Gaining Independent Prescriptive Practice: One State’s Experience in Adoption of the APRN Consensus Model

Abstract

Nurses are increasingly encouraged to be active participants in health policy. This article provides an exemplar of how nurse practitioners (NPs) in one state, North Dakota, used strategic policy actions to obtain independent prescriptive privileges. Consistent and clear communication among NPs and with key stakeholders, including legislators, contributed to a positive policy outcome. North Dakota nurse leaders in this initiative have shared their experiences with a variety of audiences including other state boards of nursing and NP organizations in states such as New York, South Dakota, and Louisiana. In addition, a webinar sponsored by the Center to Champion Nursing in America at AARP featured several of the North Dakota NP leaders, who shared their reflections of this experience and the strategies they used. Regulatory environments and public policies will continue to significantly influence the future of all nurses. This case study of one state can be useful to NPs and other nurses seeking meaningful policy change through laws or regulations with regard to scope of practice or other health policy issues.

Keywords

advanced nursing practice political action professional nursing organizations regulation of nursing practice state legislation prescriptive privileges

Health policies shape the structures, processes, and outcomes of future health care systems in our country. Such policies, whether as laws or regulations, have major impacts on nurses’ delivery of care to individuals and populations. Many factors influence health policy decisions, including input from health care professionals. Issues that are important to the profession of nursing, such as population health, nurse practice acts, payment for nursing services, quality of health care, and allocation of health care resources, are controlled or influenced by federal, state, and local governmental agencies. Therefore, it is not surprising that nursing organizations and leaders recognize the important role nurses play in health policy. White (1995) spoke to this role in her work expanding Carper’s classic framework of Patterns of Knowing in Nursing (Carper, 1978). She advocated the addition of a fifth pattern of knowing called sociopolitical knowing. In addition, the Code of Ethics for Nurses (American Nurses Association, 2001) substantiates the nurse’s duty to participate in health policy activities, specifically in provisions 7.1 and 9.4 of the Code. These provisions call for nurses to participate in civic activities to advance the profession and shape health care, particularly in areas of accessibility, quality, and cost.

The purpose of this article is to explain how nurse practitioners (NPs) in North Dakota rose above challenges to nurses’ involvement in health policy and effected change in the practice environment through legislative engagement.

Overview and Review of Literature

Many nurse scholars have encouraged nurses to be active in the health policy arena, while also questioning the extent of the profession’s engagement (Gebbie, Wakefield, & Kerfoot, 2000; Wakefield, 2001). Although nursing has long been one of the most trusted professions, a 2010 Gallup survey commissioned by the Robert Wood Johnson Foundation (2010) found that nurses are widely perceived as having a low level of influence in health policy. A clear majority of the over 1,500 opinion leaders who completed this survey responded that nurses should have an increased influence on health policy. Yet, when asked how much influence members of various professions and groups are likely to have in health reform, nurses were ranked behind government, insurance and pharmaceutical executives, physicians, and others (Khoury, Blizzard, Moore, & Hassmiller, 2010).

Oden et al. (2000) surveyed 440 members of the American Academy of Nurse Practitioners (AANP) and found that fewer than half were involved in policy-related activities beyond the act of voting. These findings supported results from an earlier study (Daffin, 1988), which found that of 192 nurses, 91% thought political activity was important, yet only 26% of the sample actually participated. Awareness of the critical role nursing has in health policy and concerns about the profession’s low level of participation call for actions and recommendations from state and national nursing organizations to promote political activity.

Although little is known about interventions that could strengthen health policy participation among nurses, evidence suggests factors that might contribute to the limited involvement. Researchers have reported barriers to nurses’ participation in health policy endeavors including (a) lack of knowledge related to legislative proceedings (Boswell, Cannon, & Miller, 2005; Chan & Cheng, 1999; Cohen et al., 1996; Deschaine & Schaffer, 2003; Des Jardin, 2001a, 2001b) (b) lack of resources to support health policy endeavors (Cramer, 2002; Gebbie et al., 2000; Oden et al., 2000); (c) low perceived self-efficacy, limited time, or heavy workloads (Cramer, 2002; Oden et al., 2000); and (d) not being a member of a professional organization (Boswell et al., 2005).

A study of 440 NPs found that “those most active in public policy had high public policy efficacy expectations and perceived a high number of benefits to public policy involvement” (Oden et al., 2000, p. 139). From their research, Gebbie et al. (2000) concluded:

Any efforts to increase the roles of nurses in policy-making should take into account the need to have support readily available when a nurse is first motivated to consider the policy process. Support could include a more widely available network of mentors, a process of seeking nurses just venturing into the policy arena, or inclusion of a wide range of engaging materials in media accessed by nurses (p. 314).

Spencely, Reutter, and Allen (2006) echoed these sentiments and stated, “as a profession we need to design inquiry to build knowledge of policy advocacy processes, and craft strategies to support nursing participation in them” (p. 186). These authors contend that nursing has too “few tools and fewer opportunities to interact or reflect on issues of policy” (p. 188). Such observations from nurse leaders are important. But they don’t address the need for scholarship on specific interventions that might be effective for increasing nurses’ involvement and political efficacy in health policy.

The purpose of this article is to explain how NPs in North Dakota were able to rise above challenges that often prevent involvement in health policy and effect change in the practice environment through legislative engagement.

A Mountain Moved

Nationally, issues of health care accessibility, affordability, safety, quality, effectiveness, and timeliness continue to be priorities on federal, state, and local government agendas. Two key documents, the Institute of Medicine’s (IOM) report on The Future of Nursing and the Advanced Practice Registered Nurses (APRN) Consensus Model, outline strategies to advance nursing in order to meet these national healthcare agenda initiatives. The IOM’s Future of Nursing report recommended that nurses, including APRNs, “function to the full capacity of their education and preparation” (IOM, 2010, p. 1). The APRN Consensus Model was developed to facilitate consistency in education, accreditation, certification, and licensure of APRNs among states (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008).

To implement statewide efforts to actualize the goals of these two national reports, NPs in North Dakota worked with the wider nursing community. North Dakota nurses took on the policy challenge to advocate for a repeal of language included in the Nurse Practices Act (NPA; NPA, Section 18 of the North Dakota Century Code (NDCC) 43.12.1-18) to allow for all APRNs to be independent healthcare providers with prescriptive privileges. Because the North Dakota NPA is in statute, revisions to it required new legislation. North Dakota Senate Bill (SB) 2148 was introduced in 2011 to remove the regulatory requirement that APRNs have a collaborative agreement with a physician on file with the North Dakota Board of Nursing (NDBON) for prescriptive privileges. This requirement for a collaborative agreement for prescriptive privileges was the only barrier to full implementation of the APRN Consensus Model in North Dakota (Madler, Kalanek, & Rising, 2011). During the 62nd North Dakota Legislative Assembly, both chambers overwhelmingly passed SB 2148. Republican Governor Jack Dalrymple signed it into law, effective August 1, 2011 (Madler et al., 2011). The following sections describe how NPs overcame the barriers to practice, described above, and succeeded in getting a new law enacted.

Rural America on the Verge of an Oil Boom

North Dakota’s population is spread over a wide geographical area and is largely rural. Major state industries are energy and agriculture. In 2011, when SB 2148 was under consideration, the state was on the verge of an oil boom. As of 2013, North Dakota was second only to Texas in crude oil production (U.S. Energy Information Administration, 2014). The surge in North Dakota’s economy has contributed to a growing population and amplified the need for health care services.

Physician practices are unevenly distributed across the state, and NPs serve many rural areas. Specifically, 40% of NPs work in North Dakota’s rural areas (North Dakota Board of Nursing Database, 2012) compared to 27% of physicians (Hart, Klug, & Peterson, 2012). Health care facilities in North Dakota struggle to recruit providers to their organizations. To encourage inward migration of NPs to serve these populations, it was important to create regulatory and practice environments that are friendly to NPs.

Prior to legislative action, the North Dakota Nurse Practitioner Association (NDNPA) recognized that in order to ensure that NPs would be able to meet their patients’ health care needs, they would need to address the regulatory barrier that required collaborative practice for NPs. The presence of NPs across North Dakota’s rural and other communities would not enable them to meet the health care needs of the state’s expanding population without addressing the regulatory barriers to NP practice.

Key Players, Movers, and Shakers

This endeavor required collaboration among many individuals and organizations. Initially, a core team of four well-respected and established NPs from the NDNPA sought the approval of the North Dakota Board of Nursing (NDBON) to obtain support (and a legislative sponsor) for a bill that would remove the requirement of a collaborative physician for NP prescriptive privileges. A primary objective was to bring together a diverse set of stakeholders who would support the legislation. To do this, NPs across the state sought and gained support from many nursing and non-nursing organizations and individuals. Major supporters, outlined in Figure 1, along with several others (such as select North Dakota hospitals, County Commissioner Boards, and North Dakota hospital CEOs, and individual physicians) facilitated the success of SB 2148.

In addition, an electronic communication network was established. This network included members and non-members of the NDNPA. Electronic communication with NPs across the state established the foundation, motivation, and encouragement for these professionals to become involved. Using the electronic communication network, NPs were offered materials to enhance their knowledge of North Dakota’s legislative process, legislative changes needed to enable them to practice without a collaborative agreement with a physician, the importance of their involvement in health policy and resources available to assist them. The core team of North Dakota NP leaders identified NPs in each state legislative district and personally contacted many of them to take specific actions in communicating with legislators from their district. NPs were given the legislators’ names, photos, e-mail addresses, phone numbers, and other relevant information. NDNPA obtained follow-up regarding the outcome of communication with legislators, which contributed significantly to the groundwork for continued lobbying efforts at the capital.

Cell Phones, E-mails, and Handshakes

Self-efficacy related to health policy involvement for both NDNPA as an organization and its individual members was bolstered by a success in the previous legislative session. During that session, NPs were successful in obtaining a change in statute to allow recognition of NPs as primary care providers for the Medicaid population in North Dakota (Madler, Kalanek, & Rising, 2012). Building upon this momentum, the NDNPA moved forward with efforts to address the regulatory barriers to NP practice (see Figure 1 for a timeline of the strategic action plan related to ND SB 2148). Strategies utilized during the effort are described below.

Communication

In October 2009, the vision to remove the collaborative agreement for NP prescriptive authority was first introduced to attendees at the NDNPA Annual Meeting. During this meeting, several NPs voiced their concern about the political ramifications of bringing this issue before the legislature, their fears of opposition, and their concerns about potential disruptions of their relationships with physicians and their work environments. NDNPA had invited a well-respected North Dakota state senator to the social time prior to the annual meeting. During the discussion regarding this issue, she took the opportunity to address the group. Through her response, she offered encouragement to proceed with legislative action to remove the collaborative agreement requirement and volunteered to sponsor the bill.

Despite having strong support from this senator, NPs had significant work to organize their efforts, relay their message, and begin an effective campaign. Key stakeholders in this work included NPs, legislators, both nursing and other health-related organizations, and health care consumers. Vital to the success of this bill was dedication to effective communication with all stakeholders. The NDNPA core team authored or approved communications regarding this bill. NDNPA’s secretary coordinated the messages and communication. Having a small core team responsible for the development and disbursement of all documents and messages allowed for timely and consistent messaging.

The strategy for communicating with legislators first concentrated on those who were members of the Senate Human Services Committee and moved to the full Senate membership subsequent to the committee’s “do pass” recommendation. The core team and NP constituents from individual legislative districts communicated with every state senator to educate them on this issue. Again, this education was based on a key talking point document approved by the NDNPA executive committee.

Communication with other organizations began prior to drafting the bill and continued throughout the legislative session. As described earlier, NDNPA first met with the NDBON to seek its approval and support. Then they convened a meeting with leaders from the North Dakota Board of Medical Examiners and the North Dakota Medical Association. Although the NDNPA leaders anticipated opposition, they also held transparency as a priority. They educated these other groups about the proposed legislation and shared with them a draft of the bill. From there, the North Dakota Nurse Leadership Council (NDNLC) was presented with information. This group comprised representatives from key North Dakota nursing organizations, who then took the information about the bill back to their respective groups. The NDNLC voted to formally support this legislative action. NDNPA provided them with monthly updates on the bill’s progress. Other key organizations that supported the proposal and collaborated in this work are listed in Table 1.

Table 1.

Supporters of SB 2148.

North Dakota Board of Nursing (NDBON)

North Dakota Nurse Leadership Council (NDNLC)

North Dakota Nurse Practitioner Association (NDNPA)

North Dakota Organization of Nurse Executives (NDONE)

North Dakota Nurses Association (NDNA)

North Dakota Association of Nurse Anesthetists (NDANA)

American College of Nurse Practitioners (ACNP)

American Academy of Nurse Practitioners (AANP)

American College of Nurse Midwives

American Association of Retired Persons (AARP)

Altru Health System

Community Healthcare Association of the Dakotas (CHAD)

Cavalier County

College and University Nursing Education Administrators (CUNEA)

Many signatures of individual physician supporters

Developing a Message

A major aspect of effective health policy engagement is a concise and consistent message. AANP, in consultation with a state lobbyist for NDNPA, provided key resources in the development of the message for legislative action. The result was the creation of a one-page fact sheet, which was distributed widely to all stakeholders (see Appendix A).

Messaging to legislators was supplemented with “on-the-ground stories” from NPs across the state. These stories offered examples of how the current law impacted the delivery of health care in various state geographic sectors. They also created awareness among legislators of how the restrictive law was an antiquated regulatory barrier that did not contribute to the advancement of North Dakotans’ health. These specific stories offered examples of how it was difficult for some NPs to secure a collaborative physician and how lack of a collaborative physician could put accessible health care at risk in some communities. The stories also showed how the required collaboration did not contribute to improving or ensuring quality or safety of care.

Lobbying

The influence of a respected lobbyist can be crucial to the success of any legislative action. Securing a lobbyist positively impacted the outcome of ND SB 2148. NDNPA leaders interviewed potential individuals to assume this role. The candidate of choice was an individual well known in the North Dakota Legislative Assembly who had a positive track record with health-related legislation. The lobbyist’s experience enabled him to mentor effective techniques for core team NPs to utilize when lobbying at the state capitol. The core team recognized the importance of personally carrying the message of this bill and was committed to having a consistent presence at the capitol. Between the lobbyist and the members of the core team of NPs, every legislator received individual communications on multiple occasions. A mechanism to track the timing and number of contacts with each legislator and their position on the bill was developed and relied upon to monitor progress. Finally, an approach to providing legislative testimony was strategically planned with the lobbyist’s assistance. Again, the core team felt strongly that testimony should come from NPs. The testimony was categorized into four main themes, with each member of the team taking responsibility for testimony related to one theme. The themes were as follows: (a) role, number, and locations of NP practices in North Dakota; (b) current licensure requirements including the regulatory barriers that collaborative agreements posed; (c) national support for the proposed legislation (e.g., the 2010 IOM report) and quality of care provided by NPs; and (d) difficulties in securing a collaborating physician and their impact on health care in rural North Dakota.

Challenges

Although both chambers eventually overwhelmingly passed the proposed bill, accomplishing this presented significant challenges. Both the North Dakota Board of Medical Examiners and the North Dakota Medical Association opposed the legislation. In addition, the state senate included two licensed physicians who were vocal in their opposition to the bill. Moreover, opponents to the bill argued that the quality and safety of care for patients would be jeopardized if policymakers removed the collaborative requirement. Another major challenge occurred the day before the final vote in the second chamber. The executive director of the North Dakota Hospital Association, who had previously indicated neutrality on this issue, sent an e-mail message to all physicians in the state, encouraging them to urge their legislators to vote “no” on SB 2148.

NDNPA addressed each challenge. First, mutual respect was maintained with organizations opposing SB 2148. The opposition and arguments against SB 2148 did not distract NDNPA. The message remained consistently focused on patients and on NPs’ goals to be afforded the ability to practice to the full extent of their education and preparation and to contribute to accessible, high-quality healthcare for the residents of North Dakota.

All of the efforts and deliberate strategies described above culminated in the passage of ND SB 2148 and Governor Dalrymple signing the bill into law, providing independent prescriptive privileges for ND APRNs. As can be seen in Figure 2, the Governor’s signing of this legislation was attended by legislators, nursing regulators, and APRNs. This law went into effect on August 1, 2011.

Conclusion

The AANP defines full practice authority as “state practice laws that regulate nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments, including prescribe medications, under the exclusive licensure authority of the state board of nursing” (AANP, 2013, para. 1). ND SB 2148 provided North Dakota NPs full practice authority as defined by AANP. This legislative decision placed North Dakota in the company of 13 other states and the District of Columbia (American Association of Retired Persons [AARP], 2014). Since that time, four other states (Nevada, Rhode Island, Minnesota, and Connecticut) have been successful with legislative efforts leading to fully authorized practice and an additional four states (Utah, Texas, Kentucky, and New York) have made incremental improvements to state statutes that influence the NP practice environment (AARP, 2014).

Dissemination of the authors’ experiences and strategies has been an important part of the policy engagement. The authors have shared their experiences with a variety of audiences including other state boards of nursing and NP organizations in states such as New York, South Dakota, and Louisiana. In addition, a webinar sponsored by the Center to Champion Nursing in America at AARP featured several of the North Dakota NP leaders as they reflected on their policy experience and the strategies they used (AARP, 2014).

To meet the health care needs of the nation under a reformed health care system, there is a critical need for providers, including NPS, who are equipped with clinical competence. To that end, we also need regulatory policies that allow NPs to practice to their full scope. Over the past five years, state policymakers have steadily revised laws and regulations to meet this need. It is important that NPs maintain the momentum for change and progress. This article provides strategies that NPs can adapt to their specific political and environmental contexts in efforts to improve access to and quality of care for myriad populations.

Footnotes

Appendix A

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Billie Jo Madler, DNP, APRN, FNP is Chair of Online and Distance Nursing Education at the University of Mary. Her clinical practice is in emergency medicine and locums work. She is Past-President of the North Dakota Nurse Practitioner Association.

Constance B. Kalanek, PhD, RN, FRE is the Executive Director of the North Dakota Board of Nursing.

Cheryl Rising, MSN, APRN, FNP is a nurse practitioner at Prairie Assisted Living Service and Dakota Eye Institute. She serves as Legislative Liaison for the North Dakota Nurse Practitioner Association.

References

American Association of Nurse Practitioners (AANP). (2013). Issues at-a-glance: Full practice authority. Retrieved from http://dhhs.ne.gov/publichealth/licensure/documents/FullPracticeAuthority.pdf.

American Association of Retired Persons. (2014). Removing barriers to practice and care: State progress in removing policy barriers to care by nurse practitioners. Retrieved from http://campaignforaction.org/sites/default/files/State%20Progress%20Removing%20Barriers%20to%20Practice%20and%20Care.pdf.

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/EthicsStandards/CodeofEthics.aspx.

APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from: https://www.ncsbn.org/aprn.htm.

Boswell

Cannon

Miller

(2005) Nurses’ political involvement: Responsibility versus privilege. Journal of Professional Nursing 21(1): 5–8.

Brassard, A., Kalanek. C. B., Madler, B. M., Delean-Botkin, S., Greenberg, H., & Reinecke, P. (2012). Strategies and tactics for successful legislation to remove barriers to APRN practice and care [Webinar]. AARP Campaign for Action. Retrieved from http://campaignforaction.org/sites/default/files/Strategies-to-Remove-Barriers-to-APRN-Practice%26Care-WebinarSummary2012-7-17_0.pdf.

Carper

B. A.

(1978) Fundamental patterns of knowing in nursing. Advanced in Nursing Science 1(19): 13–24.

Chan

S. W. C.

Cheng

B. S.

(1999) Political participation in Hong Kong: A study. Journal of Nursing Management 7: 167–175.

Cohen

S. S.

Mason

Kovner

Leavitt

J. K.

Pulcini

Sochalski

(1996) Stages of nursing’s political development: Where we’ve been and where we ought to go. Nursing Outlook 44(6): 259–266.

10.

Cramer

M. E.

(2002) Factors influencing organized political participation in nursing. Policy, Politics & Nursing Practice 3(2): 97–107.

11.

Daffin, P. N. (1988). Similarities and difference in political expectations and participation among nurses in clinical practice, education, and administration (Unpublished doctoral dissertation). University of Alabama at Birmingham, Alabama.

12.

Deschaine

J. E.

Schaffer

M. A.

(2003) Strengthening the role of public health nurse leaders in policy development. Policy, Politics & Nursing Practice 4(4): 266–274.

13.

Des Jardin

K. E.

(2001a) Political involvement in nursing: Education and empowerment. AORN Journal 74(4): 468–475.

14.

Des Jardin

K. E.

(2001b) Political involvement in nursing: Politics, ethics, and strategic action. AORN Journal 74(5): 614–622.

15.

Gebbie

K. M.

Wakefield

Kerfoot

(2000) Nursing and health policy. Journal of Nursing Scholarship 32(3): 307–315.

16.

Hart, G., Klug, M., & Peterson, M. (2012). Availability of Direct Patient Care Physicians in North Dakota. Center for Rural Health – Fact Sheet.

17.

Jones, J. M. (2010, December). Nurses top honesty and ethics list for 11^th year. Gallup Economy, pp. 1–2. Retrieved from http://www.gallup.com/poll/145043/nurses-top-honesty-ethics-list-11-year.aspx.

18.

Khoury

C. M.

Blizzard

Moore

L. W.

Massmiller

(2010) Nursing leadership from bedside to boardroom. Journal of Nursing Administration 41(7/8): 299–305.

19.

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record_id=12956&page=R1.

20.

Madler, B. J., Kalanek, C. B., & Rising, C. (2012). An incremental regulatory approach to implementing the APRN consensus model. Journal of Nursing Regulation, 3(2), 11–15.

21.

Madler

Kalanek

C. B.

Rising

(2011) An incremental regulatory approach to implementing the APRN consensus model. Journal of Nursing Regulation 3(2): 11–15.

22.

Oden, L. S., Price, J. H., Alteneder, R., Boardley, D., & Ubokudom, S. E. (2000). Public policy involvement by nurse practitioners. Journal of Community Health, 25(2), 139–155.

23.

Robert Wood Johnson Foundation. (2010). Groundbreaking new survey finds that diverse opinion leaders say nurses should have more influence on health systems and services. Retrieved from http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2010/01/groundbreaking-new-survey-finds-that-diverse-opinion-leaders-say.html.

24.

North Dakota Board of Nursing Database. (2012). Retrieved from www.nbbon.org.

25.

Spencely

S. M.

Reutter

Allen

M. N.

(2006) The road less traveled: Nursing advocacy at the policy level. Policy, Politics, & Nursing Practice 7(3): 180–194.

26.

U.S. Energy Information Administration. (2014, March 31). Five states and the Gulf of Mexico produce more than 80% of U.S. crude oil. Retrieved from http://www.eia.gov/todayinenergy/detail.cfm?id=15631.

27.

Wakefield

M. K.

(2001) What becomes visible when it disappears? Answer: The essential role of nurse in the health care system. Nursing Economics 19(4): 189–191.

28.

White

(1995) Patterns of knowing: Review, critique, and update. Advances in Nursing Science 17(4): 73–86.