BILL ANALYSIS �
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|Hearing Date:April 16, 2012 |Bill No:SB |
| |1524 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Curren D. Price, Jr., Chair
Bill No: SB 1524Author:Hernandez
As Amended:March 28, 2012 Fiscal:Yes
SUBJECT: Nursing.
SUMMARY: Deletes the requirement that a certified nurse-midwife and
nurse practitioner must complete six months of physician and surgeon
supervised experience in the furnishing or ordering of drugs or
devices.
Existing law:
1) Establishes the Nursing Practice Act which provides for the
certification and regulation of registered nurses, nurse
practitioners and advanced practice nurses by the Board of
Registered Nursing (BRN) within the Department of Consumer Affairs.
2) Provides that the practice of nursing includes direct and indirect
patient services, including but not limited to, the administration
of medications and therapeutic agents necessary to implement a
treatment, disease prevention, or rehabilitative regimen ordered by
and within the scope of licensure of a physician, dentist,
podiatrist, or clinical psychologist.
Business and Professions Code (BPC) � 2735 (b) (2))
3) Provides that the practice of nursing may be performed under
"standardized procedures," as defined, for specified functions,
treatments and procedures. (BPC � 2725)
4) Provides that a certified nurse-midwife may furnish or order drugs
or devices, including controlled substances, if furnished or
ordered incidentally to the provision of family planning services,
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routine health care or perinatal care, or care rendered consistent
with the certified nurse-midwife's practice; occurs under physician
and surgeon supervision; is in accordance with standardized
procedures or protocols as specified; is issued a number by the BRN
after the BRN certifies that the certified nurse-midwife has
completed at least six months of physician and surgeon supervised
experience in the furnishing or ordering of drugs or devices and a
course in pharmacology covering the drugs or devices to be
furnished or ordered. (BPC � 2746.51)
5) Provides that a nurse practitioner may furnish or order drugs or
devices, including controlled substances, if it is consistent with
a nurse practitioner's educational preparation or for which
clinical competency has been established and maintained; occurs
under physician and surgeon supervision; is in accordance with
standardized procedures or protocols as specified; and the BRN has
certified prior to issuing a number, as required, that the nurse
practitioner has completed (1) at least six months of physician and
surgeon supervised experience in the furnishing or ordering of
drugs or devices, and (2) a course in pharmacology covering the
drugs or devices to be furnished or ordered. (BPC �� 2836.1 and
2836.3)
6) Defines the furnishing or ordering of drugs or devices by nurse
practitioners to mean the act of making a pharmaceutical agent or
agents available to the patient in strict accordance with a
standardized procedure. (BPC � 2836.2)
This bill:
1) Would delete the requirement that a certified nurse-midwife must
complete six months of physician and surgeon supervised experience
in the furnishing or ordering of drugs or devices.
2) Would delete the requirement that a nurse practitioner must
complete six months of physician and surgeon supervised experience
in the furnishing or ordering of drugs or devices.
FISCAL EFFECT: Unknown. This bill has been keyed "fiscal" by
Legislative Counsel.
COMMENTS:
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1. Purpose. The Author is the Sponsor of this measure. According to
the Author, existing law makes newly graduated nurse practitioners
(NPs) and certified nurse midwives (CNMs), and those moving to
California regardless of how long they have been a NP or a CNM,
subject to six months of a physician-supervised period for the
purpose of prescribing drugs or devices. This is a barrier to
employment for those practitioners moving to California as well as
for new graduates. Increasing access to care is a key goal in
California, as we have a shortage of health care providers in
underserved areas around the state. The Author believes that NPs
and CNMs can be a key part of providing health care to those areas
and in increasing our health care safety net.
The Author states that NPs and CNMs are advance practice registered
nurses who are licensed, certified, and regulated by the BRN. NPs
and CNMs have an important role in the health care delivery system;
they perform comprehensive physical exams, furnish medications,
order laboratory and other diagnostic tests, and provide health and
wellness education and counseling. NPs and CNMs provide care in a
variety of settings including hospitals, community clinics and
private practice settings.
The Author further states that safely furnishing medications is a
standard component of NP and CNM practice and education. During
the graduate education programs in California, student NPs and CNMs
complete pharmacology training and have a minimum of 12 months of
direct clinical experience with a supervising NP or CNM. The
students furnish medications under direct supervision and are
evaluated as competent in furnishing/prescribing prior to
graduation based on national standards.
As stated by the Author, the six-month supervisory requirement is an
arbitrary barrier and prevents NP and CNM practice to the fullest
extent of their training. The requirement is redundant given that
the law already requires a) physician supervision of CNMs who are
furnishing and b) physician involvement in developing standardized
procedures for furnishing. New graduates frequently report facing
challenges in being hired without a furnishing number. Also, NPs
and CNMs who previously worked out-of-state are also required to
provide certification of six-months of physician supervised
prescription writing, regardless of past experience.
The Author indicates that there is no evidence that six months of
physician supervised prescription writing actually protects the
health and safety of consumers. "There is a wealth of research,
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however, that demonstrates that NPs and CNMs are safe, effective
health care professionals. The removal of this portion of statute
will significantly improve patient access to advance practice
nursing providers, without reducing any protections for the health
and safety of consumers in California."
2. Related Legislation This Session. SB 1338 (Kehoe, 2012) would
clarify that nurse practitioners, certified nurse-midwives and
physician assistants may assist in performing an abortion if
authorized within their practice to do so, and can perform an
abortion by "medication" or "aspiration techniques." Would no
longer consider a "nonsurgical abortion" as including termination
of a pregnancy through the use of "pharmacological agents" and
would instead substitute the term "medication" as specified above.
Would provide specified training requirements for nurse
practitioners, certified nurse-midwives and physician assistants to
perform abortions by aspiration techniques. This measure will be
heard in this Committee on April 16, 2012.
3. Arguments in Support. The California Association of Nurse
Practitioners (CANP) is in support of this measure and agrees with
the Author that the six-month supervision requirement puts up an
ineffective and arbitrary barrier to allowing primary care
providers such as NPs to begin practicing after they graduate from
school. CANP also agrees that in today's fast-paced health care
environment, many physicians prefer to hire NPs who have already
fulfilled this requirement, placing new graduates and NPs who have
been practicing in other states at a disadvantage. "As a result,
this antiquated requirement has become a barrier preventing access
to care as it delays NPs from entry into California's health care
workforce. Further, under existing law, physicians retain the
authority to create specific supervision requirement in the
standardized procedures developed with the nurse practitioners they
are working with. SB 1524 does not change or undermine this
authority."
The California Nurse-Midwives Association (CNMA) and the American
College of Nurse-Midwives (ACNM) are also in support of this
measure for similar reasons. They both indicate that CNMs are
trained to competency and upon graduation have completed
pharmacology training and supervised experience that amounts to
more than six months. Additionally, current law requires CNMs who
have been working in a state outside of California, no matter their
years in practice, to complete the six-months requirement prior to
receiving his or her furnishing number in California. This
requirement places a logistical barrier on practices of varying
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sizes and types and may be especially disruptive to practices in
small urban and rural areas. According to CNMA and ACNM, CNMs have
prescriptive authority in all 50 states; three other states have
similar requirements for a period of post-graduation supervision of
prescribing (Colorado, Arkansas and Louisiana); however, unlike
California, none of those states require supervision of CNMs
outside of that immediate post-graduation period. CNMA also notes
this requirement is outdated since the original furnishing language
was adopted prior to the education programs incorporating the
didactic pharmacology education. When CNMs were initially
recognized in statute, they did not have furnishing privileges.
When furnishing privileges were first granted to CNMs, the
six-months requirement was appropriate. However, it is no longer
applicable as students now gain the education, skills and
supervision during their graduate program of study.
Several Planned Parenthood organizations are also in support of this
measure and point out that in a majority of their health centers,
NPs are at the heart of clinical care services. They provide a
vast array of services including breast exams, pap smears, IUD
insertion, cervical and cervical biopsies in family planning
clinics, and many more in their primary care health centers. The
Planned Parenthood organizations believe that the heightened
supervision requirement in current law creates an arbitrary barrier
to accessing the full scope of primary care so desperately needed
in the communities they serve. Moreover, since the requirement
also applies to out-of-state NPs moving to California, many of whom
have been prescribing medications in accordance with their home
state's laws and have been in practice for many years, this
requirement has made it difficult for experienced NPs to come into
California and begin working. This measure will eliminate these
unnecessary barriers and allow for these advance practice
clinicians to help in meeting the needs of the millions of
currently uninsured people who will need health care.
4. Technical Amendment. On page 4, line 10, strike the word "Agency"
and insert instead the word " Administration ."
SUPPORT AND OPPOSITION:
Support:
American College of Nurse-Midwives
California Association for Nurse Practitioners
California Nurse-Midwives Association of Santa Barbara, Ventura and
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San Luis Obispo Counties
Planned Parenthood Action Fund of the Pacific Southwest
Planned Parenthood Action Fund, Inc.
Planned Parenthood Advocacy Project Los Angeles County
Planned Parenthood Affiliates of California
Planned Parenthood of Pasadena and San Gabriel Valley, Inc.
Planned Parenthood Shasta Pacific Action Fund
Six Rivers Planned Parenthood
One Individual
Opposition:
None on file as of April 11, 2012.
Consultant: Bill Gage