American College of Physicians: Internal Medicine — Doctors for Adults ®

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Report on nurses’ scope of practice requires clarification

From the February ACP Internist, copyright 2011 by the American College of Physicians

By J. Fred Ralston, FACP

On Oct. 5, 2010, the Institute of Medicine (IOM) released a consensus report titled “The Future of Nursing: Leading Change, Advancing Health.” There have been many discussions about this report and its recommendations, which have been interpreted in a variety of ways. ACP leadership saw the report and the various reactions and went to work to try to clarify it and see how it fits with ACP policy goals. I want to use this space both to talk about this report and, on a broader level, explain the way ACP formulates College policy and deals with others active in the broader health care policy arena.

ACP’s leadership cannot contact each member when an important issue like this comes to the surface. However, we do have policy committees that are composed of a broad range of ACP members and get input from others. Policy papers are developed for many issues and are available on ACP’s website. Before ACP policy is approved in a particular area, leadership gets input from the Board of Governors and final approval from the Board of Regents. We then try to use this established policy as the basis for responding to issues as they arise.

October’s IOM report was developed by a committee chaired by Donna E. Shalala, former Secretary of Health and Human Services, and prepared in partnership with the Robert Wood Johnson Foundation Initiative on the Future of Nursing. The committee’s charge included examining the capacity of the nursing workforce to meet the demands of a reformed health care system, reconceptualizing the role of nurses, examining innovative solutions related to care delivery and education, and providing recommendations to identify roles for nurses in designing and implementing a more effective and efficient health care system. The stated primary objective of the committee was to define a blueprint for action.

The key messages of the report are:

  1. Nurses should practice to the full extent of their education and training.
  2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
  3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
  4. Effective workforce planning and policy making require better data collection and an improved information infrastructure.

The most controversial provisions of the report suggest that states’ scope-of-practice laws should be revised to permit advanced practice nurses (APRNs) to practice independently. The IOM report also calls on the Federal Trade Commission and the Antitrust Division of the Justice Department to investigate anticompetitive practices at the state level that inhibit APRN practice.

When the 587-page IOM report was released, ACP’s Washington staff analyzed it and compared it to existing ACP policy. ACP leadership discussed this report with some of the authors and with officials at the Robert Wood Johnson Foundation. Words do matter, and we have been working to clarify what this report means and how it is to be used and, we hope, not misused during this transformational time for health care in the U.S.

In 2009, ACP produced a policy paper on nurse practitioners in primary care. I chaired the committee that wrote it. Much of what the IOM report calls for is consistent with our policy, but we do not want to see health care reform focus on nurses as a substitute for doctors. Right now a major focus of ACP and many other groups is the huge workforce need in primary care, and we see better incorporation of nurses into the primary care delivery system as part of the solution. With team-based care, nurses can focus on clinical issues that are both within their training and experience and do not require a physician, while physicians can be freed up to focus on those clinical areas that are better served by their skills. However, we do not want the report’s focus on nurses to lessen pressure to effectively deal with our growing shortage of primary care doctors.

I see no way for us to effectively meet the growing health care needs of our population without a delivery system that uses doctors, nurses and other health professionals to maximum advantage. As long as that use is determined by evidence and there is continuous quality monitoring and improvement, I would hope all (or at least most) of us could agree that doctors and nurses must work together toward our many common goals. In my day job, I practice general internal medicine in a primary care practice with a nurse practitioner who has many of the privileges called for in the IOM report. We work together and she shares with me a feeling that collaborative practice is a great way to deliver care.

ACP would like to take the release of the IOM report as an opportunity to stress the importance of team-based care that includes both nurses and physicians, ideally in a patient-centered medical home (PCMH). We feel that without a transformation in this direction, our quest for improved outcomes and a bend in the rising cost curve in health care may be impossible. We feel that a red-flag political fight over independent practice is divisive and serves no real purpose in the health care system of the future.

Positive examples of systems that use APRNs to great advantage include the Veterans Administration, integrated group practices, and PCMHs. The beauty of the PCMH is that it offers a way of promoting quality and cost while also more effectively using all health care professionals.

We have asked for clarification on some recommendations of the IOM report. At a breakfast meeting in Washington last November sponsored by the IOM and the Robert Wood Johnson Foundation, I asked tough questions and offered advice to clarify the report. I was assured by members of the IOM committee that the report is not saying that APRNs and physicians are interchangeable. A recent perspective published in the New England Journal of Medicine provided some clarification on the report but still left us with some questions. ACP’s EVP/CEO, Steven Weinberger, FACP, contacted the journal, and a letter expressing our concerns was published in expedited fashion in the same online edition containing the perspective piece. Our letter can be accessed online.

If the IOM report is not clarified, we fear that it may not accomplish what the authors tell us is intended, and certainly that it may be used in ways we feel they do not intend. We are working with other physician groups to get the necessary points clarified so doctors and nurses can work together as an effective team in this era of change.

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