BILL ANALYSIS
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| Hearing Date:April 13, 2009 |Bill No:SB |
| |294 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS AND ECONOMIC
DEVELOPMENT
Senator Gloria Negrete McLeod, Chair
Bill No: SB 294Author:Negrete McLeod
As Amended:March 31, 2009 Fiscal: Yes
SUBJECT: Nurse practitioners.
SUMMARY: Allows implementation of standardized procedures
authorizing a nurse practitioner to perform specific
functions.
Existing law:
1)Establishes the Nursing Practice Act which provides for
the certification and regulation of nurses, nurse
practitioners and nurse-midwives by the Board of
Registered Nursing (BRN) and requires the BRN to
establish categories and standards for nurse
practitioners in consultation with specified health care
practitioners, including physicians and surgeons.
2)Defines the practice of nursing as those functions,
including basic health care, that help people cope with
difficulties in daily living that are associated with
their actual or potential health or illness problems, and
that require a substantial amount of scientific knowledge
or technical skill, as specified.
3)Defines standardized procedures to mean either of the
following:
a) Policies and protocols developed by a licensed
health facility, as defined, through collaboration
among administrators and health professionals
including physicians and nurses.
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b) Policies and protocols developed through
collaboration among administrators and health
professionals, including physicians and nurses, by an
organized health care system which is not a licensed
health facility. Specifies that the policies and
protocols shall be subject to any guidelines for
standardized procedures that the Medical Board of
California (MBC) and the BRN may jointly promulgate.
If promulgated, the guidelines shall be administered
by the BRN..
4)Defines by regulation that a nurse practitioner is a
registered nurse who possesses additional preparation and
skills in physical diagnosis, psychosocial assessment,
and management of health-illness needs in primary health
care, and who has been prepared in a program that
conforms to BRN standards, as specified. Defines primary
health care as that which occurs when a consumer makes
contact with a health care provider who assumes
responsibility and accountability for the continuity of
health care regardless of the presence or absence of
disease.
5)Prescribes standards and conditions for the use of the
title "nurse practitioner." Prohibits a person from
advertising or holding himself or herself out as a nurse
practitioner who is not a licensed nurse and does not
meet the standards for a nurse practitioner as
established by the BRN.
6)Authorizes nurse practitioners to furnish or order drugs
under certain conditions, pursuant to standardized
procedures or protocols and under the supervision of a
physician and surgeon. Prohibits construing physician
and surgeon supervision to require physical presence of
the physician, but does include a) collaboration on the
development of the standardized procedure,
b) approval of the standardized procedure, and c)
availability by telephonic contact at the time of patient
examination by the nurse practitioner.
7)Requires an applicant for disability to establish medical
eligibility for disability benefits to be supported by a
certificate of a treating physician or practitioner that
establishes sickness, injury, or pregnancy of an
employee.
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This bill:
1)Authorizes the implementation of standardized procedures,
pursuant to existing law, allowing a nurse practitioner
to perform the following functions:
a) Order durable medical equipment, subject to any
limitations set forth in the standardized procedures.
Specifies that this authority does not limit the
ability of a third-party payor to require prior
approval.
b) Certify disability, as specified, after performance
of a physical examination by the nurse practitioner
and collaboration with a physician and surgeon.
c) Approve, sign, modify or add to a plan of treatment
or plan of care for individuals receiving home health
services or personal care services after consultation
with the treating physician and surgeon.
2)Specifies that the functions specified in item #1) above
are in addition to any other practices that meet the
general criteria set forth in statute or regulation for
inclusion in standardized procedures developed through
collaboration among administrators and health
professionals, including physicians and surgeons and
nurses.
3)Specifies that this bill should not be construed to
affect the validity of any standardize procedures and
protocols in effect prior to the enactment of this
section or those adopted subsequent to enactment of this
bill
4)Makes legislative findings and declarations on the need
to clarify that standardized procedures and protocols may
include specified services and functions.
FISCAL EFFECT: Unknown. This bill has been keyed "fiscal"
by Legislative Counsel.
COMMENTS:
1)Purpose. According to the Sponsor, the California
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Association of Nurse Practitioners (CANP), this measure
codifies specific minimum duties that a nurse
practitioner may perform under a standardized procedure.
Existing law authorizes nurse practitioners (who are
registered nurses who have advanced education and
training and have been certified by the BRN as a nurse
practitioner to provide services beyond the scope of a
registered nurse utilizing the standardized procedure.
The standardized procedure is developed collaboratively
with the physician and the facility that the nurse
practitioner works with. CANP points out that existing
law is silent on which specific duties a nurse
practitioner may perform and instead allows these duties
to be delineated in the standardized procedure, which
serves as the governing document outlining the duties a
nurse practitioner may perform in his or her practice
setting. Many physicians rely upon nurse practitioners
to handle the routine health care needs of their patients
and delegate great responsibility to them. However,
because ambiguity exists in current law as to what duties
may be performed under a standardized procedure, many
nurse practitioners experience bureaucratic barriers
which then delay consumers access to timely care. For
example, a physician may authorize a nurse practitioner
to order durable medical equipment for his or her
patients as needed and may have outlined this in the
standardized procedure. However, because existing law is
silent on the ability of nurse practitioners to order
these supplies, third party payers and suppliers often
reject an order placed by a nurse practitioner. This
typically results in the patient being required to come
back to the office, be seen by the physician, and then
the physician must re-place the order; all of this
results in a delay in the patient receiving needed care.
2)Background.
a) History of Nurse Practitioners. A report
published by the Center for the Health Professions of
the University of California, San Francisco entitled
Overview of Nurse Practitioner Scopes of Practice in
the United States (UCSF report), indicates that the
nurse practitioner profession originated in the
mid-1960's in response to a nationwide shortage of
physicians. The University of Colorado's School of
Nursing developed the first nurse practitioner program
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as a master's degree curriculum in 1965. Initial
programs that subsequently followed were programs in
pediatrics. In California, the first nurse
practitioner training program was established in 1972
by the University of California, Los Angeles, and in
1976 the BRN initiated voluntary nurse practitioner
certification. The UCSF report cited that according
to the most recent United States Department of Health
and Human Services Sample Survey Report in 2004, there
were an estimated 141,209 nurse practitioners in the
U.S., an increase of 38,560 from 2000. According to
the BRN, there are currently 14,579 active nurse
practitioners in California, and 23 California
universities offering nurse practitioner programs.
b) Scope of Practice of Nurse Practitioners. Current
regulations define a nurse practitioner as a
registered nurse who possesses additional preparation
and skills in physical diagnosis, psychosocial
assessment, and management of health-illness needs in
primary health care, and who has been prepared in a
program that conforms to BRN standards, as specified.
The Nursing Practice Act enunciates the scope of
practice of nurses, and it states that the practice of
nursing includes: direct and indirect patient care
services that ensure the safety, comfort, personal
hygiene, and protection of a patient; and the
performance of disease prevention and restorative
measures; direct and indirect patient care services,
including, but not limited to, the administration of
medications and therapeutic agents, necessary to
implement a treatment, disease prevention, or
rehabilitation regimen ordered by and within the scope
of licensure of a physician, dentist, podiatrist and
clinical psychologist; the performance of skin tests,
immunization techniques, and the withdrawal of blood
from veins and arteries; observation of signs and
symptoms of illness, reactions to treatment, general
behavior, or general physical condition, and
determining whether the signs, symptoms, reaction,
behaviors, or general appearance exhibit abnormal
characteristics; and implementation, based on observed
abnormalities, of appropriate reporting, or referral,
or standardized procedure, or changes in treatment
regimen in accordance with standardized procedures, or
the initiation of emergency procedures. Standardized
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procedures are the legal mechanism for RNs and NPs to
perform functions which otherwise would be considered
the practice of medicine. Standardized procedures
guidelines are to be adhered to by RNs and NPs when
performing medical functions. The standardized
procedures must be developed collaboratively by
nursing, medicine, and administration in the organized
health care system where they will be utilized. The
Medical Practice Act includes diagnosis of mental or
physical conditions, the use of drugs in or upon human
beings and severing or penetrating tissue of human
beings as the practice of medicine. The performance of
any of these functions by a registered nurse or nurse
practitioner requires a standardized procedure.
c) Standardized Procedures and Protocols. As
indicated above, standardized procedures are the legal
mechanism for registered nurses or nurse practitioners
to perform functions which would otherwise be
considered the practice of medicine. Standardized
procedures and protocols are policies and protocols
developed by a health facility, as specified, or by an
organized health care system, developed through
collaboration with the administration, physicians and
nurses. Standardized procedures must include a
written description of the method used in developing
and approving them and any revision thereof.
According to the BRN, each standardized procedure
must: (1) be in writing, dated and signed by the
organized health care system personnel authorized to
approve it; (2) specify which standardized procedure
functions registered nurses may perform and under what
circumstances; (3) state any specific requirements
which are to be followed by registered nurses in
performing particular standardized procedure
functions; (4) specify any experience, training,
and/or education requirements for performance of
standardized procedure functions; (5) establish a
method for initial and continuing evaluation of the
competence of those registered nurses authorized to
perform standardized procedure functions,
(6) provide for a method of maintaining a written record
of those persons authorized to perform standardized
procedure functions; (7) specify the scope of
supervision required for performance of standardized
procedure functions, for example, telephone contact
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with the physician; (8) set forth any specialized
circumstances under which the registered nurse is to
immediately communicate with a patient's physician
concerning the patient's condition; (9) state the
limitations on settings, if any, in which standardized
procedure functions may be performed; (10) specify
patient record-keeping requirements; and (11) provide
for a method of periodic review of the standardized
procedures. If a registered nurse or nurse
practitioner undertakes a procedure without the
competence to do so, such an act may constitute gross
negligence and be subject to discipline by the BRN.
d) Training and Education of Nurse Practitioners.
Existing law requires a nurse practitioner must be a
licensed nurse, complete a nurse practitioner program
approved by the BRN and possess a master's degree in
nursing, a master's degree in a clinical field related
to nursing, or a graduate degree in nursing. Current
regulations specify that a nurse practitioner
curriculum must include all theoretical and clinical
instruction necessary to enable the graduate to
provide primary health care for consumers, training
for practice in an area of specialization which shall
be broad, not only to detect and control presenting
symptoms, but to minimize the potential for disease
progression, and may be a full-time or part-time
program and shall be comprised of not less than 30
semester units (or 45 quarter units), which shall
include theory and supervised clinical practice.
Supervised clinical practice requires demonstration of
and supervised practice of correlated skills in the
clinical settings with patients, and at least 12 or 18
quarter units must be in clinical practice. The
curriculum must include pathophysiology, comprehensive
physical examination, psycho-social assessment,
interpretation of laboratory finds, evaluation of
assessment date to define health and developmental
problems, pharmacology, nutrition, disease management,
and initiating and providing emergency treatments.
e) Furnishing or Ordering of Drugs or Devices.
Currently, a nurse practitioner may furnish or order
drugs, including Schedules II-V controlled substances
under physician and surgeon supervision. Physician
and surgeon supervision shall not be construed to
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require the physical presence of the physician, but
does include: i) collaboration on the development of
standardized procedures; ii) approval of the
standardized procedure , and iii) availability by
telephonic contact at the time of patient examination
by the nurse practitioner. Current law limits the
number of nurse practitioners a physician could
supervise to four.
3)Other states. The UCSF report points out that
educational requirements, certification mechanisms and
legal scopes of practice are decided at the state level
and vary considerably. The variances are mostly evident
in physician affiliation, the ability to diagnose, treat
and refer, and prescriptions. According to the UCSF
report, most states require nurse practitioners to
practice in collaboration with a physician, or under a
physician's direct supervision, and few states permit
nurse practitioners to practice independently without any
physician involvement. Alaska, Arizona, New Hampshire,
New Mexico, Oregon and Washington have some of the
nation's most expansive scope of practice, where the
nurse practitioners practice without physician oversight
and may prescribe drugs without physician involvement.
The UCSF report pointed out that inconsistency in nurse
practitioner scope of practice among states may impede
the uniform expansion of nurse practitioner services,
prohibit nurse practitioners from providing in full
measure the medical care for which they are trained, and
inhibit the robust use of nurse practitioners in helping
alleviate shortages of primary care providers.
4)Workforce Shortages in California. One of the reasons
provided to justify extending the scope of practice of
nurse practitioners is the current shortage of physicians
nationally, and in California specifically. However,
workforce shortages exist not only for physicians but
also for nurses. The 2007 Final Report of the Advisory
Council on Future Growth in the Health Professions by the
University of California (UC report) indicates that
California has existing shortages in many health
professions, and looming shortages in others.
Specifically, the report pointed out that California is
expected to face a shortfall of up to 17,000 physicians
by 2015. This shortage is due to overall population
growth, aging of the current physician workforce, and the
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lack of growth in medical education programs in
California. Regional shortages of physicians already
exist and are expected to become more severe,
particularly in areas that will have the most rapid rates
of growth over the next decade. A 2006 report by the
United States Department of Health and Human Services
entitled Physician Supply and Demand: Projections to 2020
indicated that over the next 15 years, requirements for
physician services will grow faster than supply,
especially for specialist services and specialties that
mostly serve the elderly. Aside from the growing
shortage of physicians, California's nursing workforce
crisis is growing. The UC report pointed out that the
state currently ranks 49th in the nation in the number of
nurses per capita. In 2005, predictions estimated that
California would have a shortfall of 60,000 registered
nurses by 2020. A more recent federal study issued in
April 2006 predicts that California will face a shortfall
of 47,600 nurses by 2010 and a shortfall of 116,600 by
2020. The current workforce shortage in the health care
arena is compounded by the growing number of the elderly
population.
5)Previous Legislation.
a) AB 1436 (Hernandez) of 2008 defines the scope of
practice of nurse practitioners and authorizes a nurse
practitioner to provide comprehensive health care
services, as specified. This bill was heard in this
Committee but was not voted on.
b) SB 809 (Ashburn) of 2007, defines the scope of
practice of nurse practitioners and authorizes nurse
practitioners to perform specified acts. This bill
was never heard and died in this Committee pursuant to
Joint Rule 56.
c) AB 1643 (Niello) of 2007, would repeal the
prohibition against a physician and surgeon
supervising more than four nurse practitioners at one
time for purposes of furnishing or ordering drugs or
devices. This bill was never heard and died in the
Assembly Committee on Business and Professions.
d) AB X1 1 (Nunez) of 2008, would among other things,
establish a nine-member Task Force on Nurse
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Practitioner Scope of Practice, with specified
membership, to develop a recommended scope of practice
for nurse practitioners by June 30, 2009, and would
require the Director of Consumer Affairs to promulgate
regulations, consistent with existing law, that adopt
the Task Force's recommended scope of practice by July
1, 2012. ABX1 1 failed passage in the Senate Health
Committee.
e) AB 2226 (Spitzer) Chapter 344, Statutes of 2004,
require on and after January 1, 2008, an applicant for
initial qualification or certification as a nurse
practitioner to meet specified requirements including
possessing a master's degree in nursing, a master's
degree in a clinical field related to nursing or
graduate degree in nursing and completion of a nurse
practitioner program approved by the BRN.
f) AB 2560 (Montanez) Chapter 205, Statutes of 2004,
authorized a nurse practitioner to furnish drugs or
devices whenever it is consistent with their
educational preparation or clinical competency.
6)Arguments in Support. Supporters, including the United
Nurses Associations of California , indicate that this
bill will clarify the role of nurse practitioners,
promote their full utilization and improve access to
care.
7)Arguments in Opposition. The California Academy of
Family Physicians opposes this bill but does not indicate
the reasons for its opposition.
SUPPORT AND OPPOSITION:
Support:
California Association of Nurse Practitioners (Sponsor)
Numerous individuals, including nurse practitioners
Opposition:
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California Academy of Family Physicians
Consultant:Rosielyn Pulmano