe is evidenced by inclusion on the prescription of theprescribers title and as outlined in the prescribers collaborative practice agreement.All prescriptions must show collaborating physicians name. Authority to prescribe controlledsubstances includes Schedule III-V (Medscape, 2009, n.p.).” Tennessee requires: • A state issued certificate, including certificate of fitness to prescribe and identification number on file with state. • All prescriptions must show collaborating physicians name. • Authority to prescribe controlled substances includes Schedule II-V as outlined in the collaborating physicians supervisory rules and the prescribers prescriptive formulary (Medscape, 2009, n.p.). In Florida, “authority to prescribe is evidenced by inclusion on the prescription of theprescribers title, and as outlined in the prescribers collaborative practice agreement. Authority toprescribe controlled substances is not granted (Medscape, 2009, n.p.). In 2008, Florida’s Senatecommittee tabled the controlled substance prescribing bill and ordered an investigation of needfor prescriptive privileges to a task force. The report resulted in firm support for controlledsubstance prescribing for APRNs in 2009 (Advance, 2009). Florida nurses now have Senatorial
Alabama APRN Update: Prescribing 16evidence to support change in practice and improve patient care and have proposed legislationfor prescriptive legislation. 0Regionally, the states of Mississippi, Tennessee, and Georgia all have controlled substance prescribing authority. Florida is moving forward with the legislative battle due to the legislative task force report being complete and supportive of the need for controlled substance prescribing. This leaves Alabama as the most restrictive practice environment with the least progress in the legislative environment. Local There are approximately 1820 CRNPs in the state of Alabama with 2033 collaborativepractice covering different 4,426 practice sites. A summary table and break down of thesenumbers are included in Appendix E (Joint Committee, 2010, p. 9A). A map representing thedistribution of the practice sites and residential sites of the CRNPs is found in Appendix FDAANP, 2010). The map demonstrates the practice locations are lightly scattered in the ruralareas. Alabama has 60 of 67 counties declared as underserved for primary care as displayed onthe map in Appendix G (Health Resources and Services Administration (HRSA), 2009).Furthermore, Alabama is in the top five states for death related to diabetes, obesity, heart disease,and strokes (Alabama Rural Health Association, 2007). The state is number one in the number ofdeaths caused by stroke or other cerebrovascular disease according to the State Health Factswebsite (2005). At present, APRN practice is limited, access to care is decreased, and treatmentis delayed. APRNs are required to have the patient wait; locate a physician who may verbally ordercontrolled substance medications based on the APRNs assessment and diagnosis. The APRNmay refer the patient to another provider. Referral for redundant services, just to obtain a
Alabama APRN Update: Prescribing 17prescription increases the cost for the patient. The Coffey study (2009), completed in Florida, examined and attempted to tabulatevaluable APRN time required to obtain a signature/approval for a controlled substanceprescription. The study then extrapolated the time into number of patient visits lost by limitedprescribing privileges. There were 994 respondents of which 862 surveys were complete, valid,and analyzed. Significantly, yielding 8.69 additional patient visits could be completed per week.The numbers were applied to the approximate 83% of the Florida APRNs that expressed a needin practice for the privilege to provide 67,047 patient visits per week. That is 3.5 million morepatient visits per year in Florida. The study effectively and efficiently supports removing thebarrier to practice. The study supports expanded scope of practice, for the APRN, would yield asignificant increase in access to patient care without adding additional primary care providers.Similar results can be extrapolated for Alabama. The American College of Emergency Medicine (American College of EmergencyMedicine (ACEM), 2008) reports Alabama as among the lowest rates of emergency physicians(6.7 per 10,000 people) and board certified emergency physicians (3.9 per 10,000 people).ACEM (2008) also reports Alabama has the lowest rate of physicians accepting Medicare (1.8per 100 beneficiaries) which leads to significant deficiency in accessing care for the population.The need for change is overwhelmingly evident. Expanded controlled substance prescriptiveprivileges will make a difference in these areas by improving the quality and quantity of caredelivered in these areas. Prescribing controlled substances is currently authorized on military bases in Alabama.Theses sites are covered under federal regulations/rules, though the CRNP still maintains statecredentialing. APRNs practicing under military base guidelines and have been allowed to
Alabama APRN Update: Prescribing 18prescribe scheduled medications for over 20 years (anonymous, personal communication, 2010).Military hospitals and health care facilities employ APRNs and are an excellent example of thesuccessful use of APRNs and controlled substance prescribing in Alabama. Licensing CRNPs are credentialed and regulated under rules set forth by the Alabama Board ofNursing. CRNPs are required to practice under protocols approved by a Joint Committee(Appendix H). The Joint Committee is composed of three physicians from the State Board ofMedical Examiners (BME) and three nurses appointed by the Alabama Board of Nursing(ABON, 2009c, Sec. 34-21-87). APRNs are restricted, in Alabama, from using the title CRNP ifthey are not currently engaged in an approved collaboration agreement with a physician (ABON,2009c, Sec. 34-21-90 1975). Scope of Practice The APRNs scope of practice, also known as the nurse practice act, Article 5, has not beenupdated in the Code of Alabama since July 26, 1995, Appendix I (ABON, 2009c). The APRNrole has evolved as practice has expanded. The ABON Administrative Code defines the rules andregulations set forth by the Joint Committee (ABON, 2009a). According to those rules, CRNPsin Alabama are: responsible and accountable for the continuous and comprehensive management of a broad range of health services for which the CRNP is educationally prepared and for which competency is maintained” and “may work in any setting consistent with the collaborating physicians areas of practice and function within the CRNPs specialty scope of practice. The CRNPs scope of practice shall be defined as those functions and procedures for which the CRNP is qualified by formal education, clinical training, area of certification and
Alabama APRN Update: Prescribing 19 experience to perform (ABON, 2007, p. 1).Further, the CRNP functions are defined by the ABON in the standard protocol for CRNPs. Theprotocol authorize the scope of practice, is abbreviated as follows: 1. Perform complete, detailed and accurate health histories, review patient records, develop comprehensive medical and nursing status reports, and order laboratory, radiological and diagnostic studies 2. Perform comprehensive physical examinations and assessments, including bimanual pelvic examination 3. Formulate medical and nursing diagnoses and institute therapy or referrals 4. Institute emergency measures and emergency treatment 5. Plan and initiate a therapeutic regimen that includes ordering legend drugs 6. Arrange inpatient admissions and discharges at the direction of the collaborating physician; perform rounds 7. Interpret and analyze patient data 8. Provide instructions and guidance regarding health care and health care promotion to patients/family/significant others. 9. In addition to functions/procedures within the scope of RN practice, perform or assist with laboratory procedures and technical procedures, which include but are not limited to the following: • Biopsy of superficial lesions • Suturing of superficial lacerations • Management and removal of arterial and central venous lines • Debridement of wounds • Aspiration, incision and drainage of superficial lesions • Foreign body removal • Initial x-ray interpretation, with subsequent required physician interpretation
Alabama APRN Update: Prescribing 20 • Cast application/removal • Wet mount microscopy and interpretation of vaginal swab • Microscopic urinalysis Additional duties requested for the CRNP (i.e., diagnostic or therapeutic procedures requiring additional training) as provided in ABN Administrative Code Chapter 610- X-5-.10 (3) (ABON, 2007, p. 1).The full collaborative practice rules may be found in Appendix J. Continuing Education Requirements APRNs in Alabama are required to maintain national certification and collaborativepractice with a physician to be recognized as a certified registered nurse practitioner (CRNP) inAlabama. Additionally, 24 hours of continuing education is mandatory for license renewal everytwo years. For APRN license renewal, six of hours must be in pharmacology (ABON, 2009c).Current prescriptive regulation for APRNs in the state is summarized as follows: CRNPs practicing under protocols may prescribe legend drugs that are included in the formulary recommended by the Joint Committee and adopted by the BON and the BOME. The drug type, dosage, quantity and number of refills are authorized in an approved protocol signed by the collaborating physician and the CRNP. Written prescriptions must adhere to the standard recommended doses of legend drugs as identified in the Physician’s Desk Reference or Product Information Insert, not to exceed the recommended treatment regimen periods (Pearson, 2009, p. 8).The collaborative practice prescriptive formulary for the CRNP is found in Appendix K. Significance of the problemPatient Care Primary care provider shortages began and were predicted over a decade ago in Alabama.The provider shortages have decreased access to care in Alabama. The National Council of State
Alabama APRN Update: Prescribing 21Boards of Nursing (NCSBN) succinctly states: It is critical to review scope of practice issues broadly if our regulatory system is going to achieve the recommendations made by both the Institute of Medicine and the Pew Health Commission Taskforce on Healthcare Workforce Regulation. These reports urge regulators to allow for innovation in the use of all types of clinicians in meeting consumer needs in the most effective and efficient way, and to explore pathways to allow all professionals to provide services to the full extent of their current knowledge, training, experience and skills (2009, p.4). Currently, evidence demonstrates limited prescribing creates the following issues forpatients: (a) patients must do without needed pain medication, (b) creates time delays to find aphysician to prescribe needed medications (Coffey, 2009). Eliminating these prescriptive barrierswould improve care by giving patients what they need when they need it, thus, improving thequality, decreasing time to provide care, and cost of the care they receive. Examples ofmedications that are on the scheduled formulary are: Lomotil (used to treat diarrhea), coughsuppressants, pain medications (for pneumonias, bronchitis, injuries, muscle strain), or Concerta(used to treat attention deficit disorders).Nursing practice APRNs currently have the responsibility to diagnose and assess pain, disease, primaryand acute illness, yet no authority to treat it appropriately (ABON, 2009a, p). As practice evolvesand scope of practice increases changes must be to update the statutes. Alabama has neverchanged the scope of practice since it was placed in statue 15 years ago. The number of CRNPsin Alabama has not grown equivalently with the number of students graduating our programseach year. This is attributed to the attrition rate as they go to practice across state lines.
Alabama APRN Update: Prescribing 22 Project Purpose The purpose of the project is to improve quality of health care in Alabama. This projectproposes to improve the quality of health care by helping nurse practitioners develop, plan,educate, and implement a change plan. This change plan can be used to add controlled substanceprescriptive privileges to the APRN Scope of Practice. This project will provide a theoreticallybased planned step-by-step resource for implementing proposed scope of practice changes toimprove quality of care for Alabamians. Theoretical Framework The proposed framework for change incorporates Lewin’s Change Theory (Lewin, 1951)and Conger’s Organizational Change Theory (Conger, Spreitzer, & Lawler, 1999). Interaction ofthe related concepts of change, professional advocacy, and participants are demonstrated in theLioce Advanced Practice Nursing Legislative Change Model. The assumptions and variables areindentified along with operational definitions for related concepts. Evolution of primary care has created a paradigm shift in the role of the advanced practicenurse. This includes an expanded role for the advanced practice registered nurse (APRN).Therefore, the focus of this capstone project is legislative change in the APRN scope of practice,for the state of Alabama. Particularly, to obtain APRN controlled substance prescriptiveprivileges for schedules II-V. This change will improve quality of care for Alabamians. Changewill be implemented using the following concepts for planned change.Related Concepts The theoretical framework recommended by this author to support this capstone projectincludes the following major concepts: (a) legislative change in APRN scope of practice, (b)participants, and (c) professional advocacy. Definitions are included to clarify these concepts. Lewin’s (Schein, 1995) and Conger’s (Conger et al., 1999) change theories will be used as
Alabama APRN Update: Prescribing 23the theoretical guide to successful change and implementation of the expansion of scope ofpractice. Legislative change will require a bill to be submitted and passed through the legislatureto amend the Alabama Administrative Code. Implementation of professional advocacyresponsibility will be incorporated into the theoretical framework.Definition of Project Terms The terms are operationally defined as follows, for this capstone project: 1. Professional Advocacy - empowerment of the nurse to advocate for the professional role objectives while championing social justice in healthcare. 2. Participants - nurses, legislators, voters, healthcare consumers. 3. Change - legislative change in scope of practice of the APRN and change in perception of the APRN role.Specific Theories Related to Capstone Project To provide a clear understanding of the complexity of change to impact practice inAlabama, integration of theories were necessary to create the theoretical framework proposal.Specifically, blending of Lewin’s (1951) and Conger’s (Conger, Spreitzer, & Lawler, 1999)change theories. The framework incorporates Lewin’s (Schein, 1995) steps to change;unfreezing, changing, and refreezing, while utilizing Conger’s 8 steps to organizational changeto fully encompass the state organizations and clearly identify the path to change (Conger et al.,1999). The following is proposed for implementing planned change and should be used toadvocate for incremental practice changes in Alabama. The major premises of change that willbe used are identified by Conger (et al., 1999). The steps for change are detailed in the firstcolumn and the strategies for successful implementation are listed in the second column.Conger’s (1999) steps Strategies for implementation:
Alabama APRN Update: Prescribing 24to change:1. Establishing a sense Educating the APRNs, the public, and legislators on: of urgency • The shortage of providers • Barriers to practice for APRNs • Comparison of Alabama to other states and the positive effect and progress APRNs have made • The healthcare crisis • Utilizing handouts, town hall meetings, electronic communication etc. see Appendix L.2. Forming a powerful • Escalate efforts to build and unite APRNs across the state guiding coalition through website, email, state and local meetings • Utilize existing coalitions, Health Care for Alabama, Alabama Nurses Coalition, Alabama State Nurses Association, and the American Academy of Nurse Practitioners3. Creating a vision • Draft initial bill for prescriptive privilege change, Appendix M. • • Encourage professional advocacy in the nursing community4. Communicating the • Increase public relations vision • Increase APRN grassroots efforts (i.e. phone tree, email and volunteers) • Communicate the vision through the organizations • Utilize their public relations advocates • Create and publish an update on APRNs in Alabama for dissemination and presentation (capstone project)5. Empowering others to • Engage the NPAA legislative committee act on the vision • Empower and invite colleagues • Publicize need for active participation at state and regional APRN group meetings • Increase education in APRN programs on responsible professional advocacy (not optional)6. Planning for and • Publicize bill creating short-term • Obtain sponsors for bill wins • Create more nurse leaders by role modeling and mentoring to continue the advocacy for change7. Consolidating • Annual evaluation of progress toward passing legislation improvements and • Continue to create urgency in nurses to participate in process producing still more • Continue evidence based research change • Plan next incremental change (Resolution Appendix N)8. Institutionalizing new • Publish and publicize accomplishments (Appendix O) approaches • Continue training new APRN leaders for advocacy Applying these steps to legislative change to obtain prescriptive privileges will have
Alabama APRN Update: Prescribing 25greater success when merged with Lewin’s change theory of unfreezing, implementing change,and refreezing (Schein, 1995). An overview of the blended theories would include: (a)unfreezing of: the legislators to act, current beliefs held by legislators, physicians, APRNs inAlabama, and motivating nurses to be active. Strategies for (b) change include: a recommitmentto professional advocacy for APRNs, education on current prescriptive practices in the UnitedStates/evidenced-based practice dissemination. Strategies to (c) refreeze the change wouldinclude: continued evidence-based education and research for APRNs, with dissemination,mentoring new leaders, and continuing to advocate for the nursing profession. Further explanation, for clarity of Lewin’s theory (Schein, 1995) is explained in stages.Stage one is the unfreezing stage. Disconfirmation of the present prescribing conditions isdemonstrated by the proposal for change. In Alabama, this has already taken place.Disconfirmation produces anxiety for the APRN. This anxiety is motivating the APRN toadvocate for improved patient care. In stage two, the change agents must prioritize change andcontinually evaluate. The evaluation is based on patient needs and trial and error in thelegislative process efforts. The final stage is stage three, refreezing. This stage includescontrolled substance schedule II-V education and prescribing authority for APRNs in Alabama.This stage could include additional pharmacology or prescribing education and licensing toincrease the APRNs knowledge of current prescribing trends and reinforce the change.Relationship of Concepts and Theories Figure 1. Lioce APRN Legislative Change Model
Alabama APRN Update: Prescribing 27The Lioce APRN Legislative Change Model demonstrates the target audience ofparticipants/adult learners in the background circles. The overlay model of rectangles reflects thetheories guided by the central focus of legislative practice change to provide a visualization ofthe theoretical framework.Assumptions or Presuppositions The following assumptions are made: 1. There is a need for schedule II-V controlled substance prescriptive privileges in Alabama. 2. Having controlled substance prescriptive privilege will improve the quality of care in Alabama. 3. APRNs are nationally certified licensed primary care providers and demonstrate competency through continuing education and certification. 4. Changes in scope of practice are required in the evolving healthcare delivery systems. 5. Overlapping scopes of practice are common among healthcare providers.
Alabama APRN Update: Prescribing 28 6. Scope of practice regulation is intended to protect the public not a particular profession. 7. Patient’s pain is delayed and undertreated related to restricted practice. 8. Practice barriers increase the attrition rate of APRNs. APRNs are being educated in Alabama and leaving to practice in other states with less restrictive environments. 9. Nurse practitioners are safe prescribers and collaboration is necessary to provide comprehensive care of patients.Relevant Variables Five variables must be taken into consideration: (a) the legislative system, (b) the AlabamaBoard of Nursing (ABON), (c) the Board of Medical Examiners (BME), (d) the MedicalAssociation of the State of Alabama (MASA) and (e) the joint committee. The legislative systemin Alabama is difficult to navigate and effect change. Politics can prevent effective, efficient, andequitable policies from being introduced. Therefore, drafting a piece of legislation with immensesupport and agreement will be a priority. The Alabama Board of Nursing is supportive of change (G. Lee, personal communication,May 2009). The board’s priority is protecting the public and serves a vital function for the state(Alabama Board of Nursing, 2009). The ABON will be responsible for implementation andregulation of any scope of practice changes made in the legislature. The Board of Medical Examiners (BME) and the Medical Association of the State ofAlabama (MASA) are not supportive of change to APRN practice. they are the certifying body.This means the BME would have the power to grant and remove the Qualified AlabamaControlled Substance pretificates QACSC), set rules, fees, and regulations (L. Dixon, D.Whitaker, K. Aldridge, personal communications, March 2010). This increases the regulation toproviding care by requiring the APRN to be certified by one board and licensed by another. Thuscreating conflict that inhibits the legislators from introducing controversial legislation.omplicates
Alabama APRN Update: Prescribing 29th Current practice for APRNs in Alabama is regulated through a joint committee. The JointCommittee is granted powers in Article 5 of the Nurse Practice Act and became effective inApril 17, 2001(ABON, 2010, Sec. 34-21-82). The joint committee is comprised of three nursesand three physicians. The committee approves nurse practitioners collaborative practice,including specific protocols, within which the nurse practitioner must work and may prescribe anapproved formulary (Code of Alabama, 1975, 34-21-85). Alabama is one of seven states withjoint regulatory authority in the U.S. The majority of states are licensed and regulated by theBoard of Nursing. There are a few exceptions, of states that are regulated through an AdvancedPractice Boards or joint committees (AANP, 2009d; Pearson, 2010). The nursing professionmust continue to evolve with the healthcare changes and needs of our patients and advocate forcontinued sole regulation through the Board of Nursing. Further barriers identified are: (a) lack of participation by APRNs in professionaladvocacy, (b) lack of pursuit and use of personal connections to the legislators, (c) apathy, burn-out and low participation in professional nursing organizations in this state (C. Stewart, R.Brown, C. Cooke, personal communication, May 2009). The Nurse Practitioner Alliance ofAlabama currently has approximately 1000 members out of the almost 1820 licensed nursepractitioners in the state (A.Keller, personal communication, May 2010). The Alabama StateNurses Association (ASNA) has less than 3% of the 65,000 nurses in Alabama as members, (J.Decker, personal communication, May, 22, 2009). Collegial efforts to teach professionaladvocacy must be revisited and increased. Efforts to collaborate and increase communicationwith each of these organizations are a priority and are continually advocated for by the nursingleaders in the Alabama.
Alabama APRN Update: Prescribing 30 Review of the Literature The following databases were systematically reviewed for the period of 1980 through2010: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, Cochrane,EbscoHost, and PubMed. Search parameters included English language, peer reviewed scholarlyarticles utilizing the following terms interchangeably: prescriptive authority, prescribing,scheduled drugs, controlled substances, advanced practice registered nurse, certified registerednurse practitioner, nurse practitioner, and Alabama. Literature review supports the need for expanded scope of practice (ACP, 2009; ACEM,2008; AANP, 2009c). The Institute of Medicine stated “state practice acts that limit non-physician providers, e-health and multidisciplinary teams act as a barrier to innovativehealthcare” (IOM, 2001, n.p.). Barbara Safriet (1994) further states “regulations that are barriersserve no useful purpose and contribute to our health care problems by preventing the fulldeployment of competent and cost effective providers who can meet the needs of a substantialnumber of consumers” (p. 315). National regulatory boards have been discussing expanding scopes of practice since the1990s and formally documented their opinions in this study. Changes in Healthcare ProfessionsScope of Practice: Legislative Considerations (National Council of State Boards of Nursing(NCSBN), 2009) was developed in 2006 by six national regulatory boards, including medical,nursing, occupational therapy, social work, and pharmacy in the United States. This monumentaldocument plainly states that “lost among the competing arguments and assertions [regardingchanges in scopes of practice] are the most important issues of whether the proposed change willprotect the public and enhance consumers’ access to competent healthcare services (p. 5).” Thepaper further supports scope of practice changes by stating: We believe it is critical to review scopes of practice broadly if our regulatory system is
Alabama APRN Update: Prescribing 31 going to achieve the recommendations made by both the Institute of Medicine and the Pew Health Commission Taskforce on Healthcare Workforce Regulation. These reports urge regulators to allow for innovation in the use of all types of clinicians in meeting consumer needs in the most effective and efficient way, and to explore pathways to allow all professionals to provide services to the full extent of their current knowledge, training experience and skills (NCSBN, 2009, p. 5).The national boards urge legislators that “overlapping scopes of practice are a reality in a rapidlychanging healthcare environment” (p. 16). Specifically agreed upon in this document is “if aprofession can provide supporting evidence in these areas, the proposed changes in the scope ofpractice should be adopted (p. 11).” In 2003, Representative Robert Bentley (District 63) requested The Nurse PractitionerTask Force study the utilization of Nurse Practitioners in Alabama and included nursing leadersand educators in Alabama. Four co-chairs led and organized subcommittees. This included anEducational Subcommittee comprised of the states nursing experts; faculty, deans, and directorsof the nursing schools in the state. The Practice Subcommittee included; experts in the advancedpractice field, nursing consultants, and regulators. The study, stimulated by the shortage inprimary care providers, identified in 2003 is the only one of record in Alabama and resulted in“A Proposal to Increase the Utilization of Nurse Practitioners in Underserved Alabama” (NursePractitioner Task Force, 2004). The study results indicated that in 2003: 1. 61 of 67 counties were federally classified with primary care practitioner shortages 2. 60% of the people in Alabama live in rural areas 3. 58 of 67 counties are designated as underserved in Primary Care by Department of Health & Human Service and the Bureau of Primary Care Health.
Alabama APRN Update: Prescribing 32 4. Disparities between urban and rural health contrast 5. 80% of physicians practice only in urban areas (p. 5-6)The results identified the majors barriers to practice and identified the “CRNP as having noauthority to prescribe controlled substances as restrictive rules governing collaborative practice”(p.10) were identified and presented to Representative Robert Bentley in January of 2004, theABON and the Joint Committee in May 2004. Five recommendations for change were a resultof the research. To date, two of the five recommendations have been partially met, by the state orfederal government, “allocation of resources to nurse practitioner programs to retain and recruitfaculty to expand the number of graduates” and to provide incentives for CRNPs to work inmedically underserved areas” (Nurse Practitioner Task Force Proposal, 2004, p. 11). There havebeen no advances on three recommendations that dealt with reimbursement, expansion ofpractice, and establishing the Advanced Practice Nursing Committee. “Proposed changes inscopes of practice that are supported by one profession but opposed by other professions may beperceived by legislators and the public as ‘turf battles’. These turf battles are often costly andtime consuming for the regulatory bodies, the professions, and the legislators involved (NCSBN,2009, p. 8).”The National Council of State Boards of Nursing stated: Important issues for consideration by legislators and regulatory bodies when establishing or modifying a profession’s scope of practice are that the primary focus …is public protection. In defining a profession’s scope of practice, the goal of public protection can be realized when legislative and/or regulatory bodies include the following critical factors in their decision-making process:
Alabama APRN Update: Prescribing 33 1. Historical basis for the profession, especially the evolution of the profession advocating a scope of practice change, 2. Relationship of education and training of practitioners to scope of practice 3. Evidence related to how the new or revised scope of practice benefits the public, and the capacity of the regulatory agency involved to effectively manage modifications to scope of practice changes (NCSBN, 2009, p. 15). Synthesis of the literature review supports the following answers to these critical factors.Factor one: APRNs have been providing high quality, safe effective primary care for over 40years. In the U.S., multi-disciplinary studies supports the APRN scope of practice has advancedsince statues were implemented in 1995. The American College of Physicians’ PolicyMonograph supports the evolution and in the monograph’s executive summary that NursingBoard should regulate Nursing and that Boards of Medicine should regulate physicians andphysician’s assistants (AANP, 2009; ACP, 2008; Alabama Code, 1975; Brown & Grimes, 1993). Factor two: APRNs are prepared with advanced health assessment, advancedpharmacology, advanced pathophysiology, and over 600 hours of supervised clinical training inthe practice setting post baccalaureate. APRNs are nationally board certified in their primary careor other specialty area and must maintain that certification supported by 1000 practice hoursevery five years nationally and 24 continuing education hours every two years in Alabama forlicensure renewal (ABON, 2009a; ABON, 2009c; AANP, 2009; NCSBN, 2009) Factor three: The north, east, and western states have decades of patient treatmentoutcome and safety data. The Southern states have similar data but have been resistant to changelaws to authorize the practice, yet seem satisfied in the APRNs safety and competency, enoughto become business partners, profit share, be employed by, and fill in for each other; as long as
Alabama APRN Update: Prescribing 34they are not practicing independently. Studies demonstrate an increased level of patientsatisfaction with treatment outcomes equal to primary care physicians, including prescribingcontrolled substances (AANP, 2009; Coffey, 2009; Phillips, 2009; Safriet, 1994). Factor four: Boards of Nursing have successfully and responsibly set rules andregulations for controlled substances for 48 states. The ABON can efficiently and effectively addregulate APRN controlled substance prescriptive privileges. Some states have added anAdvanced Practice Council to their Board of Nursing . This council with their advancedknowledge of the APRN scope of practice would be prepared to regulate APRN issues andprescribing. Rules and regulation are determined after the legislation is passed and couldincorporate and advanced practice board (NCSBN, 2009). Overlapping scopes of practice are a reality in a rapidly changing healthcare environment. The criteria related to who is qualified to perform functions safely without risk of harm to the public are the only justifiable conditions for defining scopes of practice and restraining qualified professionals from providing care (NCSBN, 2009, p. 15). The American Academy of Nurse Practitioner’s position on prescribing supportsunlimited prescribing authority. AANP is a certifying body for APRNs. Their position issupported with descriptions of the extensive education, training, 40 years of research, and abilityto save money by providing cost-effective care without the limitation in practice. The positionstatement is included as Appendix P (2009b, n.p.) Other barriers were identified by the literature review as follows: (a) collaborativepractice requirement; which decreases the ability of the APRNs to practice in rural areas (b) lackof primary care provider designation in statue, effecting reimbursement of services; and (c)
Alabama APRN Update: Prescribing 35multiple individual policy barriers related to fractional reimbursement, direct reimbursement,radiology ordering, receiving physical therapy orders, signing of death certificates, or prescribinghandicap parking permits; and (d) exclusion of actual prescriber on prescription bottles, theAPRNs name is not listed even if they are primary prescriber; this decreases evaluation data onprescribing. Presently, the collaborating physicians name is placed on the label (AANP, 2009c).Setting The setting addressed is the State of Alabama’s legislature. The evaluation of thisenvironment is a vital first step before attempting to influence policy change for APRNs. Thepurpose is to clarify the environment in order to effectively make legislative practice changes.Institution and Unit The Alabama Legislature is located in Montgomery, Alabama. It is housed in the StateHouse on Union Street across from the Capitol. They utilize the fifth through eighth floors of thebuilding. According to the League of Women Voters study, The Alabama Legislature Facts andIssues (2006), the legislature has thirty formal meeting days in a regular session to complete in105 calendar days between January and May. The typical meeting schedule is Tuesday andThursdays with Wednesdays reserved for committee meetings. There are 105 House members and 35 senate members. In the Senate, there are 21democrats, 13 republicans and one vacant seat. Democratic affiliation represents the majority atpresent. In the House, there are 62 democrats and 42 republicans.Purpose The purpose of the legislature is as follows: “Legislatures engage in three principal functions: policymaking, representation, and oversight. The first, policymaking, includes enacting laws and allocating funds. In their
Alabama APRN Update: Prescribing 36 second function, legislators are expected to represent their constituents, the people who live in their district, in two ways. At least in theory, they are expected to speak for their constituents in the state, to do ‘the will of the public’ in designing policy solutions. In another representative function, legislators act as their constituents facilitators in state government. The oversight function, evaluating the performance of the state bureaucracy, is one that legislatures have taken on recently” (Alabama League of Women Voters, 2006, n.p.).True Leaders Senate and House members vote to elect their own leaders. In the Senate, this is knownas the President Pro Tempore. Historically, these powers belonged to the Lt. Governor but weretransferred in 1999, related to political party changes (Alabama League of Women Voters,2006). The true leader of the Senate is the President Pro Tempore, though the title “President ofthe Senate” remains with the Lieutenant Governor. In the House, there are two leadershippositions, Speaker of the House and Speaker Pro tempore. These are both elected by a majorityvote in the house. The true leaders of the Alabama legislature are selected members who represent largegroups, large campaign funds, or votes. These are not necessarily the committee heads or leadersof the Senate or House, but in many cases can correlate to positions of power. There are keymembers, who are not in positions of leadership. It is important to obtain key leader support togain the support of the majority. Using this informal leadership is key to passing legislation.Identification of the key players and persons in favor with these key politicians is crucial tosuccessfully pass legislation. Uniting the key politicians throughout the state is vital to increasethe quality of care.
Alabama APRN Update: Prescribing 37Population The citizens of Alabama are the target population of the proposed change. Increasing thescope of practice for nurse practitioners in Alabama will directly result in increased quality of thehealthcare provided to the community populations. The current estimate for the population inAlabama is 4,708,708. Race is distributed with 71% White, 26.4% Black, 2.9% Hispanic/Latino,1% Asian, and .05% American Indian (U.S. Census Bureau, 2010). Detailed Plan for Project Legislation proposed during the 2009 legislative session will be used as a draft and andsd include a plain language summary. This legislation will include wording to obtain controlledsubstance prescriptive privileges schedules II-V. Target date for revision will be January 5, 2010,so the bill may be disseminated for comments and sponsors. Sponsorship for legislation will besimultaneous with development of legislation and will be finalized mid February 2010. Efforts are directed to introduce the bill into the House of Representatives by March 2.This allows time during the session to secure a passing vote in the health committee and beintroduced on the floor. The legislative session ends in June 2010 and evaluation and revision ofthe strategic plan and objectives will be accomplished at that time. This project will complimentthe efforts of the NPAA and ASNA. Collaboration with the leaders of both organizations hasalready been established along with the additional resources listed under the qualification sectionof this document. The specific approach will be: • Develop a strategic plan for lobbying and educating legislators. This will be accomplished with colleagues, mentors, and twenty nurse practitioners on the NPAA steering committee from across the state. Feedback and evaluation from Samford University doctoral capstone project committee will be utilized along
Alabama APRN Update: Prescribing 38 with re-evaluation annually. • Begin a public relations campaign to educate the public and legislators about nurse practitioners. • Developing an appropriate piece of legislation to implement the proposed change. The legislative committee and executive committee of NPAA drafted legislation last year. Participation in revision for new legislation from November 2009 to January 2010. • Identifying and obtaining sponsors in the legislature by working with individuals in the nursing profession and executive members of AANP, NPAA, and ASNA to obtain sponsors for the legislation in both the House and the Senate. Travel to the Capitol will be required for face-to-face meetings. • Introduce legislation. Pass legislation through the House and/or Senate Health committees to be introduced on the floor. Resources The resources available for completion of this capstone project will be many of the stateand nations leaders in the nursing profession: 1. Becky Patton, ANA President 2. Mary Behrens, ANA PAC Chair 3. Rose Gonzales, ANA Government Affairs 4. Carol Stewart, MSN, FNP, past president NPAA 5. Joe Decker, Executive Director, ASNA 6. Cindy Cooke, Region 11, Director AANP, NPAA past president 7. Dr. Richard Brown, Alabama representative to AANP, UAB Faculty
Alabama APRN Update: Prescribing 39 8. Dr. Poole, Capstone Advisor, Samford University, Ida Moffet School of Nursing 9. Dr. Nena Sanders, Dean, Capstone Advisor, Samford University, Ida Moffet School of Nursing 10. Dr. C. Fay Raines, AACN President, Dean, University of Alabama Huntsville, College of Nursing Budget Expenses for the implementation of the plan are estimated to be approximately $5,662(Appendix Q). This includes: • $3,217 covers mileage for 15 visits to the Alabama Legislature in Montgomery from Huntsville • $420 for educational/lobbying materials on nurse practitioner role, practice and scope of practice for 140 legislators • $600 per diem for 15 days ($40 daily) • $1,425 for 15 nights lodging expenses (roundtrip 6 hour drive from Huntsville) Timeline This indicates the proposed timeline for the project plan implementation.
Alabama APRN Update: Prescribing 40 Evaluation Plan The project will be evaluated at the end of the 2010 legislative session based onprogress toward the following outcomes: (a) drafting appropriate legislation (b) obtaining 10 keysponsors for APN legislation in the House and the Senate (c) passing proposed legislation out ofthe health committee and into the House/Senate (d) successful passage of legislation. SamfordUniversity, Ida Moffet School of Nursing, doctoral committee will complete additionalevaluation, in May 2010. The results from these evaluations and assessments will be shared withthe leadership of AANP, NPAA, and ASNA for the continued effort toward practiceimprovement. The strategic plan will be annually reviewed annually to incorporate the outcomes/research until the goal is reached. The research derived from this experience and participation will be utilized in a capstoneproject for the University of Samford in Birmingham, Ida Moffet School of Nursing. Theinformation will be widely disseminated by email to the nurse practitioner regional groups inAlabama. The abstract will be submitted for poster presentation at the 2010 AANP, ASNA, andNPAA annual conferences for continued practice improvement.
Alabama APRN Update: Prescribing 41 Results The 2010 legislative session was convened on Tuesday January 12, 2010 and adjournedon April 22, 2010. This completed the 30 legislative days in 105 calendar days as required by theCode of Alabama. This marks the end of the quadrennial and begins a new one. Elections will beheld this year and will be monumental in restructuring the legislature. The Alabama Codeconvenes the legislature on the second Tuesday in January 2011. They may meet up to 10consecutive calendar days for reorganization of the House and Senate following elections. Thelegislature will reconvene the first Tuesday of March for the first year of the quadrennial to beginthe thirty-day session (1975, Sec. 29-1-4). The sponsor did not introduce the bill as written. He asked that the two professionalorganizations come to an agreement and set up a meeting between the MASA lobbyist andNPAA president. The sponsor was not available to the Alliance to negotiate the bill or mediatenegotiations. Negotiations continued for ten weeks with face-to-face meeting and severalrevisions of the bill. The following goals were set and are evaluated as follows: Goal Evaluation(a) Draft appropriate legislation Goal met.(b) Obtain10 key sponsors for APN Goal not met.legislation in the House and the Senate Barriers to introduction of controversial bills during an election year not anticipated from legislators. A sponsor was not obtained in the Senate until the last 5 days of the session. House Sponsor introduced the HB688 and was under the impression it had mutual agreement by other
Alabama APRN Update: Prescribing 42 parties. Sponsor recommended we negotiate with MASA to reach agreement on a bill. Eight weeks of negotiation yielded no agreement with MASA lobbyist.(3) Pass proposed legislation out of the Goal not met.health committee and into the HB688 was opposed by the NPAA. The billHouse/Senate requested the BME to be the certifying body for CRNP/CNM prescriptive privileges.(4) Successful passage of legislation Goal not met. Evaluation of the timeline for the project shows the revisions, in orange, for the time line. The legislativedrafts took longer than expected due to the ongoing negotiations. Bill sponsors were unwilling to commit theirsupport for a bill that was not fully supported by MASA. Introduction of the bill was delayed due to inadequatesponsorship and support in the legislature.Discussion
Alabama APRN Update: Prescribing 43 Many successes were noted through this project. As of May 2010, we have alreadysecured a sponsor in the House and the Senate with 3 additional sponsors. Plans are underwayfor introduction of the bill early in the 2011 session. Several new task forces have been formed toaddress changes for a new strategic plan and build alliances . Educational efforts have resulted intwo articles being published and two interviews scheduled with local television stations inMontgomery and Huntsville. New leaders have emerged throughout the state to advocate forthese important changes. Positive lessons were noted and the plan for success will undergorevisions through a think tank to be sponsored with AARP this fall. The negotiations with MASA and discussion with the BME revealed no willingness toalter their bottom line of the BME as the certifying board. There was no interest in what theevidence demonstrated or the qualifications of the nurse practitioners. The bill was offered andrefused by the BME and MASA. This was strong evidence that collaboration on controlledsubstances is not possible between the existing leadership of the organizations and APRNs. IfAlabama is going to continue to operate under collaborative practice, collaboration must beimproved. Elections are held in November this year and will be monumental in restructuring thelegislature. Recommendations for legislative session 2011 are as follows: • Educate APRNs on importance of elections this year. • Strategic planning must begin every May for next session and be continually evaluated. • Strengthen grassroots communication with APRNs . • President should attend and meet with regional groups to increase communication and visibility of NPAA and unite the members.
Alabama APRN Update: Prescribing 44 • Establish more regional groups to cover to include all APRNs; increase website information for members to participate in the interim. • Establish alliances with community partners continually and communicate frequently. • Identify policy changes outside the legislature that could impact delivery of care. • Establish a timeline for education and media coverage. • Obtain sponsors the summer preceding the legislative session. • Meet regularly throughout the year with legislators. • Negotiate only with the decision makers not the lobbyist. • Meet with all opposition. • Establish an endorsement process for NPAA based on the ANA PAC (Appendix R). • Establish a pictorial representation for NPAA to represent, inspire, and united symbol across the state (Appendix S)). • Train good leaders and followers and strive for excellence. • Re-evaluate. • • • Lessons Learned Research from this project revealed advanced practice nursing in this state has beensignificantly underfunded. APRN primary care pilot projects are virtually non-existent. APRNs
Alabama APRN Update: Prescribing 45are crossing state lines to practice in states with fewer barriers. A significant educational deficitis noted in the general public and legislators regarding the role/scope of practice of APRNs. Individuals and organizations do not have to write the bill themselves. They can secure alegislative sponsor and a list of the items they would like to change and the legislative referenceservice will write the bill for the sponsor. This saves time for the organization or individual toimplement change. I learned once the bill is given to the legislator it is no longer “your” bill.Legislators can change the bill any way they would like, without informing you, or providingyou a copy. Lobbyists are paid a salary to either get legislation passed, or keep it from gettingpassed. Negotiations must be completed between the decision makers of the organizations. Ifdecision makers are not willing to talk, there will be no true negotiation. The effort is worth the potential success. The experience of working on the controlledsubstance bill provided an immersed learning experience. Politics is complicated. APRNs haveto be willing to continue to pursue alternatives for professional progress to be made. There areadvocates and alliances that share interests. Finding and building those alliances is foundationalwork that takes several years to develop, but the collaboration and progress you make will betremendous. Negotiations give you great insight to the needs of all parties. Willingness to discuss issueswithout confrontational speech and body language opened many doors and allowed freeexchange of information. Being knowledgeable and prepared with the facts earns respect andbuilds coalitions. Limitations Limitations were noted in the amount of time APRNs could implement the recommendedstrategies. The need for staff persons within the NPAA organization was recognized andsuggested to carry out the daily communication required for executing the planned change.
Alabama APRN Update: Prescribing 46Limitations were also noted in finances. NPAA does not charge any dues; rather the regionalgroups charge a small fee to fund their regional meetings and organization functions. NPAArelies on donations by individuals and regional groups. The budget for this project will limitfuture use of the plan unless a policy for reimbursement is implemented for the executiveofficers. A comprehensive strategic planning meeting for growth of NPAA has been addressedand is planned for 2010. Broader educational events and projects are a priority to increase theoutreach efforts. Nurse Practitioners work long hours and are dedicated to their patients andteaching responsibilities, therefore cannot spend large amounts of time lobbying for changes. Bias was noted throughout the legislature to not get involved if the legislation wascontroversial. Several comments were made about talking to “the nurse practitioner group” withunfavorable reactions by the legislature. Legislators overwhelming felt the NPAA should obtainthe opposition’s agreement prior to introducing the bill. In the end, the NPAA agreed to disagreewith the MASA lobbyist and the BME physicians on what was best for the patients in Alabamaand the nursing profession. Additionally, the project analysis revealed organizational structures in Alabama withconflicting responsibilities. These state boards should maintain some degree of separation toeffectively fulfill the function and mission ethically. The lack of separation of public boards ofhealth and private professional associations creates a roadblock in progress in those fields. Thislimitation must be addressed. The overlapping structures of three organizations are referencedherein for clarity in advancing future legislation and for future research. The Medical Association of the State of Alabama (MASA) annually elects a Board ofCensors, from the medical societies, to be the governing body for the organization (MedicalAssociation of the State of Alabama (MASA), 2010). The mission of the organization is stated in
Alabama APRN Update: Prescribing 47their constitution, as “The Medical Association of the State of Alabama exists to serve, lead, andunite physicians in promoting the highest quality of healthcare through advocacy, information,and education.” The constitution further lists five objectives. The fifth objective states “(5) tocombine the influence of the member of the medical profession of the state for the purpose ofprotecting their legitimate rights and of promoting the health of the people” (2010, p. 299). The MASA constitution (MASA, 2009) and the Code of Alabama (1975) and 540X1.07,), designate the MASA Board of Censors as board members for the Board of MedicalExaminers (Code of Alabama 540X1, 1975) and for the Alabama Department of PublicHealth/State Board of Health (MASA Bylaws, 2010; Code of Alabama 420-1-5). The MASABoard of Censors, therefore, is responsible both legally and ethically to fulfill all three boardsfunctions and objectives. The Code of Alabama (1975, 540-1-.07) sets out the function of the BME as follows: The Board is authorized to: (a) Adopt and promulgate rules and regulations and to do such other acts as may be necessary to carry into effect the duties and powers which accrue to the Board under laws now in force or which may hereafter be in force. (b) Issue certificates of qualification to the Medical Licensure Commission for applicants meeting the statutory qualifications for licensure. (c) Commence and maintain proceedings to restrain the unlawful practice of medicine. (d) Serve as the certifying board for physicians applying for an Alabama Controlled Substances Certificate. (e) Carry out the provisions of law relating to assistants to physicians.
Alabama APRN Update: Prescribing 48 (f) Administer and/or approve an examination in certain specified branches of medical learning. (g) Keep complete records of all examinations held by the Board. (h) Keep complete minutes of all the Boards proceedings. (i) Keep records of all reports of claims or actions for negligence in the performance of a licensees professional services and review the reports annually. (j) Approve, jointly, with the Alabama Board of Nursing, qualified applicants for collaborative practice as Certified Registered Nurse Practitioners and Certified Nurse Midwives. (k) Record and maintain a permanent file on all professional corporations incorporated by physicians and osteopaths. (l) Administer and enforce the provisions of the Controlled Substance Therapeutic Research Program. (m) Furnish all personnel and facilities necessary to administer and enforce the provisions of law relating to the Medical Licensure Commission. (n) Employ investigators, attorneys, agents and other employees necessary to aid the Medical Licensure Commission in the administration and enforcementThe Code of Alabama states:The Board of Censors of the Medical Association of the State of Alabama, as constitutedunder the laws now in force, or which may hereinafter be in force, and under theconstitution of said association, as said constitution now exists or may hereafter exist, isconstituted the State Board of Medical Examiners (1975, Section 540x1.01).The Alabama Department of Public Health’s website displays the following statements:
Alabama APRN Update: Prescribing 49“Alabama law designates the State Board of Health as an advisory board to the state in allmedical matters, matters of sanitation and public health. The Medical Association, which meetsannually, is the State Board of Health.” Further it states, the “purpose of the AlabamaDepartment of Public Health is to provide caring, high quality and professional services for theimprovement and protection of the public’s health through disease prevention and the assuranceof public health services to resident and transient populations of the state regardless of socialcircumstances or the ability to pay (2010, n.p.).” The description of the ADPH responsibilitypurports that it “serves the people of Alabama by assuring conditions in which they can behealthy (2010).” Alabama law additionally states: The Board functions through the State Committee of Public Health as constituted by Code of Ala. 1975§2224, which is composed of 12 members of the Medical Association of the State of Alabama and the chairman of each of four councils provided for by statute. The 16 members function under the leadership of a chairman and a vice chairman, [who are] elected by the membership for a term of four (4) years. (1975, Section 540x1.01, #2). This committee is authorized to employ a State Health officer who is empowered to act on behalf of the State Committee of Public Health when the committee is not in session. (ADPH, 2010, n.p.). More than 130 years ago, medical leaders in Alabama advocated constitutional authority to oversee matters of public health. The purpose of the authority was to preserve and prolong life; to plan an educational program for all people on rules, which govern a healthful existence; and to determine a way for enforcing health laws for the welfare of all people (ADPH, 2009, n.p.).
Alabama APRN Update: Prescribing 50 In reflecting on the purpose of these three boards, comparing the Alabama Code andrevisions, and analyzing the organizations missions and functions, it is apparent they areintended for completely separate functions. One is a private, dues paying member onlyassociation with lobbyist advocating for a profession, MASA. Two are public boards. The ADPHand BME were established to protect the public. The BME was established to license, regulate,and discipline physicians. The public boards should be comprised of a balanced group of healthcare and scientificrepresentatives. Currently, there is not diverse professional leadership nor does it appear todemonstrate the legislative checks and balances, to ensure the welfare of the public, these boardsare intended, both ethically and fundamentally, to provide. It is apparent that governance of theBME by board members of MASA presents a conflict of interest. Research demonstratessignificant structural changes including separation, balance, and oversight should be mandated tothese state boards. Plans for Dissemination A poster presentation and power point modules have been prepared and the abstractsubmitted for the ASNA September annual convention as a 4-hour Legislative workshop.Current presentations are scheduled for May 11, 2010, at the Ida V. Moffet School of Nursing,and the NPAA Annual convention May 13 in Florida. Future dissemination will be throughtravel to regional NPAA meetings, state nurses’ publications, newspaper and TV interviews,literature dissemination to the legislators, article submissions and abstracts submitted to AANPand NSNA. Recommendations for Future Research Further research is indicated to eliminate barriers in providing primary care. Researchshould address the following; primary care provider designation, reimbursement policies for all
Alabama APRN Update: Prescribing 51primary care providers, state medical organizations overlapping structure, sole regulation by theBoard of Nursing (as in 48 other states) and collaborative practice requirements preventing careto rural areas. Questions directing future research in Alabama must include maximizing the useof APRNs and other providers. Conclusion Continuation of this project is recommended for historical and future progress of thenursing profession. The interventions were successful in building alliances and educatinglegislators and the public. The impact will be greater in dissemination of the results. Successfulchange in the scope of practice for APRNs by attaining controlled substance prescriptiveprivileges schedule II-V, will improve the quality of care provided by APRNs in Alabama andthe length of time patients are in pain. This prescriptive privilege expansion increases access tocare and authorizes appropriate treatment for patient’s pain relief. The elimination of one of thebarriers that restrict practice is positive incremental change. It is made possible withparticipation, education, and advocacy. The patients in the State of Alabama are paying the pricefor the barriers to providing quality care. To truly address the primary care shortage, barrierssuch as collaborative practice, reimbursement and primary care designation in statue will need tobe addressed. APRNs must vote, be proactive, present at the decision tables, or other professionswill make decisions for our profession alone. Nurses should continue to advocate for theirpatients needs as part of their professional responsibility. It is time to decrease the barriers inAlabama to allow full scope of practice for APRNs to improve the quality and community healthof the Alabama citizens. APRNs can help solve the primary care shortage with increasedutilization.
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