NP and physician collaboration, or supervision statutory requirements, has turned into a way for medical boards to increase barriers to NP practice. While the current regulations and statutes related to collaboration present barriers to practice, new efforts by medical boards to inject additional restrictions are placing further burdens on NPs and healthcare delivery in general.
Collaboration restrictions
Boards of medicine in Alabama and Arkansas have taken action to impose further restrictions on collaborative agreements; California is also considering such rules. The Alabama Board of Medical Examiners has taken action by passing emergency rules to assess an annual fee paid to physicians for each collaborative practice agreement. In California, discussions are taking place to tighten regulations on physician/NP collaboration.1
An article in the Arkansas Democrat Gazette2 reported that the Arkansas State Medical Board was working on rules to further define the physician's role in collaborative agreements. While these rules have been finalized by the medical board, they have not been approved by the legislature. Arkansas NPs have strenuously objected to the new rules, and legislators are seeking a compromise between the two groups before approving the new regulations.
On a positive note, the Kentucky Board of Medical Licensure (KBML) was forced to withdraw their Guidelines for Physician/ARNP Collaborative Agreements last fall, following objections from the Legislative Administrative Regulatory Review Subcommittee. The KBML guidelines, first published in 1997, imposed restrictions on ARNP practice beyond those in statute or regulation. The KBML guidelines were opposed by the Kentucky Board of Nursing (KBN) and the Kentucky Coalition of Nurse Practitioners and Nurse Midwives (KCNPNM) on the grounds that KBN had sole regulatory authority over ARNPs and KBML did not have authority to place additional limitations on ARNP practice. In 2008, the Legislative Administrative Regulatory Review Subcommittee agreed with KBN and KCNPNM. Now, KBML has published a 12-page opinion on physician/ARNP collaboration, and while it is a bit intimidating because of its length, it clearly states it is an opinion of the board and does not have the force and effect of the law.
Taking action
In response to increased efforts by medical associations and boards of medicine to impose greater control and restrictions on advanced nursing practice, some NP organizations are meeting these challenges head-on. Rather than seeking compromise, NP organizations are gearing up legislative efforts to eliminate the requirement for mandatory collaborative agreements. For example, the Vermont Nurse Practitioner Association's efforts to eliminate the requirement for a collaborative practice agreement have succeeded.
The Vermont Board of Nursing is in the process of writing new regulations that will no longer require NPs to have a collaborative practice agreement. Arkansas, Illinois, and New York are also challenging the required collaborative agreements. (The New York Nurse Practitioner Association has an aggressive 2009 legislative agenda available at http://www.thenpa.org/displaycommon.cfm?an=1&subarticlenbr=271.)
Since its inception in the 1960s, the NP profession has been steadily evolving. However, it is becoming clear that right now, the profession is in a period of accelerated change. According to the 2009 Legislative Update in The Nurse Practitioner,1 23 states and the District of Columbia grant NPs autonomous practice. Of those, 14 also have independent prescribing. Over the next few years, other states are sure to add to these numbers.
If NPs want to provide access to care in accordance with their education and scope of practice and they think that the recent actions to restrict NP practice by organized medicine are unreasonable and self-serving, then the only reasonable recourse is to seek full autonomy as a profession.
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