Advanced Practice Registered Nurse Legislation

Minnesota Nurses Association Advanced Practice Registered Nurse Legislation Minnesota Nurses Association Revised September, 2005 1625 Energy Park Drive, Suite 200 St. Paul, MN 55108 Phone: (651) 646-4807 Fax: (651) 647-5301 Web: www.mnnurses.org E-Mail: mnnurses@mnnurses.org Advanced Practice Registered Nurse Legislation Page 1 of 8

Minnesota Nurses Association Mission Statement The Minnesota Nurses Association (MNA) is the professional organization for Registered Nurses and speaks for our members and for nursing to: Promote the professional, economic, and personal well-being of nurses. Uphold and advance excellence, integrity and autonomy in the practice of nursing. Advocate for quality care that is accessible and affordable for patients and consumers. Goals Ensure that the Minnesota Nurses Association thrives by preserving and enlarging membership and resources, increasing member activism, and mastering threats and opportunities in the environment. Promote and defend the practice of nursing, for the benefit of the public, by educating and mobilizing members to exert power and influence within the profession and in the public arena. Prepare Minnesota Nurses Association members to design their own professional futures. Advanced Practice Registered Nurse Legislation Page 2 of 8

Background 1999 was an historic year at the legislature for MNA with the passage of the Advanced Practice Nurse Act of 1999. What made this legislative effort particularly gratifying was the manner in which MNA, the Minnesota Board of Nursing and advanced practice registered nurses from throughout the state joined to build consensus on the content of the legislation and the legislative strategy. Overview Advanced Practice Registered Nursing (APRN) is an umbrella term for registered nurses with advanced education, usually a master s degree, who provide complex, specialized health care, and are certified by a national nurse certification program. These highly trained nurses are able to do 60 to 80 percent of primary and preventive care traditionally done by physicians. The law specifies the following groups of registered nurses as APRNs: Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Certified Registered Nurse Anesthetist (CRNA) and Certified Nurse Midwife (CNM). APRNs diagnose and treat, consult, coordinate care and collaborate with other health care providers. The Advance Practice Registered Nurses legislation of 1999 was signed into law by Governor Ventura on May 17, 1999. This legislation defines the scope of practice for each category of advanced practice nurses. Although prescriptive authority for Nurse Practitioners, Nurse Midwives and Clinical Nurse Specialists in psychiatry is unchanged, these APRNs no longer need to apply to the Board of Nursing to secure this authority. As of July, 1999, Clinical Nurse Specialists in Psychiatric and Mental Health Nursing may now have a prescriptive agreement with any physician, rather than only with a psychiatrist. In addition, Clinical Nurse Specialists and Nurse Anesthetists are now authorized to prescribe. Advanced Practice Registered Nurses have their own scopes of practice under the law. As long as APRNs practice within their own scopes of practice, they are practicing independent advanced practice registered nursing functions. The APRN must practice within a health care system that provides for consultation, collaborative management and referral as indicated by the health status of the patient. With regard to prescribing, APRNs (with the exception of CNMs) have a written agreement that conforms to the memorandums of understanding between the Minnesota Nurses Association/Minnesota Medical Association and the Minnesota Psychiatric Association. If APRNs wish to write prescriptions, that is a function delegated to the APRN through the written prescriptive agreement from a physician. Employers may place additional restrictions on APRNs through the employment relationship, as long as these restrictions do not conflict with state law and accepted standards of care. For example, a clinic may hire an APRN to do only diabetic care. The nurse s scope of practice in the law is actually much broader, but the employer hires the nurse to carry out only a part of their total scope of practice. This has always been the prerogative of the employer. Advanced Practice Registered Nurse Legislation Page 3 of 8

Benefits to Health Care Consumers APRNs are developing an increased role in delivering quality health care to the general population and to chronically underserved populations like the elderly, the poor and those in rural areas. The Office of Rural Health and Primary Care at the Minnesota Department of Health has emphasized that Advanced Practice Registered Nurses enhance cost-effectiveness by expanding the scope of services available to their patients in such areas as patient education, counseling and disease prevention. Benefits to Nursing For Advanced Practice Registered Nurses as a whole, scopes of practice are defined, titles are protected and roles are differentiated from those of other registered nurses. This law makes it clear to potential employers or to payors the proper roles of Advanced Practice Registered Nurses in our health care systems. It is clear that APRNs practice under their own independent scopes of practice. There is no supervisory language in the law to imply that M.D. supervision is needed. Individual specialty benefits are detailed as follows: Clinical Nurse Specialists Are included in the third party reimbursement insurance law. May prescribe if they take appropriate course work in pharmacology and have a written agreement 1 to prescribe with a physician. Nurse Anesthetists May prescribe if they have a written agreement 1 to prescribe with a physician. Prescribing agreements are not needed for administering anesthesia perioperatively, which is considered to be part of the nurse anesthetist s scope of practice. Nurse Midwives Prescriptive privileges remain unchanged. No prescribing agreement is required for this group of APRNs. Nurse Practitioners Prescriptive privileges remain under a written agreement 1 with a physician as it has been in the past. Benefits to Employers The new law clearly states the scope of practice for APRNs, which is the legal framework to guide the employers expectations of APRNs in the workplace. 1 The written agreement to prescribe must follow a particular format which the MMA, the Minnesota Psychiatric Association and the MNA have jointly established. Information may be obtained from the Minnesota Board of Nursing. Advanced Practice Registered Nurse Legislation Page 4 of 8

Q & A 1. What is Collaborative Management? The definition of Nurse Practitioner, Clinical Nurse Specialist and Certified Registered Nurses Anesthetist require these specialists to work within the context of collaborative management. Collaborative management is defined in the law as: a mutually agreed upon plan between an advanced practice registered nurse and one or more physicians or surgeons licensed under chapter 147 that designates the scope of collaboration necessary to manage the care of patients. Session laws 1999, Chapter 172, Section 2 Subdivision 7 Does the collaborative management plan require M.D. supervision? The mutually agreed upon plan referred to in this definition could be as simple as a handshake or as complex as a written contract. The nurse and the physician must agree on how they will collaborate. The agreed upon plan may also be contained within a job description or a contract as long as the contract or job description says that they both agree to collaborate in a particular way. The physician does not give the nurse permission to practice through this agreement. The nurse must simply ensure that they have a specific plan to collaborate with physicians and each party must understand what their responsibilities are in the relationship. The definition of collaborative management continues: The advanced practice registered nurse and the one or more physicians must have experience in providing care to patients with the same or similar medical problems, except that certified registered nurse anesthetists may continue to provide anesthesia in collaboration with physicians, including surgeons, podiatrists licensed under chapter 153, and dentists licensed under chapter 150A. Certified registered nurse anesthetists must provide anesthesia services at the same hospital, clinic, or health care setting as the physician, surgeon, podiatrist, or dentist. ibid This section directs nurses to collaborate with physicians who have experience in caring for similar types of patients. For example, it is not appropriate for the pediatric nurse practitioner to collaborate with gerontologist. The clarification for the nurse anesthetist makes it clear that collaboration may occur with any physician performing surgery in which the nurse anesthetist is providing anesthesia. It is not intended that the nurse anesthetist collaborate only with an anesthesiologist. The definition recognizes that nurse anesthetists appropriately collaborate with physicians including podiatrists and dentists who are doing surgery in the same settings as nurse anesthetists. Advanced Practice Registered Nurse Legislation Page 5 of 8

2. Could advanced practice nurses be independent contractors or own their own business? Yes. However, they must have a collaborative relationship with a physician. The relationship with a physician that is required is as follows: 1) APRNs need written agreements with physicians to prescribe. The physician need not be onsite. 2) APRNs must establish a mutual understanding with a physician on general collaboration. This does NOT need to be in writing. The physician must have experience in care for patients with similar health problems. 3) Minnesota law now allows nurses to serve as corporate partners with other health care professionals. All health care providers in our current health care system should be collaborating with one another in order to provide safe patient care. Referrals and collaboration are essential parts of everyday practice for nurses, doctors, dentists, chiropractors and other providers. Essential to collaborative relationships is the idea of mutuality. Both the nurse and the physician have to agree on the relationship and both acknowledge that the other brings a different perspective and skills to the situation. This is not a supervisory relationship in which the supervisor makes the decisions for the other individual in the relationship and the decision of the supervisor prevail if there is a disagreement about the relationship. 3. May APRNs work with providers other than M.D. s? Yes. The law specifically states that APRNs may accept referrals from, refer to, consult with, and cooperate with all other types of providers such as chiropractors, podiatrists and dentists. 4. Are physicians required to supervise APRNs? No. The law does not contain any supervisory requirements, nor does it imply that a nurse is supervised by the physician. 5. Can employers restrict practice? A qualified yes. Employers may utilize APRNs in a role which is clearly narrower than their legal scope of practice. When employers narrow a nurse s scope of practice in this way, they are doing so as a response to the internal needs of the organization. Nurses must be cautious of any restrictions that may put them in conflict with the Nurse Practice Act and/or prevailing standards of care. Advanced Practice Registered Nurse Legislation Page 6 of 8

As an example of an appropriate employer restriction, a Pediatric Nurse Practitioner may be hired by a clinic to do only diabetic care for children. This nurse could legally do much more. The employer has chosen to narrow his/her scope of practice based upon the needs of the clinic. It is inappropriate for the clinic to restrict clinical decision-making of the APRN in such a way as to make it impossible for the nurse to follow accepted clinical standards of care. 6. What steps should RNS take if they disagree with an APRN drug order? The procedure is the same as it is with physicians communication your concern and/or refusal directly with the APRN. 7. Are APRNs eligible to be credentialed by the hospital under the JCAHO standards? Yes. 8. Can APRNs give verbal or telephone order for treatments, medications, x-rays, labs, etc. in hospitals? Yes, if they have staff privileges from the hospital to provide services there. Special Acknowledgments MNA wishes to thank the members of the Advanced Practice Nurses Partnership for their assistance in passing this legislation. In addition to MNA, the partnership includes: The National Association of Pediatric Nurses Associates and Practitioners, Minnesota Association of Nurse Anesthetists, Minnesota Chapter of American College of Nurse Midwives, Minnesota Board of Nursing, Individuals representing Clinical Nurse Specialists and Women s Health Nurse Practitioners. Advanced Practice Registered Nurse Legislation Page 7 of 8

Minnesota Nurses Association Revised September, 2005 1625 Energy Park Drive, Suite 200 St. Paul, MN 55108 Phone: (651) 646-4807 Fax: (651) 647-5301 Web: www.mnnurses.org E-Mail: mnnurses@mnnurses.org Advanced Practice Registered Nurse Legislation Page 8 of 8