BILL ANALYSIS                                                                                                                                                                                                    


          |SENATE RULES COMMITTEE            |                   SB 294|
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                                 THIRD READING

          Bill No:  SB 294
          Author:   Negrete McLeod (D)
          Amended:  3/31/09
          Vote:     21

           SENATE BUS., PROF. & ECON. DEVEL. COMMITTEE :  6-1, 4/13/09
          AYES:  Negrete McLeod, Corbett, Oropeza, Romero, Walters,  
          NOES:  Aanestad
          NO VOTE RECORDED:  Wyland, Correa, Florez

           SENATE APPROPRIATIONS COMMITTEE  :  Senate Rule 28.8

           SUBJECT  :    Nurse practitioners

           SOURCE  :     California Association of Nurse Practitioners

           DIGEST  :    This bill authorizes entities delivering health  
          care services to establish standardized procedures that  
          expand the duties of a nurse practitioner as specified.

           ANALYSIS  :    

          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  


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             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  

             (1)   Policies and protocols developed by a licensed  
                health facility, as defined, through collaboration  
                among administrators and health professionals  
                including physicians and nurses.

             (2)   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/herself out as a nurse  


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             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:  (1) collaboration on  
             the development of the standardized procedure, (2)  
             approval of the standardized procedure, and (3)  
             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.

          This bill:

          1. Authorizes the implementation of standardized  
             procedures, pursuant to existing law, allowing a nurse  
             practitioner to perform the following functions:

             (1)   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.

             (2)   Certify disability, as specified, after  
                performance of a physical examination by the nurse  
                practitioner and collaboration with a physician and  

             (3)   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  


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          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  

          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  

          4. Makes legislative findings and declarations on the need  
             to clarify that standardized procedures and protocols  
             may include specified services and functions.

           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:  (1) direct and indirect  
          patient care services that ensure the safety, comfort,  
          personal hygiene, and protection of a patient; (2) and the  
          performance of disease prevention and restorative measures;  
          (3) 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; (4) 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; (5)  


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          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 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.

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes    
          Local:  No

           SUPPORT :   (Verified  4/29/09)

          California Association of Nurse Practitioners (source)
          California Association for Health Services at Home
          United Nurses Association of California/Union of  Health  
          Care Professionals

           ARGUMENTS IN SUPPORT  :    According to the Sponsor, the  
          California Association of Nurse Practitioners (CANP), this  
          bill 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  


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          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.

          JJA:do  4/29/2009   Senate Floor Analyses 

                         SUPPORT/OPPOSITION:  SEE ABOVE

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