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Tennessee: Hearing Proposed Rule That Could Restrict Practice of Nurse Midwives, Nurse Anesthetists

August 27, 2009

A hearing is went on yesterday afternoon on a proposed rule on tamper-resistant prescriptions, but there has apparently been a push for a language change in the proposed rule that could effectively keep nurse midwives and nurse anesthetists from doing their jobs, as it would exclude them from having the authority to prescribe medications.

The problem lies in a section of the rule [PDF, 0880-02-.23 2(b)] defining who is a “prescriber,” which states:

(b) “Prescriber” means an individual licensed in Tennessee as a medical doctor, podiatrist, advanced practice nurse with a certificate of fitness to prescribe, dentist, optometrist, osteopathic physician, or physician assistant.

According to my source, the Tennessee Medical Association (an organization for physicians, whose prescribing power is not threatened by the rule) is pushing to get this language changed. They contend that the General Assembly could have given the four categories of advance practice nurses the authority to prescribe simply by using the term “advance practice nurse” when it amended TCA 63-7-123(a) [on prescribing authority for nurse practitioners], but it did not do so – it stayed with the term “nurse practitioner.” They claim that this use of “nurse practitioner” in those rules was intentional, and that prescriptive authority was meant to be extended *only* to nurse practitioners and not the other 3 categories of advanced practice nurses (which includes nurse practitioners, nurse anesthetists, nurse-midwives, and clinical nurse specialists).

The change in language suggested by the TMA – from advanced practice nurses to nurse practitioners in the tamper-proof prescription rule now up for consideration – would exclude nurse-midwives and nurse anesthetists from issuing prescriptions, something essential to their clinical practice. The actions of the TMA are being perceived as an administrative way to effectively restrict the practice of some of their advance practice nursing colleagues (or, more bluntly and cynically, potentially eliminating some of their competition). Apparently the TMA is asking for an opinion from the attorney general and pushing for a temporary rule, while the Tennessee Nurses Association is working to oppose the change.

You all know I’m a big fan of nurse-midwives, and given the findings on prenatal care and birth outcomes in that TN women’s health report, I’d hate to see fewer providers available to women in a state where women are already struggling to get care. I’m a big fan of advanced practice nurses in general, and get most of my care from them – so there’s my bias, I support advanced practice nurses.

This is all very inside baseball, and something I’m no expert on, but it’s important, I think, to know that while we have serious healthcare reform and access issues, there is a territory battle happening over who gets the patients and who is gets to have the ultimate authority in patient care. The video is not up from yesterday’s hearing yet, so I don’t know how it went, but the dispute, I think, illustrates a larger push going on across the country. The national American Medical Association initiated a “scope of practice” partnership campaign a couple of years ago to work at the state level through rules and lawsuits to restrict the practice of non-physician providers and have oversight of other professions (such as over nursing boards, and often couched in language about expertise and safety), and has expressed an intent to target advanced practice nurses in the past. The Coalition for Patient’s Rights was formed in opposition to those efforts, and includes a number of advanced practice nursing organizations. So while a seemingly tiny language change may not appear to be a big deal, it may be part of a larger turf war in healthcare, one that attempts to limit patients’ choice of providers.

Note: This really, truly is not my area of expertise, although it’s something I’d like to understand better. If any of you know more about this specific situation or about how the AMA efforts have been playing out across the country, I’d be happy to hear about it in the comments.

5 Comments leave one →
  1. August 27, 2009 10:33 am

    Hmm, I find this a little confusing, too. The nurse midwife who was at the school where I trained is a nurse practitioner. She is certified as an ARNP. I guess not everyone who is a CNM is an ARNP?

    She definitely prescribed medicine, with definite limits. She signed our scripts for antibiotics for group B strep positive mothers, among other meds. If we had to rely on a supervising physician to do so, it would be a burden. However, direct entry midwives already have to do that.

    • Molly V Walker, CNM permalink
      August 28, 2009 9:02 am

      Yes, CNM and ARNP are similar, yet separate advance practice degrees and have separate licenses. In the state of New Jersey, I hold my RN license under the Board of Nursing and my CNM license under the Board of Medical Examiners. It is a little different in each state. I got my RN/BSN from Vanderbilt, my CNM/MSN from Penn.

  2. Becky J. permalink
    August 27, 2009 10:36 am

    As an RN this sort of thing makes me incredibly angry. If we want to make health care more efficient and affordable a huge thing we need to do is get more advanced practice nurses out into the field, not less. Studies have shown nurse midwives in particular provide just as good, if not better, care than physicians and at a much lower cost. Thank you TMA for putting physicians’ profits ahead of your patients’ health.

  3. Michael E. Conti, CRNA, MSN permalink
    August 27, 2009 12:29 pm

    This proposal, in its current form, will increase health care costs and will limit access to health care, particularly those in rural Tennessee. Since rural areas tend to have less physicians per capital than urban areas, Certified Registered Nurse Anesthetists seek to provide care to those individuals who otherwise may not seek care outside of their rural area or may have to travel a great distance. Healthcare consumer costs would increase as basic, routine non complicated care would be provided practitioner at a higher fee for the same service. Outcome studies have proven no statistical difference between routine care provided by a physician or an advance practice RN, i.e. a CRNA.

  4. June 25, 2010 3:58 am

    The restriction should apply only when a higher medical authority is permanently available, like in hospitals.
    Otherwise, when they are experienced and/or with advanced practice,
    registered nurses should be allowed to prescribe medications, most especially in critical or emergency cases.

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