Scope of Practice in IA Cheryll JonesThe passage of the Affordable Care Act will give millions of Americans better access to primary care—if there are enough providers. The United States has a shortage of primary care physicians, especially in rural areas, but Alison Mitchell, president of Texas Nurse Practitioners, told the Dallas Morning News in April 2010 that nurse practitioners (NPs) are ready to step in: “We would be happy to help in the trenches and be primary care providers.” Many states are considering ways to permit NPs to function in this capacity with fewer restrictions (AP, 2010).

In 2001, 23 percent of NPs in the United States worked in rural areas and almost 41 percent in urban communities, where most provided primary care services to underserved populations (Hooker and Berlin, 2002). The NP’s scope of practice is governed by state laws and regulations that differ in their requirements for physician supervision and prescriptive authority—the ability to prescribe medications. In rural communities, NPs may be the only available primary care providers, and it is important that they be able to practice independently, if need be, although they value collaboration with physicians and other providers regardless of state authorization.

Iowa is one of 22 states where advanced practice registered nurse (APRNs)—NPs, certified nurse midwives, certified registered nurse anesthetists (CRNAs), and clinical nurse specialists—practice without physician oversight and one of 12 states that permit them to prescribe without restriction (Phillips, 2010). Iowa’s APRNs must be nationally certified in their specialty; meet state requirements for continuing education; provide evidence of their education; and collaborate with a physician on “medically delegated tasks,” such as circumcision and hospital admission. Several studies have shown that APRNs produce outcomes comparable to those of physicians and that the care they provide encompasses 80 to 90 percent of the services provided by physicians (Lenz et al., 2004; Mundinger et al., 2000; Office of Technology Assessment, 1986).

One pediatric NP in Ottumwa, Iowa, has worked to remove barriers faced by APRNs for more than three decades. Cheryll Jones, BSN, APRN, BC, CPNP, said that permitting all nurses to practice to the fullest extent of their education has been essential to improving access to care for rural Iowans. Iowa’s gains have been realized largely through regulations rather than through incremental changes to the state’s nurse practice act, as has been the case in other states. Ms. Jones attributes those successes to the diligence of Iowa nurses and others interested in promoting access to care, who:

  • emphasized the issue of access to care for rural and disadvantaged populations;
  • ensured that policy-makers knew what APRNs do (Ms. Jones invited legislators to her clinic);
  • promoted unity among Iowa nursing groups and with organizations such as the Iowa Hospital Association; and
  • partnered with leaders, such as former Iowa governor Tom Vilsack (now U.S. secretary of agriculture), the first governor to opt out of Medicare’s requirement that the state’s CRNAs be supervised by physicians.

Evidence that it is safe to remove restrictions on APRNs comes from an annual review of state laws and regulations governing APRNs that now includes malpractice claims in its analysis. The 2010 Pearson Report documents no increase in claims registered in the Healthcare Integrity and Protection Data Bank in states where APRNs have full authority to practice and prescribe independently. The report also notes that the overall ratio of claims against NPs is 1 for every 166 NPs in the nation, compared with 1 for every 4 physicians (Pearson, 2010).

In June 2010 President Barack Obama addressed the House of Delegates of the American Nurses Association to announce “a number of investments to expand the primary care workforce.” These included increased funding for NP students and for nurse- and NP-run clinics—two important steps, the President said, in “a larger effort to make our system work better for nurses and for doctors, and to improve the quality of care for patients.” (White House, 2010).