HEALTH POLICY
APRN prescribing in Georgia: An evolving environment Dellarie L. Shilling, DNP, FNP-BC (Assistant Professor) & Donna Hodnicki, PhD, FNP-BC, FAAN (Professor Emeritus) Georgia Southern University, Statesboro, Georgia
Keywords Nurse practitioners; prescribing; policy; scope of practice; advanced practice nurse (APN). Correspondence Dellarie L. Shilling, DNP, FNP-BC, Georgia Southern University, Statesboro, GA 30460. Tel: 912-531-2414; Fax: 912-478-0536; E-mail: [email protected] Received: 8 October 2013; accepted: 30 December 2013 doi: 10.1002/2327-6924.12203
Abstract Purpose: While it took over 20 years to achieve legal authority to write prescriptions in Georgia, effective July 1, 2006, nearly 40% of Georgia advanced practice registered nurses (APRNs) are still not using this method of prescribing. An investigation was conducted to identify the current practice environment and barriers to practice in order to identify causes for this lack of participation and implications for advanced practice nursing and the provision of health care. Data sources: A survey of APRNs in Georgia in 2011 describes demographics, practice environment, APRN education, barriers to practice, and prescribing activity. Conclusions: Georgia is one of the most restrictive states in terms of APRN scope of practice, and has an anticipated escalation of underserved population with health disparities demanding attention. Implications for practice: Many of the identified barriers are common to APRNs nationwide, but specific barriers to Georgia APRNs are being strategically addressed. Policy changes are recommended to enhance the practice environment of APRNs to support the delivery of quality care.
The battle to overcome barriers to advanced practice registered nurses’ (APRNs) scope of practice has been onerous, marked by one skirmish after another for decades in many states. While APRNs in 16 states and the District of Columbia have full independent scope of practice, Georgia remains a state with a restrictive environment (American Association of Nurse Practitioners [AANPs], 2013). Nationally, it has been recommended that barriers to APRN practice that impede patient access to care need to be removed (Brassard & Smolenski, 2011; Cassidy, 2012; Institute of Medicine [IOM], 2010; Lugo, O’Grady, Hodnicki, & Hanson, 2007). To remove the barriers, identification of the obstacles to APRN practice is essential to develop successful models of care delivery and policies to increase patient access to quality healthcare providers who can improve healthcare outcomes (IOM, 2010). The implications of a nationwide shortage of primary care providers (Health Resources and Services Administration [HRSA], 2011) will be expounded with implementation of the Affordable Care Act (ACA) in 2014 and the addition of over 30 million insured persons to the burdened care system (ACA, 2009). With the need for more primary care providers, there is a national push to fully utilize the 300
knowledge and skills that APRNs can provide (National Governor’s Association [NGA], 2012; Sargen, Hooker, & Cooper, 2011). Georgia is among the 27 states electing not to operate a state insurance exchange. In addition, Georgia along with other states has opted not to expand Medicaid coverage. These two actions are expected to result in an increase in the number of persons who are unable to obtain insurance yet will still be in need of health care. With the increase demand for providers, action is required to remove unnecessary barriers to APRN practice to avoid any compromise in the ability to provide quality patient care (IOM, 2010; Safriet, 2011). In the state of Georgia, barriers to APRN practice are a continuing issue of concern. A 2007 study (Lugo, O’Grady, Hodnicki, & Hanson, 2007) that investigated each state’s APRN regulatory environment for nurse practitioners (NPs) placed Georgia at 48 of 51 states. This ranking earned a grade of “F” as one of the most restrictive states in the country because of the limitations placed on APRN scope of practice that affects patients’ freedom to choose providers and the APRN’s ability to provide advanced nursing care (Lugo et al., 2007). The Georgia restrictions have been noted since 1989 in The Pearson Journal of the American Association of Nurse Practitioners 27 (2015) 300–307 C 2014 American Association of Nurse Practitioners
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Report, an annual descriptive, detailed compendium of state rules and regulations affecting APRN practice (Pearson, 2009, 2011). APRNs in Georgia are accustomed to vigorous organized opposition, primarily via the Medical Association of Georgia (MAG, 2011), resulting in slow progression toward a less-restrictive practice environment. The MAG annual policy compendiums routinely include opposition to any expansion of APRN practice including the addition of Schedule II to prescribing (DEA, 2013; MAG, 2013), which places a barrier to the care of patient in labor and the treatment of patients with attention-deficit disease. In addition, the insistence on “supervisory” language, as opposed to “collaborative” practice has been an ongoing issue (MAG, 2013). Federal statistics also underline the need to support fully participatory and unrestricted APRN practice to meet the needs of the state population. The U.S. Census Bureau (2010) ranked Georgia ninth in the nation for cumulative population increase. The state is highest among national regions designated with underserved populations (HRSA, 2011) while ranking 10th in the nation for lack of primary care providers (Advisory Board, 2012; Georgia Senate, 2007). With ample research supporting the value and effectiveness of APRN care and outcomes (Bauer, 2010; Brown & Grimes, 1995; Horrocks, Anderson, & Salisbury, 2002; Laurant et al., 2008; Lugo et al., 2007; Mundinger et al., 2000; Venning, Durie, Roland, Roberts, & Leese, 2000), the nature of the economic emergency in Georgia makes removal of scope of practice barriers imperative to meeting the continuing and increasing healthcare needs of its citizens. A description of the evolving environment of APRN prescribing practice and the barriers to care that inhibit advanced practice nursing care highlight the changes that are needed. More efficient and productive use of APRNs is imperative in order to provide quality health care to an increasing population with diverse needs.
APRN medication legislation Up until recently, the Georgia Board of Nursing (GBON) recognized NPs, certified nurse midwives (CNMs), psychiatric mental health clinical nurse specialists (PMHCNSs), and certified registered nurse anesthetists (CRNAs) as APRNs. Approximately 2 years ago, the APRN definition was amended to include clinical nurse specialists who meet specific criteria. APRNs in Georgia may use one of two legislative options to provide medications for patients; however, they may not use both options concurrently with a collaborating physician.
1988 Legislation The 1988 APRN legislation, Delegation of Authority to Nurse or Physician Assistant (OCGA § 43–34–23, 2010), is overseen by the GBON for APRNs. Through physician delegation the APRN may assess a patient, determine the medication needed, and write the order in a chart. Under the physician’s name, the APRN can phone in orders for legend drugs and Schedule II–V drugs and order radiologic tests. No Drug Enforcement Association (DEA) is required. All written prescriptions or diagnostic orders require a physician signature. A 2002 study (Hodnicki, Dietz, McNeil, & Miles, 2004) investigated APRN prescribing under this law. Data were gathered on every patient encounter and medications ordered by 79 APRNs (68 NPs, 10 CNM, and 1 PMHCNS) for 1 week between November and December of 2002. The findings indicated that a total of 7999 medications were ordered for 3776 patient encounters. When the NPs determined a consultation on a drug order was needed, only three of every 1000 (0.003%) orders were changed by the delegating physician. The study findings supported discussions with legislators, physicians, and consumers on the safety of APRN medication ordering and identified multiple hindrances to patient care that occurred as a result of APRNs having no written prescriptive authority.
2006 Legislation With legislation effective July 1, 2006, Georgia APRNs began written prescriptive authority for legend drugs and Schedule III–V drugs under an agreement with a delegating physician (Delegation of Authority to Nurse or Physician Assistant, OCGA § 43–34–25, 2010; referred to as 2006 written authority in this article). The CRNAs, by choice, opted out of the 2006 legislation but supported all efforts for passage. With this legislation Georgia became the last state in the country to provide written prescriptive authority for APRNs. Prior to this 2006 legislation, all aspects of APRN practice were totally under the GBON. To pass the 2006 legislation, APRNs had to agree that the Georgia Composite Board of Medicine (GCBOM) would have a role in writing the rules and regulations for written prescriptive authority. Through physician delegation, APRNs may sign for legend and Schedule III–V drugs under their own name. A protocol must be submitted for approval to the GCBOM by the delegating physician. The fee for protocol submission was initially $50, but has steadily increased to a current rate of $150, which must be paid with every new physician protocol submitted. A DEA number is required for scheduled drugs. The 2006 law states that radiologic tests may be ordered only in life-threatening circumstances. The names 301
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of all APRNs with approved protocols are listed on the GCBOM website. Over the years some of the more restrictive GCBOM rules and regulations for the 2006 legislation have been modified as a result of input from the APRN community.
Need for the study With passage of the 2006 written authority it was assumed that a significant number of APRNs would submit protocols. In 2011, 5 years after the 2006 legislation, barely one third of APRNs in Georgia were approved for written prescriptive authority per the GCBOM website. While the GBON had 4582 NPs, 425 CNMs, and 292 CNSPMHs licensed as APRNs (5299 total; GBON, 2011), the GCBOM had 2072 approved protocol agreements listed on their website (GCBOM, 2011). With such a lack of approved protocols and no studies of prescribing trends after the 2006 written authority, it was determined that an investigation was needed to identify the current APRN prescribing practice environment in the state, especially related to how medication prescriptions were provided for patients.
Purpose of the study The first author completed this study to determine the factors contributing to a lack of participation under the 2006 written authority legislation. In addition, the lack of studies describing the current environment of APRN practice in Georgia indicated a need for investigation of APRN demographics, barriers, and concerns. The overall goal of the study was to identify where policy changes would be most beneficial to remove barriers to APRN practice to meet the increasing healthcare needs of the state. There were four questions guiding the study. What are demographics of the APRN population in Georgia? What descriptors identify APRN practice? What prescribing methods are used in APRN practice? What barriers do APRNs identify to their scope of practice?
Methodology This descriptive study utilized a survey instrument approach to collect data from the Georgia APRN population. The instrument was adapted from a survey tool developed by Kaplan and Brown for research conducted with Washington state’s APRNs in 2004 and 2006 (Kaplan & Brown). With authors’ permission, the Washington tool was modified and validated for use in the Georgia study. The Georgia tool with 58 items collected data on demographics, education, certification, practice environment, prescribing activity, perceived barriers to practice, retirement plans, and professional organizational 302
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activity. The Georgia tool was pilot tested and peer reviewed by five practicing APRNs in the state. Upon receipt of Human Subjects Protection approval from the university affiliate, a postcard detailing the aim of the study, along with the link to access the survey on SurveyMonkey was bulk-mailed to each of the 4358 APRNs listed on the purchased 2011 GBON registry list. In addition, e-mail announcements and postings regarding the study were placed on professional websites frequented by Georgia APRNs. APRNs were directed to access the survey online via SurveyMonkey. Surveys were collected from July to September of 2011. The survey was targeted to NPs, CNMs, and PMHCNSs as they were approved for medication ordering under the 2006 written authority legislation. While extended data were obtained, this article will report on APRNs who provide care in any clinical practice setting.
Analysis of data A total of 4358 postcards were mailed in spring 2011 to GA APRNs. A total of 617 surveys were returned for a response rate of 14.1%. Data from 14 students and 62 APRNs in administrative or teaching positions who were not in clinical practice were deleted. While a total of 541 surveys from NPs and CNMs were analyzed, there were some incomplete responses to items that resulted in number (n) variations.
Demographics Analysis of respondent zip codes indicated that all regions of the state were represented. The majority of APRNs were female (92%), educated within a graduate nursing program (82%), or postmaster’s certificate program (18%). Certification was identified as family (61%), adult (14%), pediatric (10%), women’s health (9%), or nurse midwifery (7%). The majority of respondents (47%) reported 6–15 years of experience, followed by those reporting 1–5 years of experience (32%; see Table 1). Dual APRN licensure in another state was held by 13% of those surveyed with 7% providing patient care services in other states, primarily those bordering Georgia (SC, TN, AL). Many were members of professional organizations such as the American Academy of NPs (52%), United APRNs of Georgia (39%), American Nurses Association (34%), and the Georgia Nurses Association (28%).
Practice environments The majority (72%) worked in urban areas and most were employed either in private practice (28%) or in a hospital setting (24%). Respondents identified
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Table 1 GA APRN demographics Gender Female Male APRN Education Program Certificate (post and non-Master’s) Master’s degree DNP degree Doctorally prepared (non-DNP) Area of certification Family Adult Pediatric Women’s health Nurse midwives Years experience as APRN (n = 538) 1–5 6–15 16–26 27+
495 (92%) 41 (8%) 95 (18%) 438 (82%) 2 (0.4%) 43 (5%) 317 (61%) 70 (14%) 51 (10%) 46 (9%) 34 (7%) 172 (32%) 255 (47%) 78 (14%) 33 (6%)
employment in a wide variety of specialty practice areas (see Table 2). While most (56%) provided some acute care in the hospital, 38% did not provide any care in the hospital setting.
ciated with obtaining prescriptive authority was cited by 15% (see Table 3). A DEA number is not needed to write for legend drugs. While 281 APRNs acknowledged using the 2006 written authority, only 234 had registered for a personal DEA number (83%). The APRNs who are limiting their medication prescribing to legend drugs only identified several reasons for not applying for a DEA number. Most (46%) reported a physician or other provider writing their prescriptions for controlled drugs. Some (29%) reported practicing without the use of controlled substances. The 25% who did not want to write for controlled substances (III–IV) indicated that they were ambivalent about prescribing them (24%); they lacked the expertise to prescribe them (13%); they were concerned about their ability to deal with patients exhibiting drug-seeking behaviors (11%); or they were concerned about the potential for disciplinary action by regulators (11%). In contrast, those prescribing Schedule III–V medications indicated that they did not feel that they were prescribing any more scheduled drugs than they were prior to the 2006 written authority (91%) and felt moderately to extremely well prepared by their APRN education to prescribe scheduled drugs (63%).
Perceived barriers to practice Prescribing option used The 2006 written authority legislation was not being used by 46% of the respondents. When asked to rank reasons for not applying for written prescriptive authority, 53% cited that they used the 1988 ordering authority that permits a designated nurse to order medications and treatments under the physician’s name. In this group, 25% have a physician write or sign all of their prescriptions. Other reasons for nonuse of the 2006 written authority included employer-created barriers (15%) and practicing in a Federal or Public Health agency under a separate protocol (17%). Limited time or money to cover costs asso-
Table 2 GA APRN specialty practice areas GA APRN top 10 specialty practice areas OBGYN Pediatrics Internal medicine ER/trauma Oncology (breast, pediatric, orthopedic) Cardiology Psych/mental health Geriatrics ICU/CCU Neurodevelopmental pediatrics
Using an open-ended response, respondents identified the major barriers that impede their ability to provide care in Georgia using the full scope of their APRN education (see Table 4). The most frequently cited barrier was related to physician collaboration and supervision. The respondents cited issues with the onerous requirement to review charts, the cumbersome nature of collaborative agreements, and the multistep process to obtain them. In addition, they cited the need for joint supervision by the GCBOM and the BON, and difficulty being accepted as caregivers by a consulting physician. Also noted were the domineering attitudes of physicians in protecting their perceived domain and a generally negative attitude toward APRNs. The second barrier is the inability to prescribe Schedule II medications to patients suffering from attention-deficit disorder. The third barrier is the inability to order diagnostic testing (CT, MRI, and stress tests being specifically identified) unless it is a life-threatening situation. One respondent commented that this testing barrier compromised her ability to get prompt access to reports on patients she had treated, and others mentioned that failing to identify the APRN as the provider on the report caused delays in obtaining the reports for treatment purposes. The fourth barrier is resistance from physicians, specifically via the MAG to remove barriers to practice. Billing and reimbursement issues, followed by the lack 303
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Table 3 GA APRN prescribing activity Personal DEA number I pay for Facility pays
Yes: 234 (44%) 43 (8%) 150 (28%)
Number of Schedule III–V written/week 1–15 16–30 31–60 61+ More III–IV written under own signature No A little more Somewhat more Moderate/great deal more
191 (64%) 60 (20%) 26 (9%) 24 (8%)
In process of applying Other provider writes Practice without Do not want to write for Use institutional number Too expensive
52 (19%) 128 (46%) 80 (29%) 69 (25%) 16 (6%) 42 (15%)
254 (91%) 13 (5%) 7 (3%) 4 (2%)
Table 4 Barriers to practice Reported barriers to practice Physician collaboration/supervision Inability to prescribe Schedule II drugs Inability to order diagnostic tests (CT, MRI, stress tests, etc.) Physicians’ lack of education and negative attitude re: APRNs Billing/insurance/reimbursement/credentialing issues Employer restrictions Inability to order home health/durable medical equipment Georgia Composite Board of Medicine APRN practice ownership/partnering hampered by protocol necessity
of medical professionals’ knowledge regarding the role of the APRN, ranked as fifth and sixth barriers. Other barriers identified were a lack of credentialing as a primary care provider by insurance companies, difficulty finding a collaborative physician, restrictions by the employing institutions, inability to initiate or maintain home health orders, difficulty in obtaining hospital or nursing home credentialing, underutilization in health department settings, and the inability to order durable medical equipment, including diabetic shoes, as well as, speech therapy. One respondent noted that by Federal law she was able to serve as an attending provider for hospice patients, but could not provide the needed opioid therapy for control of their pain or a bed for them to die in at home. Many listed unequal reimbursement policies, with APRNs receiving lower reimbursements for the same services provided by physicians, which resulted in financial challenges to the professional practices, including the prevention of the establishment of a nurse-managed practice. Most respondents (66%) stated that they were not able to fully utilize the APRN scope of practice that their educational programs prepared them to provide. When asked about familiarity with the Consensus Model for APRN 304
No: 283 (54%)
Regulation: Licensure, Accreditation, Certification & Education (APRN Consensus, 2008) that led to the development of a national APRN model for licensure (National Council of State Boards of Nursing [NCSBN], 2008), 57% of the respondents had no knowledge of the report. The report addresses many barriers to practice and delineated strategies to remove them through legislation and regulation.
Limitations of the study This study was limited by a response rate of 14.1%. The use of bulk mail to save mailing costs may have impinged on delivery as bulk mail can be delayed. First class mail might have yielded a higher postal delivery rate, as less than 30 postcards were returned for nondelivery, yet many APRNs known to the authors reported never receiving a postcard. While additional recruitment was solicited through various state websites, no follow-up mailings were conducted.
Discussion of the findings Many of Georgia’s APRNs have moved to embrace written prescribing, but a solid percentage appears caught between ambivalence and resistance. One APRN commented, “If I can’t have it the way I want it, then I don’t want any of it.” Many of the barriers noted in studies of other state’s APRN practice are also present in Georgia, such as strained relationships with physicians, restrictive policies, concerns regarding ordering scheduled drugs, and the expense of obtaining a DEA number. The surprising number of recent APRN graduates participating in the survey compared to those with much lengthier NP careers may herald a substantial shift in APRN demographics in the state. With only 29% of
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family nurse practitioners (FNPs) working in primary care, this does not bode well to support the growing underserved population in Georgia needing primary care services. Many APRN prescribers commented on the increased autonomy and efficiency of their practices, and their satisfaction with patient safety because of a “paper trail” with written prescribing. However, the increasing use of E-prescribing reported by APRNs working with electronic medical record (EMR) systems (involving a perprovider subscription averaging between $3000 and $9000 annually; HRSA, 2013) may be encouraging inertia in attaining a protocol agreement for written prescriptions because of growing healthcare practice cost constraints, which will further mask the impact of APRNs as independent prescribers. When APRNs enumerate barriers to practice, it is clear that frustration is present regarding the barriers that remain from multifactorial influences. There is a clear lack of awareness regarding a proposed licensure model that has significant implications for APRNs (Cassidy, 2012). Adoption into law of the 2012 APRN Model (found at https://www.ncsbn.org/4213.htm) by states without independent practice for APRNs would remove many identified barriers as well as address competency and credentialing matters. The survey data indicated that productivity and salary appear similar to national averages, and most APRNs feel they are practicing very independently, considering present policy limitations, and report high levels of job satisfaction. In considering stability of the current APRN population, more APRNs appear to be entering the provider pool than the number planning to leave.
Implications for APRNs The effect of barriers in Georgia and other states have significant effects on the delivery of quality health care to meet the needs of the population. In Georgia, maintaining a productive practice is increasingly difficult for APRNs feeling the burden of redundant and restrictive policies, thus many are choosing not to prescribe under the current 2006 written authority legislation. In February of 2011, a statewide call to attend a Georgia Nursing Summit to bring together multiple stakeholders in response to the 2010 IOM Report, Future of Nursing recommendations was extended (GA Nursing Leadership Coalition, 2011). The discussion centered around the IOM recommendation to remove scope of practice barriers, specifically addressing “unduly restrictive regulations . . . .and [to] allow advanced practice registered nurses to provide care to
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patients in all circumstances in which they are qualified to do so” (IOM, 2010, p. 2). The presence of two different laws under which APRNs may order or prescribe in Georgia results in unnecessary confusion, with both being needlessly restrictive (see Table 5). Apathy among Georgia APRNs is a factor in the lack of written prescribing activity. However, this could change as a new cadre of practitioners enters the practice arena who have not experienced the over 20 years of grinding opposition from the medical profession before the passage of the 2006 written authority legislation. The number of APRNs who are members of the state nursing organizations remains underrepresentative of the number of practicing APRNs in the state. Efforts are needed to inform all APRNs that a strong voice is needed in all states to effect legislative changes. There is a lack of supportive representation for advanced practice providers in the Georgia state legislature. Georgia currently has only two nurses as legislators, a registered nurse and a CRNA. A larger legislative voice representing APRN interests and an increase in lobbying activities supportive of the APRN perspective is critical in all legislative bodies. With only 22% of the survey respondents interested in a faculty position, unless successful recruitment efforts are utilized, the declining numbers of nursing faculty will continue to be a limiting factor in preparing sufficient APRNs to meet the needs of the state and the nation. A centralized technology communication format for APRNs in each state, without limitation to those within any particular organization, would improve discussions about policy and promote more grassroots participation in policy change within states. The IOM recommendation to build an infrastructure for collection and analysis of interprofessional healthcare workforce data has come at a critical juncture for Georgia and other states that have no central repository for healthcare workforce data. In states with joint regulation of some aspects of APRN practice, communication and shared data can be complicated. The existence of impediments to practice in effect block the ability of APRNs to provide quality holistic care (Cassidy, 2012). For example, in Georgia, there is no evidence to support regulation that prohibits APRNs to prescribe diabetic shoes, to order durable medical equipment, or to order a CT scan. There is no logic in allowing an APRN to be a federally designated provider to terminally ill patients, yet not permit them to order the opioids needed for a terminal patient’s pain control because APRNs are not allowed to write for Schedule II drugs. APRNs in Georgia are able to pronounce death, but they cannot order a hospital bed for a terminally ill patient. Legislators and the public
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Table 5 GA APRN prescribing legislation 1988 Ordering authority House Bill 209 (§ 43–34–23) Physician delegation Written protocol with MD kept in office Protocol under GA BON Phone in legend RX and Schedule II–V under MD name No DEA available Any radiographic tests may be ordered under MD name
at large need to be made aware that legislation and regulation that are not supported by evidence create barriers that diminish the ability to provide quality health care. Continued emphasis upon the evidence that APRNs provide superior and economical quality patient care, as well as the detrimental costs of practice restrictions, is essential. At this time there is a dearth of qualified providers in many areas across the nation, while a growing population of chronically ill patients has an inadequate number of providers (Cassidy, 2012; Keckley, Coughlin, & Korenda, 2011). Changes resulting from implementation of the ACA already point to a rapid escalation in the need for providers (NGA, 2012). APRNs need to systematically attack barriers that exist to their full scope of practice through cultivating personal relationships with their legislators, as well as exercising a unified voice through professional membership in organizations promoting legislative progress. A strategic eye, focused on achievable goals, taken singularly or en masse, can win this battle. Strategies are needed to remove the barriers. APRNs need to be active in developing and implementing policy that allows APRNs the unimpeded ability to deliver quality evidence-based care aimed at improving healthcare outcomes across the state and nation.
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2006 Written prescriptive authority Senate Bill 480 (§ 43–34–25) Physician delegation Protocol submission to Board of Medicine for approval May write for legend RX and Schedule III–V with own name DEA available No radiologic tests unless life-threatening circumstances
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Laurant, M., Hermens, R., Braspenning, J., Akkermans, R., Sibbald, B., & Grol, R. (2008). An overview of patients’ preference for, and satisfaction with, care by general practitioners and nurse practitioners. Journal of Clinical Nursing, 17(20), 2690–2698. doi:10.1111/j.1365-2702.2008.02288.x. Lugo, N., O’Grady, E., Hodnicki, D., & Hanson, C. (2007). Ranking state NP regulation: Practice environment and consumer healthcare choice. American Journal for Nurse Practitioners, 11(4), 8–24. Retrieved from http://www.eileenogrady.net/upload/Ranking%20of%20states%20AJNP April 07 [final].pdf Medical Association of Georgia (MAG). (2011). Policy compendium. Retrieved from http://www.mag.org/sites/default/files/downloads/HOD2012-policycompendium-final.pdf Medical Association of Georgia (MAG). (2013). Actions taken by the house of delegates. Retrieved from http://www.mag.org/sites/default/files/ downloads/HOD2013-final-actions.pdf Mundinger, M., Kane, R. Lenz, E., Totten, A., Tsai, W., Cleary, P., ..., Shelanski, M. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association, 283(1), 59–68. National Council of State Boards of Nursing (NCSBN). (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from https://www.ncsbn.org/Consensus Model for APRN Regulation July 2008.pdf National Governor’s Association (NGA). (2012) The role of nurse practitioners in meeting increasing demand for primary care. Retrieved from NGA Center for Best
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Practices at http://www.nga.org/cms/home/nga-center-for-bestpractices/center-publications/page-health-publications/col2-content/maincontent-list/the-role-of-nurse-practitioners.html Pearson, L. (2009). The Pearson Report. The annual state-by-state national overview of nurse practitioner legislation and healthcare issues. Retrieved from http://www.npwh.org/files/public/PEARSON.pdf Pearson, L. (2011). The Pearson Report: The annual state-by-state national overview of nurse practitioner legislation and healthcare issues. Retrieved from http://www.pearsonreport.com/ Safriet, B. (2011). Federal options for maximizing the value of advanced practice nurses in providing quality, cost-effective health care. In Institute of Medicine, the future of nursing: Leading change, advancing health (Appendix H). Retrieved from http://www.iom.edu//media/Files/ Activity%20Files/Workforce/Nursing/Federal%20Options%20for%20 Maximizing%20the%20Value%20of%20Advanced%20Practice%20Nurses. pdf Sargen, M., Hooker, R. S., & Cooper, R. A. (2011). Gaps in the supply of physicians, advanced practice nurses and physician assistants. Journal of American College of Surgeons, 212(6), 991–996. doi: 10.1016 U. S. Census Bureau. (2010). Retrieved from http://www.census.gov/ compendia/statab/2011/ranks/rank01.html Venning, P., Durie, A., Roland, M., Roberts, C., & Leese, B. (2000). Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. British Medical Journal, 320, 1053. doi: http://dx.doi.org/10.1136/bmj.320.7241.1048
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APRN prescribing in Georgia: An evolving environment Dellarie L. Shilling, DNP, FNP-BC (Assistant Professor) & Donna Hodnicki, PhD, FNP-BC, FAAN (Professor Emeritus) Georgia Southern University, Statesboro, Georgia
Keywords Nurse practitioners; prescribing; policy; scope of practice; advanced practice nurse (APN). Correspondence Dellarie L. Shilling, DNP, FNP-BC, Georgia Southern University, Statesboro, GA 30460. Tel: 912-531-2414; Fax: 912-478-0536; E-mail: [email protected] Received: 8 October 2013; accepted: 30 December 2013 doi: 10.1002/2327-6924.12203
Abstract Purpose: While it took over 20 years to achieve legal authority to write prescriptions in Georgia, effective July 1, 2006, nearly 40% of Georgia advanced practice registered nurses (APRNs) are still not using this method of prescribing. An investigation was conducted to identify the current practice environment and barriers to practice in order to identify causes for this lack of participation and implications for advanced practice nursing and the provision of health care. Data sources: A survey of APRNs in Georgia in 2011 describes demographics, practice environment, APRN education, barriers to practice, and prescribing activity. Conclusions: Georgia is one of the most restrictive states in terms of APRN scope of practice, and has an anticipated escalation of underserved population with health disparities demanding attention. Implications for practice: Many of the identified barriers are common to APRNs nationwide, but specific barriers to Georgia APRNs are being strategically addressed. Policy changes are recommended to enhance the practice environment of APRNs to support the delivery of quality care.
The battle to overcome barriers to advanced practice registered nurses’ (APRNs) scope of practice has been onerous, marked by one skirmish after another for decades in many states. While APRNs in 16 states and the District of Columbia have full independent scope of practice, Georgia remains a state with a restrictive environment (American Association of Nurse Practitioners [AANPs], 2013). Nationally, it has been recommended that barriers to APRN practice that impede patient access to care need to be removed (Brassard & Smolenski, 2011; Cassidy, 2012; Institute of Medicine [IOM], 2010; Lugo, O’Grady, Hodnicki, & Hanson, 2007). To remove the barriers, identification of the obstacles to APRN practice is essential to develop successful models of care delivery and policies to increase patient access to quality healthcare providers who can improve healthcare outcomes (IOM, 2010). The implications of a nationwide shortage of primary care providers (Health Resources and Services Administration [HRSA], 2011) will be expounded with implementation of the Affordable Care Act (ACA) in 2014 and the addition of over 30 million insured persons to the burdened care system (ACA, 2009). With the need for more primary care providers, there is a national push to fully utilize the 300
knowledge and skills that APRNs can provide (National Governor’s Association [NGA], 2012; Sargen, Hooker, & Cooper, 2011). Georgia is among the 27 states electing not to operate a state insurance exchange. In addition, Georgia along with other states has opted not to expand Medicaid coverage. These two actions are expected to result in an increase in the number of persons who are unable to obtain insurance yet will still be in need of health care. With the increase demand for providers, action is required to remove unnecessary barriers to APRN practice to avoid any compromise in the ability to provide quality patient care (IOM, 2010; Safriet, 2011). In the state of Georgia, barriers to APRN practice are a continuing issue of concern. A 2007 study (Lugo, O’Grady, Hodnicki, & Hanson, 2007) that investigated each state’s APRN regulatory environment for nurse practitioners (NPs) placed Georgia at 48 of 51 states. This ranking earned a grade of “F” as one of the most restrictive states in the country because of the limitations placed on APRN scope of practice that affects patients’ freedom to choose providers and the APRN’s ability to provide advanced nursing care (Lugo et al., 2007). The Georgia restrictions have been noted since 1989 in The Pearson Journal of the American Association of Nurse Practitioners 27 (2015) 300–307 C 2014 American Association of Nurse Practitioners
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Report, an annual descriptive, detailed compendium of state rules and regulations affecting APRN practice (Pearson, 2009, 2011). APRNs in Georgia are accustomed to vigorous organized opposition, primarily via the Medical Association of Georgia (MAG, 2011), resulting in slow progression toward a less-restrictive practice environment. The MAG annual policy compendiums routinely include opposition to any expansion of APRN practice including the addition of Schedule II to prescribing (DEA, 2013; MAG, 2013), which places a barrier to the care of patient in labor and the treatment of patients with attention-deficit disease. In addition, the insistence on “supervisory” language, as opposed to “collaborative” practice has been an ongoing issue (MAG, 2013). Federal statistics also underline the need to support fully participatory and unrestricted APRN practice to meet the needs of the state population. The U.S. Census Bureau (2010) ranked Georgia ninth in the nation for cumulative population increase. The state is highest among national regions designated with underserved populations (HRSA, 2011) while ranking 10th in the nation for lack of primary care providers (Advisory Board, 2012; Georgia Senate, 2007). With ample research supporting the value and effectiveness of APRN care and outcomes (Bauer, 2010; Brown & Grimes, 1995; Horrocks, Anderson, & Salisbury, 2002; Laurant et al., 2008; Lugo et al., 2007; Mundinger et al., 2000; Venning, Durie, Roland, Roberts, & Leese, 2000), the nature of the economic emergency in Georgia makes removal of scope of practice barriers imperative to meeting the continuing and increasing healthcare needs of its citizens. A description of the evolving environment of APRN prescribing practice and the barriers to care that inhibit advanced practice nursing care highlight the changes that are needed. More efficient and productive use of APRNs is imperative in order to provide quality health care to an increasing population with diverse needs.
APRN medication legislation Up until recently, the Georgia Board of Nursing (GBON) recognized NPs, certified nurse midwives (CNMs), psychiatric mental health clinical nurse specialists (PMHCNSs), and certified registered nurse anesthetists (CRNAs) as APRNs. Approximately 2 years ago, the APRN definition was amended to include clinical nurse specialists who meet specific criteria. APRNs in Georgia may use one of two legislative options to provide medications for patients; however, they may not use both options concurrently with a collaborating physician.
1988 Legislation The 1988 APRN legislation, Delegation of Authority to Nurse or Physician Assistant (OCGA § 43–34–23, 2010), is overseen by the GBON for APRNs. Through physician delegation the APRN may assess a patient, determine the medication needed, and write the order in a chart. Under the physician’s name, the APRN can phone in orders for legend drugs and Schedule II–V drugs and order radiologic tests. No Drug Enforcement Association (DEA) is required. All written prescriptions or diagnostic orders require a physician signature. A 2002 study (Hodnicki, Dietz, McNeil, & Miles, 2004) investigated APRN prescribing under this law. Data were gathered on every patient encounter and medications ordered by 79 APRNs (68 NPs, 10 CNM, and 1 PMHCNS) for 1 week between November and December of 2002. The findings indicated that a total of 7999 medications were ordered for 3776 patient encounters. When the NPs determined a consultation on a drug order was needed, only three of every 1000 (0.003%) orders were changed by the delegating physician. The study findings supported discussions with legislators, physicians, and consumers on the safety of APRN medication ordering and identified multiple hindrances to patient care that occurred as a result of APRNs having no written prescriptive authority.
2006 Legislation With legislation effective July 1, 2006, Georgia APRNs began written prescriptive authority for legend drugs and Schedule III–V drugs under an agreement with a delegating physician (Delegation of Authority to Nurse or Physician Assistant, OCGA § 43–34–25, 2010; referred to as 2006 written authority in this article). The CRNAs, by choice, opted out of the 2006 legislation but supported all efforts for passage. With this legislation Georgia became the last state in the country to provide written prescriptive authority for APRNs. Prior to this 2006 legislation, all aspects of APRN practice were totally under the GBON. To pass the 2006 legislation, APRNs had to agree that the Georgia Composite Board of Medicine (GCBOM) would have a role in writing the rules and regulations for written prescriptive authority. Through physician delegation, APRNs may sign for legend and Schedule III–V drugs under their own name. A protocol must be submitted for approval to the GCBOM by the delegating physician. The fee for protocol submission was initially $50, but has steadily increased to a current rate of $150, which must be paid with every new physician protocol submitted. A DEA number is required for scheduled drugs. The 2006 law states that radiologic tests may be ordered only in life-threatening circumstances. The names 301
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of all APRNs with approved protocols are listed on the GCBOM website. Over the years some of the more restrictive GCBOM rules and regulations for the 2006 legislation have been modified as a result of input from the APRN community.
Need for the study With passage of the 2006 written authority it was assumed that a significant number of APRNs would submit protocols. In 2011, 5 years after the 2006 legislation, barely one third of APRNs in Georgia were approved for written prescriptive authority per the GCBOM website. While the GBON had 4582 NPs, 425 CNMs, and 292 CNSPMHs licensed as APRNs (5299 total; GBON, 2011), the GCBOM had 2072 approved protocol agreements listed on their website (GCBOM, 2011). With such a lack of approved protocols and no studies of prescribing trends after the 2006 written authority, it was determined that an investigation was needed to identify the current APRN prescribing practice environment in the state, especially related to how medication prescriptions were provided for patients.
Purpose of the study The first author completed this study to determine the factors contributing to a lack of participation under the 2006 written authority legislation. In addition, the lack of studies describing the current environment of APRN practice in Georgia indicated a need for investigation of APRN demographics, barriers, and concerns. The overall goal of the study was to identify where policy changes would be most beneficial to remove barriers to APRN practice to meet the increasing healthcare needs of the state. There were four questions guiding the study. What are demographics of the APRN population in Georgia? What descriptors identify APRN practice? What prescribing methods are used in APRN practice? What barriers do APRNs identify to their scope of practice?
Methodology This descriptive study utilized a survey instrument approach to collect data from the Georgia APRN population. The instrument was adapted from a survey tool developed by Kaplan and Brown for research conducted with Washington state’s APRNs in 2004 and 2006 (Kaplan & Brown). With authors’ permission, the Washington tool was modified and validated for use in the Georgia study. The Georgia tool with 58 items collected data on demographics, education, certification, practice environment, prescribing activity, perceived barriers to practice, retirement plans, and professional organizational 302
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activity. The Georgia tool was pilot tested and peer reviewed by five practicing APRNs in the state. Upon receipt of Human Subjects Protection approval from the university affiliate, a postcard detailing the aim of the study, along with the link to access the survey on SurveyMonkey was bulk-mailed to each of the 4358 APRNs listed on the purchased 2011 GBON registry list. In addition, e-mail announcements and postings regarding the study were placed on professional websites frequented by Georgia APRNs. APRNs were directed to access the survey online via SurveyMonkey. Surveys were collected from July to September of 2011. The survey was targeted to NPs, CNMs, and PMHCNSs as they were approved for medication ordering under the 2006 written authority legislation. While extended data were obtained, this article will report on APRNs who provide care in any clinical practice setting.
Analysis of data A total of 4358 postcards were mailed in spring 2011 to GA APRNs. A total of 617 surveys were returned for a response rate of 14.1%. Data from 14 students and 62 APRNs in administrative or teaching positions who were not in clinical practice were deleted. While a total of 541 surveys from NPs and CNMs were analyzed, there were some incomplete responses to items that resulted in number (n) variations.
Demographics Analysis of respondent zip codes indicated that all regions of the state were represented. The majority of APRNs were female (92%), educated within a graduate nursing program (82%), or postmaster’s certificate program (18%). Certification was identified as family (61%), adult (14%), pediatric (10%), women’s health (9%), or nurse midwifery (7%). The majority of respondents (47%) reported 6–15 years of experience, followed by those reporting 1–5 years of experience (32%; see Table 1). Dual APRN licensure in another state was held by 13% of those surveyed with 7% providing patient care services in other states, primarily those bordering Georgia (SC, TN, AL). Many were members of professional organizations such as the American Academy of NPs (52%), United APRNs of Georgia (39%), American Nurses Association (34%), and the Georgia Nurses Association (28%).
Practice environments The majority (72%) worked in urban areas and most were employed either in private practice (28%) or in a hospital setting (24%). Respondents identified
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Table 1 GA APRN demographics Gender Female Male APRN Education Program Certificate (post and non-Master’s) Master’s degree DNP degree Doctorally prepared (non-DNP) Area of certification Family Adult Pediatric Women’s health Nurse midwives Years experience as APRN (n = 538) 1–5 6–15 16–26 27+
495 (92%) 41 (8%) 95 (18%) 438 (82%) 2 (0.4%) 43 (5%) 317 (61%) 70 (14%) 51 (10%) 46 (9%) 34 (7%) 172 (32%) 255 (47%) 78 (14%) 33 (6%)
employment in a wide variety of specialty practice areas (see Table 2). While most (56%) provided some acute care in the hospital, 38% did not provide any care in the hospital setting.
ciated with obtaining prescriptive authority was cited by 15% (see Table 3). A DEA number is not needed to write for legend drugs. While 281 APRNs acknowledged using the 2006 written authority, only 234 had registered for a personal DEA number (83%). The APRNs who are limiting their medication prescribing to legend drugs only identified several reasons for not applying for a DEA number. Most (46%) reported a physician or other provider writing their prescriptions for controlled drugs. Some (29%) reported practicing without the use of controlled substances. The 25% who did not want to write for controlled substances (III–IV) indicated that they were ambivalent about prescribing them (24%); they lacked the expertise to prescribe them (13%); they were concerned about their ability to deal with patients exhibiting drug-seeking behaviors (11%); or they were concerned about the potential for disciplinary action by regulators (11%). In contrast, those prescribing Schedule III–V medications indicated that they did not feel that they were prescribing any more scheduled drugs than they were prior to the 2006 written authority (91%) and felt moderately to extremely well prepared by their APRN education to prescribe scheduled drugs (63%).
Perceived barriers to practice Prescribing option used The 2006 written authority legislation was not being used by 46% of the respondents. When asked to rank reasons for not applying for written prescriptive authority, 53% cited that they used the 1988 ordering authority that permits a designated nurse to order medications and treatments under the physician’s name. In this group, 25% have a physician write or sign all of their prescriptions. Other reasons for nonuse of the 2006 written authority included employer-created barriers (15%) and practicing in a Federal or Public Health agency under a separate protocol (17%). Limited time or money to cover costs asso-
Table 2 GA APRN specialty practice areas GA APRN top 10 specialty practice areas OBGYN Pediatrics Internal medicine ER/trauma Oncology (breast, pediatric, orthopedic) Cardiology Psych/mental health Geriatrics ICU/CCU Neurodevelopmental pediatrics
Using an open-ended response, respondents identified the major barriers that impede their ability to provide care in Georgia using the full scope of their APRN education (see Table 4). The most frequently cited barrier was related to physician collaboration and supervision. The respondents cited issues with the onerous requirement to review charts, the cumbersome nature of collaborative agreements, and the multistep process to obtain them. In addition, they cited the need for joint supervision by the GCBOM and the BON, and difficulty being accepted as caregivers by a consulting physician. Also noted were the domineering attitudes of physicians in protecting their perceived domain and a generally negative attitude toward APRNs. The second barrier is the inability to prescribe Schedule II medications to patients suffering from attention-deficit disorder. The third barrier is the inability to order diagnostic testing (CT, MRI, and stress tests being specifically identified) unless it is a life-threatening situation. One respondent commented that this testing barrier compromised her ability to get prompt access to reports on patients she had treated, and others mentioned that failing to identify the APRN as the provider on the report caused delays in obtaining the reports for treatment purposes. The fourth barrier is resistance from physicians, specifically via the MAG to remove barriers to practice. Billing and reimbursement issues, followed by the lack 303
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Table 3 GA APRN prescribing activity Personal DEA number I pay for Facility pays
Yes: 234 (44%) 43 (8%) 150 (28%)
Number of Schedule III–V written/week 1–15 16–30 31–60 61+ More III–IV written under own signature No A little more Somewhat more Moderate/great deal more
191 (64%) 60 (20%) 26 (9%) 24 (8%)
In process of applying Other provider writes Practice without Do not want to write for Use institutional number Too expensive
52 (19%) 128 (46%) 80 (29%) 69 (25%) 16 (6%) 42 (15%)
254 (91%) 13 (5%) 7 (3%) 4 (2%)
Table 4 Barriers to practice Reported barriers to practice Physician collaboration/supervision Inability to prescribe Schedule II drugs Inability to order diagnostic tests (CT, MRI, stress tests, etc.) Physicians’ lack of education and negative attitude re: APRNs Billing/insurance/reimbursement/credentialing issues Employer restrictions Inability to order home health/durable medical equipment Georgia Composite Board of Medicine APRN practice ownership/partnering hampered by protocol necessity
of medical professionals’ knowledge regarding the role of the APRN, ranked as fifth and sixth barriers. Other barriers identified were a lack of credentialing as a primary care provider by insurance companies, difficulty finding a collaborative physician, restrictions by the employing institutions, inability to initiate or maintain home health orders, difficulty in obtaining hospital or nursing home credentialing, underutilization in health department settings, and the inability to order durable medical equipment, including diabetic shoes, as well as, speech therapy. One respondent noted that by Federal law she was able to serve as an attending provider for hospice patients, but could not provide the needed opioid therapy for control of their pain or a bed for them to die in at home. Many listed unequal reimbursement policies, with APRNs receiving lower reimbursements for the same services provided by physicians, which resulted in financial challenges to the professional practices, including the prevention of the establishment of a nurse-managed practice. Most respondents (66%) stated that they were not able to fully utilize the APRN scope of practice that their educational programs prepared them to provide. When asked about familiarity with the Consensus Model for APRN 304
No: 283 (54%)
Regulation: Licensure, Accreditation, Certification & Education (APRN Consensus, 2008) that led to the development of a national APRN model for licensure (National Council of State Boards of Nursing [NCSBN], 2008), 57% of the respondents had no knowledge of the report. The report addresses many barriers to practice and delineated strategies to remove them through legislation and regulation.
Limitations of the study This study was limited by a response rate of 14.1%. The use of bulk mail to save mailing costs may have impinged on delivery as bulk mail can be delayed. First class mail might have yielded a higher postal delivery rate, as less than 30 postcards were returned for nondelivery, yet many APRNs known to the authors reported never receiving a postcard. While additional recruitment was solicited through various state websites, no follow-up mailings were conducted.
Discussion of the findings Many of Georgia’s APRNs have moved to embrace written prescribing, but a solid percentage appears caught between ambivalence and resistance. One APRN commented, “If I can’t have it the way I want it, then I don’t want any of it.” Many of the barriers noted in studies of other state’s APRN practice are also present in Georgia, such as strained relationships with physicians, restrictive policies, concerns regarding ordering scheduled drugs, and the expense of obtaining a DEA number. The surprising number of recent APRN graduates participating in the survey compared to those with much lengthier NP careers may herald a substantial shift in APRN demographics in the state. With only 29% of
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family nurse practitioners (FNPs) working in primary care, this does not bode well to support the growing underserved population in Georgia needing primary care services. Many APRN prescribers commented on the increased autonomy and efficiency of their practices, and their satisfaction with patient safety because of a “paper trail” with written prescribing. However, the increasing use of E-prescribing reported by APRNs working with electronic medical record (EMR) systems (involving a perprovider subscription averaging between $3000 and $9000 annually; HRSA, 2013) may be encouraging inertia in attaining a protocol agreement for written prescriptions because of growing healthcare practice cost constraints, which will further mask the impact of APRNs as independent prescribers. When APRNs enumerate barriers to practice, it is clear that frustration is present regarding the barriers that remain from multifactorial influences. There is a clear lack of awareness regarding a proposed licensure model that has significant implications for APRNs (Cassidy, 2012). Adoption into law of the 2012 APRN Model (found at https://www.ncsbn.org/4213.htm) by states without independent practice for APRNs would remove many identified barriers as well as address competency and credentialing matters. The survey data indicated that productivity and salary appear similar to national averages, and most APRNs feel they are practicing very independently, considering present policy limitations, and report high levels of job satisfaction. In considering stability of the current APRN population, more APRNs appear to be entering the provider pool than the number planning to leave.
Implications for APRNs The effect of barriers in Georgia and other states have significant effects on the delivery of quality health care to meet the needs of the population. In Georgia, maintaining a productive practice is increasingly difficult for APRNs feeling the burden of redundant and restrictive policies, thus many are choosing not to prescribe under the current 2006 written authority legislation. In February of 2011, a statewide call to attend a Georgia Nursing Summit to bring together multiple stakeholders in response to the 2010 IOM Report, Future of Nursing recommendations was extended (GA Nursing Leadership Coalition, 2011). The discussion centered around the IOM recommendation to remove scope of practice barriers, specifically addressing “unduly restrictive regulations . . . .and [to] allow advanced practice registered nurses to provide care to
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patients in all circumstances in which they are qualified to do so” (IOM, 2010, p. 2). The presence of two different laws under which APRNs may order or prescribe in Georgia results in unnecessary confusion, with both being needlessly restrictive (see Table 5). Apathy among Georgia APRNs is a factor in the lack of written prescribing activity. However, this could change as a new cadre of practitioners enters the practice arena who have not experienced the over 20 years of grinding opposition from the medical profession before the passage of the 2006 written authority legislation. The number of APRNs who are members of the state nursing organizations remains underrepresentative of the number of practicing APRNs in the state. Efforts are needed to inform all APRNs that a strong voice is needed in all states to effect legislative changes. There is a lack of supportive representation for advanced practice providers in the Georgia state legislature. Georgia currently has only two nurses as legislators, a registered nurse and a CRNA. A larger legislative voice representing APRN interests and an increase in lobbying activities supportive of the APRN perspective is critical in all legislative bodies. With only 22% of the survey respondents interested in a faculty position, unless successful recruitment efforts are utilized, the declining numbers of nursing faculty will continue to be a limiting factor in preparing sufficient APRNs to meet the needs of the state and the nation. A centralized technology communication format for APRNs in each state, without limitation to those within any particular organization, would improve discussions about policy and promote more grassroots participation in policy change within states. The IOM recommendation to build an infrastructure for collection and analysis of interprofessional healthcare workforce data has come at a critical juncture for Georgia and other states that have no central repository for healthcare workforce data. In states with joint regulation of some aspects of APRN practice, communication and shared data can be complicated. The existence of impediments to practice in effect block the ability of APRNs to provide quality holistic care (Cassidy, 2012). For example, in Georgia, there is no evidence to support regulation that prohibits APRNs to prescribe diabetic shoes, to order durable medical equipment, or to order a CT scan. There is no logic in allowing an APRN to be a federally designated provider to terminally ill patients, yet not permit them to order the opioids needed for a terminal patient’s pain control because APRNs are not allowed to write for Schedule II drugs. APRNs in Georgia are able to pronounce death, but they cannot order a hospital bed for a terminally ill patient. Legislators and the public
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Table 5 GA APRN prescribing legislation 1988 Ordering authority House Bill 209 (§ 43–34–23) Physician delegation Written protocol with MD kept in office Protocol under GA BON Phone in legend RX and Schedule II–V under MD name No DEA available Any radiographic tests may be ordered under MD name
at large need to be made aware that legislation and regulation that are not supported by evidence create barriers that diminish the ability to provide quality health care. Continued emphasis upon the evidence that APRNs provide superior and economical quality patient care, as well as the detrimental costs of practice restrictions, is essential. At this time there is a dearth of qualified providers in many areas across the nation, while a growing population of chronically ill patients has an inadequate number of providers (Cassidy, 2012; Keckley, Coughlin, & Korenda, 2011). Changes resulting from implementation of the ACA already point to a rapid escalation in the need for providers (NGA, 2012). APRNs need to systematically attack barriers that exist to their full scope of practice through cultivating personal relationships with their legislators, as well as exercising a unified voice through professional membership in organizations promoting legislative progress. A strategic eye, focused on achievable goals, taken singularly or en masse, can win this battle. Strategies are needed to remove the barriers. APRNs need to be active in developing and implementing policy that allows APRNs the unimpeded ability to deliver quality evidence-based care aimed at improving healthcare outcomes across the state and nation.
References Advisory Board Company. (2012). The 10 states facing the biggest physician shortages [Today’s Daily Briefing]. Retrieved from http://www.advisory.com/DailyBriefing/2012/10/22/The-10-states-facing-the-biggest-physician-shortages American Association of Nurse Practitioners (AANPs). (2013). 2013 Nurse practitioner state practice environment. Retrieved from http://www.aanp. org/images/documents/state-leg-reg/stateregulatorymap.pdf APRN Consensus Work Group & NCSBN APRN Advisory Committee. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification and education. Retrieved from http://www.aacn.nche.edu/education-resources/ APRNReport.pdf Bauer, J. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners, 22(4), 228–231. doi: 10.1111/j.1745–7599.2010.00498.x Brassard, A., & Smolenski, M. (2011). Removing barriers to advanced practice registered nurse care: Hospital privledges. Washington, DC: AARP Public Policy Institute.
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2006 Written prescriptive authority Senate Bill 480 (§ 43–34–25) Physician delegation Protocol submission to Board of Medicine for approval May write for legend RX and Schedule III–V with own name DEA available No radiologic tests unless life-threatening circumstances
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