BARRY WILLIAMS /Special

"We believe ... they [the state medical board] are going to take a second look at the proposed rules, and that is a good thing. I'm hopeful."
- LUCY MARION, Dean of the Medical College of Georgia School of Nursing

Battle-weary advanced practice registered nurses, who for more than a decade fought for the authority to write prescriptions and won it last spring in the Legislature, are fighting again - this time with more visible support.

At a public hearing on Sept. 14, many doctors, nurse educators and health administrators came forward to oppose proposed regulations written by the Composite State Board of Medical Examiners to govern prescriptive privileges.

"There must have been 60 to 65 people in the room, and, when you added up all the comments, the arguments were very compelling that the rules and regulations proposed had some serious issues," said Lucy Marion, Ph.D., RN, FAAN, dean of the Medical College of Georgia School of Nursing. "All of the presenters made good points and backed them up. Some speakers were analytical, and others were emotional. They all made me proud."

The board voted to back off on the regulations for now.

"After hearing testimony, the board proposed and immediately passed a resolution to table discussion until later," Marion said. "We believe that means that they are going to take a second look at the proposed rules, and that is a good thing. I'm hopeful."

Nursing officials say the proposed regulations would force doctors who work with APRNs who write prescriptions to face a mountain of red tape, undermining the intent of the legislation.

"A lot of care went into writing the legislation for SB 480 (which granted prescriptive authority to Georgia APRNs working under protocol agreements with physicians) to include safety issues for patients," said Linda Easterly, president of the Georgia Nurses Association. "The rules they [the state medical board] have written are so much more restrictive and cumbersome than the legislation intended."

For example, the Legislature rejected an amendment to the bill that would have required physicians to see at least 25 percent of an APRN's patients, yet the rules proposed requiring a review rate of 100 percent in certain circumstances.

Restrictive rules

Easterly testified that the rules would limit the role of APRNs by placing practice restrictions on the physicians working with them. She also stated that the rules encroached on the regulatory authority of the Georgia Board of Nursing and could inadvertently regulate the Nurse Protocol Statute of 1989, under which physicians and advanced practice nurses work collaboratively.

"That model has worked well since 1989. Why would you fix something that isn't broken?" said Karen Schwartz, MS, WHNP, legislative chair for United Advanced Practice Registered Nurses of Georgia.

"I would hate to see physicians quit working with NPs [nurse practitioners] because of the additional administrative burden or cost these rules impose," Easterly said.

Regulations that would require doctors to countersign all prescriptions written by APRNs within seven days and monitor APRNs under their direction four hours per week "are a slap in the face to nurse practitioners," Schwartz said. "It's like saying we don't trust that you can do it, when the nation has 30 years of research to show that the care administered by advanced practice nurses is high-quality, safe and effective.

"A rule that calls for a six-month re-evaluation by a physician of a patient seen by a nurse practitioner is not standard medical practice. You don't ask patients to come in for additional appointments or take away their right to choose their provider."

Brian Loopy, associate general counsel for the Medical Association of Georgia called the rules "an appropriate level of physician oversight to make sure quality [of health care] is maintained."

But physicians and public health nurses from around the state pointed out how the proposed rules would hamper public health in Georgia and deny access for thousands of people, particularly in rural areas and inner cities, where there aren't enough physicians.

"People don't realize how valuable NPs having prescriptive privileges is to the state," Schwartz said.

Marion told the Composite State Board of Medical Examiners that Georgia has dire shortages of health care workers, as confirmed by the recent Board of Regents Task Force on Health Professions Education. She also emphasized the role of APRNs in the Medical College of Georgia's mission to improve health and reduce the burden of illness for the people of Georgia.

"APRN prescriptive authority is important to fulfill our missions," she said.

Georgia is the last state to allow advanced practice registered nurses to write prescriptions.

Misconceptions

The new law was not intended to expand the scope of practice for APRNs, who are already nationally accredited and certified to provide comprehensive health care through assessment, intervention, consultation and referral within a collaborative model with physicians and other specialists, Marion said.

Nor was it meant to eliminate or reduce physician participation in the treatment process.

Marion urged the medical board to consider recommendations by the Department of Human Resources and governor's office to write rules that are consistent with the legislative intent and that would not create excessive administrative work.

Meanwhile, the federal Drug Enforcement Administration has approved Georgia APRNs to apply for prescriptive DEA numbers.

Some nurses are applying, after submitting their protocol agreements with physicians to the medical board for approval.

"At least the doors weren't slammed at the hearing," Easterly said. "That's always a positive, but we don't know how long before they'll repost the rules, and then there will be another 30-day waiting period for public comments before voting, so the saga continues."