Editor’s Note: Toni Inglis, MSN, RN, CNS, FAAN, writes opinion for the Austin (TX) American-Statesman. She works at the Seton Healthcare Family in Austin as a neonatal ICU staff nurse and also writes a nursing blog for Seton and edits its monthly NursingNews. This article is a reprint of an April 22nd commentary in the Statesman. Toni was inspired to write the column after a particularly disappointing legislative session, in which Texas advanced practice nurses made fewer gains than in past sessions—despite Texas ranking last in access to health care and having the most restrictive laws in the country regarding APRN scope of practice and prescriptive authority. She believes the poor access and barriers to practice are related.
AJN finds the article particularly relevant as legislatures across the country deliberate on APRN barriers to practice. You can read her commentaries at ingliscommentary.com.
Here’s an idea that wouldn’t cost Texas a dime but would save millions of dollars every year: Remove all barriers restraining nurses from practicing to the full extent of their education and training.
No state needs primary care providers more than Texas, which has a severe shortage. Texas ranks last in access to health care and in the percentage of residents without health insurance. Of Texas’ 254 counties, 188 are designated by the federal government as having acute shortages of primary care physicians. Of that number, 16 counties have one and 23 have zero.
If every nurse practitioner and family doctor were deployed, we still couldn’t meet the need. Texans are desperate for health care.
Doing the math and to help meet the need, the Legislative Budget Board recommended autonomous practice of advanced practice nurses after a preceptorship.
In Texas, our legislature — session after session — keeps the most restrictive laws in the country. Nurse practitioners don’t want to perform brain surgery. They just want to provide primary care and are quick to refer cases to a doctor when necessary.
Most states with far less need do not legislate practice barriers to nurse practitioners. Given the severity of our problem, shouldn’t we at least bring ourselves in line with those other states?
Texas has a large cadre of licensed, competent and qualified nurse professionals supremely educated, trained and eager to provide primary care. Hundreds of studies have shown their safety records to be equal to those of doctors —with the exception of their communication skills, which rank higher.
Superior communication skills are exemplified by nurse practitioner Naomi Warren from Winkler County in far West Texas, now famous for the whistle-blower/retaliation case. Having practiced in Winkler for more than a decade, she knew her patients well. They trusted her and were devoted to her.
When she quit her job in Winkler County rather than work alongside the doctor she and many others viewed as incompetent and dangerous, she moved her practice to neighboring Monahans Clinic. Even though they had to drive 50 miles round-trip to see her, 600 of her patients followed her.
The main legislative hurdle, or sticking point, is physician delegation. For example, a nurse cannot diagnose and treat the medical conditions of a patient without a physician willing to leave his or her practice, travel to a nurse practitioner’s site and sign charts for care that had already been provided.
Medically underserved areas are lucky to have one provider, much less two, necessitated by the delegation rule. In addition, the number of patients a doctor can see in a day is diminished. This rule significantly exacerbates Texas’ severe access problem. But physician delegation is embodied in Texas law, not federal law, so it’s amenable to legislative reform.
Hungry to have the human resources to meet the health care needs of their constituents, a wide variety of interest groups support nursing’s bills. Stakeholders include the Texas Association of Business; AARP Texas; the Texas Organization of Rural and Community Hospitals; insurance companies such as United HealthCare Texas, AmeriGroup and WellPoint; and many affected individual physicians and others.
As in years past, the only organized opposition comes from physician groups. Their opposition is vehement, and they make large campaign contributions. But why bother? It’s not as if primary care doctors could even remotely fill the need, and they won’t in the foreseeable future.
Older physicians saw the long, on-call hours of practicing primary care as an honorable profession. In turn, they were greatly respected by the people in the community with whom they developed strong relationships over the years. They were often paid in kind. But their numbers are dwindling; many are retiring.
Seeing poor reimbursement rates, few doctors in training choose primary care, where they will make two to 10 times less than their colleagues.
Organized medicine’s powerful opposition is not in the best interest of Texans with no health care. Is it about control? Is it about money? Perhaps they see autonomous advanced nurse practice as an encroachment on their territory. I don’t know why.
But I do know that given the economy, the state budget deficit, the severity of the access problem and the longevity of medicine’s success in killing nursing bills, that turning the tide will be difficult. But it will be historic, a victory for those desperate for health care.
For that to happen, legislators will need to recognize and resist the inherent conflict of interest of deep-pocketed organized medicine. It will take compassion and courage on their part. But they can be proud of their votes because it’s the right thing to do.