Advanced-practice registered nurses have been part of Minnesota’s health care workforce since the 1970s. These RNs have an additional two-year postgraduate degree and are certified to practice in one of four roles. They provide essential services for Minnesotans from primary care to mental health care to prenatal care and delivery to operating room anesthesia.
Yet APRNs are not physicians. Physicians typically have a four-year, science-intensive college degree, a four-year medical degree, plus a residency of at least three years — and that’s before any subspecialty training.
The APRN Coalition is at the State Capitol with a big push to change the law so that such nurses could practice independent of physicians. The APRNs want full authority to diagnose and treat patients, including ordering and interpreting diagnostic tests and prescribing all medications (“Will legislation help or hurt nursing?” March 11). This push is part of a national movement to enact the “Consensus Model for APRN Regulation,” which would include removing barriers for APRNs to move their practices from state to state.
Minnesota law says that APRNs must manage patients in collaboration with a physician and that they can prescribe only under a written agreement with a physician. This has worked well for most, but for some, the legal requirement has become an expensive formality and an impediment to practice when a collaborating physician can’t be found. That part of the law should be fixed.
However, I strongly believe that when nurses diagnose and treat illnesses and diseases, they should maintain collaboration with physicians, especially in their early years of practice. Studies show that patients benefit greatly from a team approach to health services — a policy direction that has helped make Minnesota a health care leader.
One of the most troubling issues in the APRN Coalition’s bill is the role of certified registered nurse anesthetists, a subgroup of APRNs. CRNAs are trained to manage anesthesia during and after surgery — in collaboration with and at the direction of physicians. The APRN bill would let them also provide interventional pain management independently, without any physician oversight.
Physicians who provide interventional pain management have extra years of special training — beyond even that of an anesthesiologist or other specialist. They need the extra training because their patients often have pain that primary-care physicians, neurologists or other physicians cannot resolve. Some techniques used to treat chronic pain can be crippling or even fatal if used improperly. CRNAs are not trained to independently diagnose and treat these patients and must not be allowed to do so.
I introduced a different bill that would draw careful lines around the expansion of CRNA practice, but that would remove the formality of a prescribing agreement and allow experienced APRNs to practice independently. However, before practicing independently, a newly graduated APRN would have to work for three years in an integrated clinical setting with mentoring from physicians and other APRNs. This mentored work setting would help hone clinical skills and teach graduates how to work in a team. My bill also would require those APRNs who practice in an independent setting to disclose to patients their arrangements for assistance when the patient’s needs are beyond their expertise. These are reasonable steps to help assure patients that they would receive quality care from a nurse who is ready to ask for help should the need arise.
If APRNs become independent, who will determine when an APRN goes beyond education and training? The Board of Nursing currently oversees APRNs, but only one of 16 board members is an APRN. My bill would address this by setting up a joint committee of APRNs and physicians to advise the Board of Nursing on scope of practice and disciplinary matters.
We have a good health care system in Minnesota. We have among the lowest uninsured rates and the lowest costs in the country, along with a reputation for the highest quality of care. We rely upon and value our APRNs and should address unnecessary barriers to their practice. But we must not sacrifice safety and quality of care in a rush to give them independence from the physicians who support them and back them up.
Tina Liebling, DFL-Rochester, is chair of the Health and Human Services Policy Committee in the Minnesota House of Representatives.