In rural Minnesota, a highly educated nurse who has spent years developing therapeutic relationships with dozens of people with mental illness, monitoring and adjusting their psychiatric medications, must tell them she can no longer help them. Insurance isn’t the problem, and it has nothing to do with either the patients or the specialized nurse. It’s because someone else is retiring. The nurse specialist paid that person, a physician, several thousand dollars for permission to practice. When he retires, that agreement and the nursing care it permitted ends. He has never seen the nurse’s patients and has not collaborated in their care, yet he controls their access to the health care they appreciate and need.
Two bills introduced at the State Capitol take opposite approaches to this problem. Powerful DFL health committee chairs — one in the House and one in the Senate — have authored opposing bills.
The Senate bill would remove paternalistic medical gatekeeping, allowing the nurse to continue providing her specialized care. Allowing this work without a requirement for permission from physicians is supported by a former dean of the University of Minnesota medical school, by Gov. Mark Dayton’s health care reform task force and by the Institute of Medicine, along with decades of research. The bill wouldn’t change or expand what advanced-practice nurses do; it would simply remove an archaic, unnecessary layer of bureaucracy, in keeping with the “unsession.”
In contrast, the House bill would leave the rural patients mentioned above without their mental-health-care provider. It also proposes additional new restrictions that increase physician gatekeeping over the specialized health care provided by advanced practice registered nurses (APRNs), defined as nurse practitioners, nurse anesthetists, clinical nurse specialists and nurse midwives.
Language confusion doesn’t help. Reports mistakenly say APRNs want to practice independently, snubbing teamwork and collaboration. Independence is being confused with autonomy. Independence means: “I don’t need you.” Autonomy means: “I decide what you can do to me.” APRNs in many states, including some of our neighbors, have practiced autonomously for years without a different profession deciding when and where they can work.
Nobody in health care, even the highest-paid surgeon, practices independently. As a former emergency nurse, I can attest that the efficient interdependence of nurses, paramedics, physicians, social workers, dentists and pharmacists saves countless patients from needless suffering and premature death.
But there is more to health care than medicine. While physicians and nurses work shoulder to shoulder to improve health, they are different. Nurses combine deep knowledge of the health care sciences with comprehensive understanding of individual situations in order to build on what works and to fix what doesn’t, calling on colleagues in other health care professions as needed.
Nurses practice nursing, and advanced-practice nurses practice advanced nursing. APRNs may borrow from the medical toolbox, but they are no more practicing medicine than a dentist who prescribes antibiotics, injects novocaine or does a root canal.
Last year, the state Health Department pointed out that rural access to maternity care is reduced because physicians refuse to give midwives permission. That rankism prevails in the House bill.
The hallmark of nursing is presence. There are more nurses, in more roles, helping people in more ways, in more places and with more trust (according to years of Gallup polling) than any other health care profession. That includes care where the provider shortage hits hardest.
Despite unwarranted gatekeeping on the excellent care APRNs provide, they work in homeless shelters, in Minnesota’s 106 primary-care shortage areas and in the state’s 53 mental-health shortage areas. In 46 rural Minnesota counties, anesthesia is available only because there are nurse anesthetists there to deliver it.
As Minnesota increases access to insurance, it would be a shame if it neglects to improve what really matters — access to care.
Eileen Weber, of Hastings, is a nurse attorney finishing a nursing doctorate at the University of Minnesota.