Presenter Lisa Emrich, MSN, RN, FRE, Program Manager, Practice, Education and Administration, Ohio Board of Nursing

2017 NCSBN APRN Roundtable - Staying in Your Lane APRN Alignment of Practice with Education and Certification in a Role and Population Video Transcript 2017 National Council of State Boards of Nursing, Inc. Event 2017 NCSBN APRN Roundtable More info: https://www.ncsbn.org/9921.htm Presenter Lisa Emrich, MSN, RN, FRE, Program Manager, Practice, Education and Administration, Ohio Board of Nursing - [Lisa] Yeah, this is not necessarily a story about Ohio's highway system, but we do want to give you sort of the story of where Ohio has been within actually the last...especially several months with respect to responding to questions regarding especially acute care versus primary care certified nurse practitioners. So first, just a very brief history. APRNs, as we know them today, got this statutory authority back in 1996. Just prior to 1996, there was a temporary law that established a pilot program for APRNs, okay, and then that temporary law went away and then we have the current law that authorizes APRNs as certified nurse practitioners, clinical nurse specialists, certified nurse midwives, and, of course, CRNAs. CRNAs continue, as they had prior, to practice under supervision. They do not have prescriptive authority. The CNSs, CNPs, and CNMs all got prescriptive authority in about 2000. So then, CRNAs, why do they not have prescriptive authority? Well, within their practice, again, they are under supervision of a physician, or dentist, or a podiatrist, and the latter two they have to practice consistent with that, but they cannot exceed those certain practices. CRNAs do not need prescriptive authority to select and themselves administer the drugs that they need to provide the anesthesia care they are authorized to provide. This came into question probably about eight to nine years ago and we had to provide some clarifying information to CRNAs about their inability to issue a prescription or order another health care provider to administer a drug for them. This did result in an Attorney General opinion that reinforced the statute. Okay. Now, with respect to the law that... the Scope of Practice for certified nurse practitioners, this has been in effect since 1996 and a nurse practitioner is a nurse authorized to practice in collaboration with one or more physicians or podiatrist and may provide preventive and primary care services, provide services for acute illnesses, and evaluate and promote patient wellness within the nurse's nursing specialty, importantly here, consistent with the nurse's education and certification. Of course, emphasis was added. There are circumstances for their practice as well. A CNP must enter into a standard care arrangement with one or more collaborating physicians or podiatrists, okay? The standard care arrangement being, what we call in Ohio, their practice agreement. It's a statement of services that the CNP may provide, it discusses when consultations are to be obtained, when referrals are to be obtained. The latter part of this is very significant with respect to the CNP's practice, and that is, each collaborating physician or podiatrist must be actively engaged in direct clinical 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 1

practice in Ohio and is practicing in a specialty that is the same or similar as the nurse's nursing specialty. Okay? So it all has to align with the nurse's specialty. So what are we talking about when we talk about alignment? We're talking about the registered nurse completes an accredited formal graduate nursing program, and it provides them with the theoretical and clinical preparation for their CNP chosen practice. Okay? So, ahead of time you know what area of practice you want to go into, you choose an appropriate graduate program, you complete that. It's maybe a master's, or a doctorate, or a postgraduate certificate, regardless, it prepares you for that certain specialty. You pass the national certification examination. This is the examination that validates what was learned in that educational experience, and importantly, I should say, it psychometrically validates what was learned within that educational experience. Once the individual is then certified, has her certificate of authority to practice, they then identify a physician who is qualified to be their collaborating physician. Again, a physician whose practice is the same or similar to that of the nurse practitioner's practice. Okay? So alignment, in the most straight and narrow form, this is what we're talking about. Graduate program for family CNP. Individual goes to that and completes the program. They pass a CNP national certification in family, family practice. They then collaborate with a physician whose practice is family practice. Again, this is the most aligned or linear of when we're talking about alignment of practice with their education and certification. Similarly, we have a graduate program that prepares individuals to be psych-mental health CNPs. They then are qualified, too, and they pass their national certification and examination in psychmental health, and then after that, they collaborate with a physician whose practice is the same or similar to their education and certification, which is a physician who has a practice in psych and mental health. Again, the most linear of alignments that you could have with this type of education and with certification. Factors that do not necessarily affect alignment is the location, site, or type of facility where the CNP is located. That is not a factor. We do not regulate places of practice. So we don't say a nurse practitioner may not work in a hospital, we don't tell nurse practitioners they cannot work in longterm care, it's not about the location. It is about the patient, the patient's age, the condition to be managed or stabilized, and the patient's needs. What is that particular nurse practitioner educated and prepared to evaluate, diagnose, and manage, okay, within that particular patient? Those absolutely are the factors. And these should sound familiar. Yes? No? Yes, because it's the APRN Consensus Model. Okay. The APRN Consensus Model says that education, certification, and licensure of an individual must be congruent in terms of role and population foci and the services or care provided by APRNs is not defined or limited by setting, but rather by the patient care needs. Okay? So this is all consistent. However, we have continued over the years to get questions about what lane am I in, or am I changing lanes, or what do I need to do, can I do this or not do that? So I'm going to provide you with three examples of some, I'll call them reconstituted questions that we've received, some of them fairly recently, and let you determine whether or not these are in the right lane or not. Okay? Is this lane drift? So we have an adult certified CNP. They decided to sub-specialize in cardiology because, as a registered nurse, they had over 15 years, probably as even a CCRN, in an ICU, okay? Collaborating physician is obviously in a cardiology practice. The nurse practitioner evaluates adult patients in the clinic. They round in the step-down unit for inpatients, they give them their discharge instructions, write their discharge medications, and additionally, on the side and as an extra practice, they're covering for the group one night a week in the CCU where they manage patients with acute MI, determine the needs for thrombolytics, thrombolytic administration, inserts temporary pacemakers, Swan-Ganz, but they assert the collaborating physician is available to them telephonically. So I'll let you all decide if that's an issue or not. It's an issue. Okay. Another one. We have a psych-mental health CNP. Collaborating physician is a pediatrician. The CNP practices within the physician's office, and I will say this is an employment situation, okay? And the CNP evaluates and manages children with ADHD, ADD, and some more 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 2

milder forms of autism. They provide diagnoses, they prescribe Schedule IIs and other medications that are diagnosis-appropriate. Issues with this? Yes, no? Pediatricians, can their practice be ADD, ADHD, so forth so... So just I'm letting you decide. I have no yes or no at this point, so. Very good. Okay. Another one, this is my third one. So we have an adult certified nurse practitioner. They're employed by and practice within the hospital emergency department. Collaborating physician is an emergency department physician. The CNP sees and evaluates patients within the emergency department. Some patients are seen independently by the nurse practitioner, some are in conjunction with the emergency department physician, but the CNP is now seeking to independently evaluate and treat children because it's okay because the physician later signs off on the prescriptions that are issued by the nurse practitioner and signs off on the chart. No? Okay, I'll let you all be deciders. Okay. So then, I want to also share with you some actual questions or comments we have received from employers, okay? Employers are very significant in Ohio and a number of CNPs are actually employed rather than having their own practices per se. So employers are very... write to us quite a bit. So is it acute care experiences as an RN? Is it acceptable for CNP to count their acute care experience as an RN in lieu of acute care education and certification? - [Audience] No. - No. Okay. Gee, they got 15 years, they were CCRN, they managed the ICU. Okay, very good. Okay, other employer questions. Would it be acceptable for our hospital to provide education and competency checks for APRNs to practice as we need, or is acute care certification required by the board? This has been a significant question over the last several months. Employers want a generalist that they actually educate to do what they need them to do within their hospitals, so. - [Woman] What do they define as acute? - We'll get to that, so yeah. This is just the baseline question at this point, so. Okay? Then this comment from an actual CNP, who is within the emergency department. The urgent types of patients seen on any given day in the emergency department vary from a sprained ankle to a pulmonary embolism. My management would be the same in an office as it is in the emergency department, which is to stabilize and admit to the appropriate physician for further work up and care. Okay? Is that...okay, did they manage to treat pulmonary emboli? If a patient is having respiratory distress, do they go to an office or they go to the emergency department? Okay, okay, okay, I'm just...so. For discussion's sake, very good. So how do we, as a board, respond to these various questions? Okay. It's important that we keep the same message out there. We have consistent responses over the years. Remember, these scopes of practices and this requirement for a standard care arrangement, and the requirement that they have a collaborating physician whose practice is the same or similar to their specialty, it's been in the books since 1996. Okay. So we have been very consistent in the responses over the years. We've published an APRN decision model to help with especially new APRNs and helping them to define their practice and the procedures and different things. We also point them into the direction of the APRN Consensus Model as it is now. We also have referred persons to past responses we have sent. So when they tell us, "This is a new interpretation, you're interpreting differently now." No, this is the same response as we sent several years ago. Here it is, we've done that. Then, in the fall, this past fall, because of the types of questions that we were receiving, we felt it very important to provide some greater written clarity to APRNs. What Maureen was describing as the opinion, it was really an article that we published in our newsletter Momentum Magazine, and it was differentiating, discussing primary versus acute care practice, and the certifications, and the requirements for that. Okay. You actually have a copy of that article within your information, so if you'd like to see that. Importantly about the article is that it did differentiate the preparation and the test validation. It talked about that the actual physical location of where the practice was occurring was not the factor, it was really about the patient's needs, okay? And then the patient's...obviously, the patient's care and condition, they're paramount. So what I would love to tell you is that after that Momentum article was published, that we received accolades or maybe a, "Thank you, this really clarifies things for 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 3

me," or even no acknowledgement would have been fine because at least we would known it had been read. But the responses we've received, these are some of the words and descriptors taken from either communications we received, or communications about us, or other things. We were told that it negatively impacts our practice, the word "consternation" has been used, that it was inflammatory, and we have also told it delegitimized practice. Regardless, we, as a board, are authorized to enforce the statutory requirements which are consistent with the APRN Consensus Model. We want safe care for the patients in Ohio, we also want the alignment of practice with appropriate education and certification. Certification, again, psychometrically validates all that was learned in the graduate program schools. So what conclusions can we draw? Well, from the reaction that we received, we have to know that it's more of an issue than we actually even thought out there. You know, we always start with trying to provide written clarification. If it's in a one-to-one email, we've always done that. So we've taken even a greater step in providing more public information to a wider range of persons through the article. And again, it created some unusual comments. So we have no conclusion at this point about what's happening or to what extent. However, we're led to some different conclusions, these are possible conclusions. One is that nurse practitioners, they do not review or understand the statutory requirement. You know, we get that. I cannot tell you that persons who are out there practicing every day and who are trying to do the best they possibly can do for their patients, we understand that that's probably maybe what's happening. Do you always pick up the statutory book and look at it? No. It's not in an everyday worldview. It is a responsibility, though. It's very much a professional responsibility to know the statutes and the rules that govern practice in your particular state, okay? But this is one possibility. Ignorance of the statute or not fully understanding the statute requirements and limitations. Another is that the CNP may have began their career path thinking, "I'm going to go into this specialty," and then after they get out of their program, they'd see this really good job opportunity over here that's in a different specialty and so they're looking to jump over for a shortcut. Again, I appreciate and know that, you know, education is lengthy and time-consuming, but it is obviously there for a purpose as well. But yes, this is one possibility, too. Another is hospital systems see CNPs as generalists and believe that they can credential them and mold them into the individual that they need to cover for their circumstances. So this is another possibility, and in fact, this is a question we've received, again, like I said before, quite a bit. Okay. And then another, which is probably our least favorite, but it cannot ever be ruled out, and that is, that the statutory requirements are known, but they may be disregarded to the extent that to test the limits of the board's enforcement or current law. That's always a possibility. So with that being said, any of these could be a factor, but regardless, we do enforce our statutory requirements for APRNs. To that extent, what we did do after this much discussion and the reaction that received to the article, the Board of Nursing has requested a formal Attorney General opinion. So we will...that hopefully will be available when it is completed and done, and the request is on the Attorney General's website. Then once the opinion is available, it also will be posted on the Attorney General website. So we will keep you posted. I think maybe nurses who start out for Cleveland and then they wind up in Toledo, that's always...may not be the trip envisioned, but that may be the trip that some are attempting to take. We just want everyone to...we want the safest patient care for those in Ohio. We also want APRNs to practice in a manner that aligns with their formal education and their certification. So anyway, thank you, and that's Ohio's story. - [Woman] Thank you, ma'am. I'm questioning what methods of communication, beside the 2016 fall newsletter? - Communication about scopes and alignments. Individual emails, we have the APRN decision model, we have CPG, we have different committees, the specialized committee on prescriptive governance, where APRNs and physicians all are on that committee, which, that's about the formulary, but it discusses, you know, practice as well. But the article is the most significant global article that we've had, though, so. - And secondly, have you changed the 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 4

discipline process as a result? Do you do cease and desist letters? - I'm not within that section of our board. The board has the ability to do a range of actions. So everything from a warning letter, which, for minor violations, to any kind of disciplinary action. We have a statute that says that an APRN is prohibited from collaborating with a physician whose practice is not the same or similar to that of the APRN's specialty. So that's a possibility. Our goal is always to, though, put information out when we believe there's a more global misunderstanding, in a similar way as we did with the CRNAs 10 years ago. There was very much a seemingly global misunderstanding that they were able to prescribe. We sent out a letter, and through that, we still came back with, "No, the board may be interpreting wrong," so we got an AG opinion in that case as well. So this is following along that similar path. - Thank you. - [Suzy] Hi, Suzy-Ann Stabler [SP] from Georgia. - Yes. - I would be interested in knowing how the board polices this whole arena. So do you proactively, when you have new licensures or license renewals, have the APRN designate who they are and where they're working and then you look for matches, or is it just based on a reporting system? - Right. It's primarily based on a reporting system, though the APRNs who are required to collaborate, they have to tell the board, inform the board of who their collaborating physician is. But we have a reporting system, a mandatory reporting of employers. - Okay. Thank you. - [Woman] My question is regarding the APRN Consensus Model that you mentioned and the two points at which you are, you know, consistent with it. But I was wondering, are you moving at all toward removal of the requirement for collaboration and allowing for prescriptive authority? Because that seems to me two big issues and I wonder if that might be some of the consternation that, you know, happened in the response because it's like it defies the APRN Consensus Model in my understanding. So I was just wondering if you were working toward that. - Well, CNMs, CNSs, and CNPs presently have prescriptive authority, okay? Though it is consistent with the formulary that they have. - But they're all required to collaborate. - To collaborate. - That's the one maybe we should focus on. - The Ohio Association of Advanced Practice Nursing this past year sought and achieved a law change that actually becomes effective April the 6th. My understanding is that there was an attempt to not have collaborating physicians and that was possibly in their early versions of the bill, but that did not stay. So that attempt to remove the collaborating physician was not successful by the APRNs in Ohio. So the bill is Substitute House Bill 216, if anyone wants to look at that. That did change quite a bit of APRN, but not with respect to collaboration. That is staying the same. They're staying the same. However, their formulary, it does charge our committee on prescriptive governance to...it changed the composition of that committee somewhat. It created a advisory committee of APRNs for the board and it also charged the committee on prescriptive governance with developing an exclusionary formulary only. So the formulary will only be the drugs and the devices that an APRN may not prescribe. - Thanks. - [Woman] Lisa, just one more. - Yes. Okay, one more last question. - [Gretchen] Gretchen Schumacher, I am neighbor to the north for Michigan. - Hi. - And I'm wondering, in your process, if you could speak to any strategy you used or anything where you were collaborating with your APRN professional organizations on this particular endeavor, or maybe you could share little strategies, or as we are following in some of the same footsteps as you, I think that would be helpful to me. - Are you referring to the bill that recently passed? - No, I'm referring to what you presented here. Did you have engagement in this process with your state organization, and how did you utilize them? We're looking at coalition building and things in our state, so I just was curious if you did and if you could speak to that for a second. - Correct. We always have communications with individuals, and APRNs, and so forth. I can tell you that with their searching for the language they had in their current bill that went through, we had even difficulty getting versions of the bill from that association as it became, as it progressed through, and even received the final version of it before it actually passed from other entities besides the association. So we have certainly continued to have interested party meetings when we have law and 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 5

rule issues or changes in rule especially, and we have continued to communicate with our APRN organizations. We have had communications with their attorneys, with the information, the prior information that I've discussed and unfortunately, it did come to us needing to issue the article so that we could get it more globally distributed. So we're hoping to continue to grow that communication and we believe that the APRN advisory committee will be helpful with that as well. It's a good opportunity. - Thank you, Lisa. Is that it? Okay, thank you so much. 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 6