The following is a summary of the Coalition on Nursing Futures' conference held May 1-3, 1997. This summary presents areas of consensus, areas that need further development, and recommendations that resulted from the conference. We welcome your responses and feedback to this material.
This article is presented in several parts: Background information on why and how this conference came about; an overview and context of the changing health care climate driving the topical areas for discussion; areas of consensus and those areas needing follow-up; and an appendix, including brief summaries of the formal presentations delivered at the conference.
The American Academy of Nursing (AAN) and the Coalition on Nursing Futures convened a two-day conference May 1-3, 1997, in Miami, Florida, called Nursing Futures and Regulation.
The planning group for the conference was chaired by Barbara Nichols for AAN and included representation from the American Nurses Association (ANA), the American Organization of Nurse Executives (AONE), Commission on Graduates of Foreign Nursing Schools (CGFNS), National League for Nursing (NLN), American Association of Colleges of Nursing (AACN), National Federation of Licensed Practical Nurses (NFLPN), and the National Association for Associate Degree Nurses (NAADN). In addition to representatives of these organizations, State Nurses Associations (SNAs), State Boards of Nursing (SBONs), and nursing organizations representing specialty practice were invited to send members to the conference.
The impetus for the conference in part grew out of a December 5, 1995 meeting held by the National Council of State Boards of Nursing (NCSBN) following the release of the Pew Commission report of the task force on Health Care Workforce Regulation which raised a number of controversial recommendations and conclusions about the future of nursing practice and its regulation.
The objectives set for the Nursing Futures and Regulation conference were to:
- help nursing leaders discuss diverse perspectives on six important regulatory issues and to identify areas of agreement and disagreement. The six issues included:
- scopes of nursing practice,
- articulation of education and practice,
- continuing competence,
- regulatory systems, and
- roles/responsibilities of professional associations and state regulatory boards;
- develop consensus on policy options and a plan that can be used as a frame of reference to revise existing health care workforce regulations;
- identify regulatory reform issues that require further in-depth analysis and discussion;
- facilitate ongoing INTERNET discussion on unresolved issues and potential policy options.
Formal presentations from multiple perspectives (Appendix A) were given on scopes of practice, legal issues of delegation/accountability, articulation of education and practice, assuring continuing competence, regulatory systems-evolving models, and roles and responsibilities of professional associations and licensure bodies. Each speaker was requested to include policy options.
OVERVIEW AND CONTEXT OF THE CHANGING HEALTH CARE CLIMATE
I. Overview and Context for the Conference
Health care in the U.S. is undergoing a dramatic transformation, that is clear. What is not as clear is where health care will end up by 2010. What follows are four plausible scenarios of where the future might head (based on the work of Clement Bezold, Institute for Alternative Futures, adapted from "Five Futures,"The HealthCare Forum Journal, May/June, 1992).
Scenario 1: Business as "Usual" -- National health care reform was sent back to the states, resulting in great diversity. Expensive advancing technology and therapeutics, including function-enhancing bionics, help healthcare's share of the GNP grow to 17 percent by 2005. Health care providers shift to forecasting and then managing illness far earlier and more successfully. Poverty and lack of access to healthcare persist.
Scenario 2: Hard Times/Government Leadership -- Recurrent hard times and a political revolt against healthcare lead to a frugal Canadian-like healthcare system. Most states follow Oregon in consciously setting priorities. Heroic measures for terminal patients decline and more frugal, yet successful, approaches to innovation are adopted. Healthcare's percentage of the GNP is reduced to 11 percent by 2001. Thirty percent of Americans "buy up" to affluent, higher-tech care, and two different systems of healthcare emerge.
Scenario 3: Buyer's Market -- Many thought the Eighties was the decade of healthcare's entry into the marketplace - that competition would lead to better, less expensive service. What failed during the Eighties worked very well over the next two decades. Markets, including healthcare, now do a much better job of giving consumers a range of high-quality services, delivered in convenient ways at relatively low cost over the long term, while maintaining a high degree of innovation. These amazing changes are coupled with better social policies to blunt the inequities and lack of access that accompany the stronger market approach.
Scenario 4: Health Gains and Healing -- Virtually all homes have highly intelligent information systems. Healthcare organizations, their customers and the communities they serve joined to develop and pursue powerful partnerships and shared visions. These generally lead to health gains, through a variety of paths. This activity was reinforced by "smarter markets" which allow consumers and large purchasers to understand the outcomes of health care providers both for individuals and for the communities they serve.
There are many forces that are converging at the national and international levels that make it imperative for local efforts on health care workforce regulation to result in consistent, efficient, and enforceable policies. Four issues identified by nursing leaders as affecting nursing regulation, practice, and education are: the changing finances in the evolving health care systems, including the lack of public money, corporatization, and lack of reimbursement for alternate care providers; the evolving global community with implications for disease transmittal as well as globalization of health care systems and the workforce; the technological advances and expanding ability of individuals to access information and specialists; and the empowerment of nurses for expanding access for all populations to quality health care.
The meeting was convened by The American Academy of Nursing, in collaboration with major nursing organizations. The purpose of the meeting was to discuss and reach consensus on regulation for the future that will promote effective health outcomes and protect the public.
AREAS OF CONSENSUS AND FOLLOW-UP
Areas of Consensus
- There should be a single core scope of practice for all of nursing roles and functions in regulation.
- Nurses are responsible for the regulation of nursing practice.
- There are generic minimal competencies for entry and continuing practice for all levels of nursing practice to ensure public safety.
- A national strategic plan for the transition to an articulation model for nursing education should be developed and used.
- Assessment of nursing competence is essential to assure the protection of the public. New methodologies to assess an individual nurse's initial and ongoing competencies must be developed. Methods to "trigger" events or indicators of the need for competency evaluation should be identified and developed.
- New models of licensure should be developed to ensure consistency in minimum competencies across state boundaries and between nursing and other disciplines, to allow flexibility in the changing health-care systems without diminishing assurances for public safety.
- To facilitate a national model (even international) for licensure to protect the public, that reflects core nursing scope of practice, the ANA and NCSBN should collaborate on one model practice act, that is disseminated and used by all SNAs and State Boards of Nursing.
- Continued exploration of regulatory systems that ensure accountability for the practice of nurses, such as the driver's license model with states accountable for the practice of nurses who reside in their state, and also allows flexibility and adaptability to the changing health care system is essential.
Areas Needing Additional Analysis and Discussion
- The purpose, roles and responsibilities of statutory entities and professional associations, inclusive of all levels of nursing, needs articulation.
- Common areas of interest and concern need to be identified among ANA, NOADN, and NFLPN and an ongoing dialogue should occur.
- Consensus needs to be developed among nursing organizations and other health care organizations at the state, regional and national levels on regulatory issues.
- Nursing should respond to the demand of the public for population focused quality health care. This should drive future nursing education and practice requirements related to entry into practice.
- There should be continued exploration of common nursing education, practice and regulatory issues with nurses in other countries.
- Regulatory organizations should use a basic set of standards that form the foundation for all nursing practice.
APPENDIX A -- SUMMARY OF PRESENTATIONS
There are many different ideas and perspectives within nursing about regulation of practice. However, the public and consumers concerns must be recognized as well. An open dialogue about the issues outlined is necessary to advance the profession of nursing and build on our strengths.
A. Scopes of Practice
There are fifty different nursing practice acts and interpretations. These have developed historically around physician practice acts in an effort to avoid overlap. States have utilized the ANA model, the NCSBN model, and developed hybrids of their own to meet specific needs. There is general confusion in the nursing community over what is written in legislation, what is included in regulations and descriptive definitions, educational requirements, and standards and scopes of practice as defined by the profession. We need clearly stated and uniform standards, scopes of practice and educational requirements that articulate an independent scope of practice for nursing.
ANA Scopes of Practice
ANA is working collaboratively with specialty nursing organizations in updating the standards for clinical nursing practice and in developing new areas of clinical specialty standards. Experts are working to define practice in a measurable way using a common language and format. As science and technology continue to advance, nurses practice within many scopes and standards of practice. Specialty practice in nursing crosses many domains. The intent is not to restrict practice but to acknowledge the common dimensions of practice. Issues to be addressed for the future include the following: (a) the need for a common scope with specialized guidelines; (b) certification only or other forms of recognition for licensure; recognition of the rich diversity of practice versus exclusive domains of practice regulation; and (d) recognition of the shift in the nature and scope of nursing practice, promoting the contemporary nature of standards of nursing practice.
Mary Joan Ladden
The traditional definition of interdisciplinary practice is two or more disciplines working together, usually forming a core team with additional disciplines participating on specific programs or problems. The goal is to manage the care across the continuum. Frequently, there is parallel practice with communication, but not true integration. A recent development is to see true integration and collaboration in the provision of services to patients and their families. New team members include health insurers, employers, and consumers. Emerging interdisciplinary models are more population focused, value real collaboration, keep membership and leadership fluid, welcome new team members, and focus on outcomes. Recommendations for the future include the following: document outcomes (quality, cost, and access) and the impact of different models of care; cultivate new models of care; focus on complementary nursing practice versus substitution; describe successful models and the impact on outcomes; and educate practitioners for core skills, such as the evaluation of population needs and negotiation skills.
Roles & Activities Across the Continuum
Ann Marie Brooks
We need to think differently about nursing roles and positions with our changing health care systems in rapid transition. We can no longer use simple functional titles as we cross the continuum of care. This is a time of unlimited potential and we need to be opportunistic. Students must understand that they will not have a job in a setting, but will have a career in health care with new roles serving new populations. The traditional knowledge, skills and abilities expected of practicing nurses must be translated into competencies. It is these competencies that should be recognized in our statutes and regulations. Competencies should be responsive to patient needs and the needs of population groups. Nursing roles and responsibilities will be linked with common goals shared with our evolving organizational systems and with educational programs and continuous learning. Nurses should be prepared to practice across settings and be accountable for patient outcomes, patient advocacy, and coordinated care.
B. Issues of Delegation/Accountability
Authority is the power to act and accountability for action needs to be considered from an internal and external perspective. Nursing practice can be viewed as an up side down pyramid with limited practice at the bottom and independent practice at the top. Delegation is essentially a management tool for working through people to complete tasks. Policies are guidelines for actions. So as we consider delegation and accountability within regulatory authority, we should stay focused on the need for nurses to use judgement and the need to learn when and how to delegate. A list of tasks does not work. We also should consider that there are other options to delegation, such as consultation. Nurses may not have control of delegation but nurses are accountable for the process.
Legal Issues of Delegation and Accountability
Delegation is a tool where tasks are completed through others. All states allow nurses to delegate even when the word delegation is not mentioned in the nurse practice acts. There are 3 approaches to view delegation in nurse practice acts: (1) the act may be silent and not addressed; (2) it is given in general authority, i.e. the definition of scope of practice; or (3) in preemptions to practice.
Licensed nurses are accountable for delegation decisions. Seldom are they accountable for all aspects of delegation. Among the nursing community there is generalized confusion regarding delegation, where a universal language would be beneficial. Nurses need to be taught the concept and authority of delegation-- it is an acquired skill. The outcome of delegation should not affect the quality of care. Thus, research based outcomes are needed.
Consumer Driven Care
Policies are guidelines for practice. When evaluating policy, look first at existing practices. If it is found less than substantial, change the practice. As a recent hospital patient and regional coordinator of the Prostate Cancer Network for Florida, the general concerns of consumers were stated. They are as follows: (1) to whom is the nurse responsible to, the patient, the physician, and/or the institution; (2) what connotes proper patient treatment; (3) is the nurse obligated to carry out an incorrect medical order; (4) how are patient requests which are not ordered by the MD accomplished; (5) who reviews the medications provided; (6) what are the managed care restrictions on providers; (7) improperly or inadequately trained personnel; (8) dress code relaxation; (9) who is the final decision maker with a team approach; (10) communication channels as the patient looks to the nurse for explanations; and (11) how do nurses keep pace with current information. These issues are all very important as the patient looks to the doctors and nurses for help.
Health care systems
We already have examples of organizations that cross state boundaries, i.e. the military. The Veterans Administration (VA) provides a model of licensure which transcends state jurisdictions. The problem: Advanced Practice Nurses (APNs) will not risk performing a task within the VA if the given state does not recognize it within the nurse practice act. Other options need to be developed and reviewed for nursing to maintain competence within the profession. Licensure and certification need further clarification. Certification tends to focus on a specialty area. Thus, nursing may further narrow its field of practice. Consider which method, licensure or certification has the greatest potential for keeping up with change. Laws lag behind practice. Certification has the option to lead practice. Another option is privileging in organizations. This includes the assessment of skills and knowledge. Usually this is built into job descriptions as one way of assuring competence. Our existing data base for decision making regarding competency is not adequate. Presently, we cannot link individual practice with patient outcomes. Through certification with national licensure the issue of liability arises. Aside from CEUs, competency is dependent on complaints or legal aspects creating negative overtones. There is a need for both positive and negative identifiers for tracking. From identifiers, nursing can develop a measuring tool for competency evaluation. Is credentialing in a given area of practice important enough to nursing to address our own accountability to manage these tough issues?
C. Articulation of Education and Practice
In comparison to Canada and the U.K., the U.S. has the highest percent of the gross national product (GNP) spent on health care expenditure. Yet, all countries are interested in decreasing this cost. All countries have the same key issues for rethinking health care. The momentum for change is lead by the following: (1) the population is aging thus, changing the type of service and changing the demand for service. The Duke Study (1982-1994) found less disability than projected and the population is healthier than expected. (2) There is a paradigm shift moving away from looking at individual episodic management of a health issue to managing disease cohorts in populations. We need to decide where to focus time and management. (3) New technologies ie. telemedicine and telenursing have arisen; (4) The consumer will play a more prominent role in health management. To assist with these changes nursing needs to develop a position that brings clinical operational issues and thoughts from a system to a population perspective.
BSN as Entry
Health care reform failed because the public was unwilling to subsidize care for those who cannot pay. This conflicts with nursing's view of health care as a right. If it is not a right, then the fundamental issue of health care providers giving health care to as many people as possible is inconceivable. Nursing's mission is to improve the quality of patient care. First we must improve the caliber of those who provide care. Both nursing and health care are ripe for change.
Nursing needs to address five issues for change: (1) access to education programs; (2) adequacy of education programs; (3) appropriateness of preparation of the nursing workforce; (4) advance of the discipline through education; (5) articulation of episodic programs into integrated mechanisms for education of the nursing workforce. Some nursing education programs prepare nursing for only one segment of the health care industry.
The future of health care is based on a system of care where services cut across settings for care. Four elements characterize the future of the health care industry: (1) case management; (2) education and prevention; (3) surveillance and monitoring; (4) care.
We created a caste system in nursing. We accommodate change in the health care system within a paradigm of nursing education. Recommendations are as follows; (1) slow the rate of new admissions into nursing; (2) increase the preparation time; (3) produce more homogeneity; (4) consolidate educational costs; (5) retrain the existing work force for what changes are occurring.
We need to become one in spirit, not in opinion. To give nursing back its' future, we need to be competent in care management, information management and resource management. We must learn to manage health across the life span.
Diversity in Meeting Community Needs
The most important strategy to meet the educational requirements for nursing is to organize local communities, regions, and states in a local regional collaborative system - an ongoing network. We need the commitment to bring diverse organizations together for the common good of health care and nursing.
Studies of nursing mostly look at numbers. Educational policy used to be driven by the nursing shortage. A seamless educational system is required. We need to change the curriculum to accommodate workforce changes. Once this is accomplished, we can discuss entry into practice. We need to consider other disciplines when we make policy decisions. We need to think of our profession in an economic, political and societal context. Our nursing education system needs reform to reach the changing health care system.
Foreign Graduates and Educational Requirements
There are two types of occupational visas for registered nurse. (1) The H1B temporary visa requires a bachelors degree or equivalent, and permits a stay up to 6 years. Per year 65,000 are granted. (2) Trade NAFTA, (TN Visa), permits a 1 year entrance and can be extended annually. It is not capped in Canada. Mexico is capped at 5500 per year during the first 10 years of the agreement.
The regulation of international mobility of nurses is challenging due to the different, inconsistent, and conflicting regulations and practices. Nurses must examine how to promote free trade. NAFTA eliminates citizenship and permanent resident requirements for North American Nurses who wish to practice in a country within the treaty. It provides procedures to review qualifications and promotes mutual recognition based on objective criteria. The practice of a licensed professional still requires compliance with all applicable state regulations which may vary from state to state.
There are eight strategies for change where the common ground must be achieved through collaborative efforts for nursing education, regulation, and practice.
- Education must demystify the global trends that affect nursing practice in the U. S.
- Education and practice must take an active and collaborative role in recognizing value in different cultures through formal and continuing education which addresses regulation, education, and practice issues through an international perspective.
- Countries must collaborate and pull together resources to establish international methods for assessing qualifications and equivalence of education.
- Globalization of nursing can only be achieved thru collaboration.
- Trade agreements provide unparalleled opportunities to nursing. In 1994, the Trilateral Initiative for North American Nursing was the first organized effort by health care to identify opportunities presented by NAFTA. The outcome was the publication of the monograph, An Assessment of North American Nursing: The Trilateral Initiative of North American Nursing. This is an assessment of North American Nursing in four different aspects: nursing program accreditation, education, licensure, and special certification.
- Common standards are vital to protect consumers and maintain professional integrity. Increased international partnerships lead to growth.
- Develop an understanding of the global economy and how it affects nursing.
- Nursing must learn to master the technology that allows international collaboration and communication.
To promote nursing across borders is challenging. We need to form new alliances. This will help us look from a broader perspective and expand our vision when change presents unique opportunities to nursing.
D. Assuring Continuing Competence -- State of the Science
Dorothy del Bueno
We must hold nurses accountable for changing their behavior. Then we will see change in the practice. We already know what does not work in assuring competence.
- Mandatory CEUs -- there is no evidence that it changes overall behavior.
- Credentials, there is not a measurable difference.
- Skill or job analysis is not relevant to assuring competence.
- Scores and multiple choice questions are not real life. We take care of patients not questions.
- Technical procedures.
- Policies and absolutes.
There are three dimensions to competency: critical thinking, interpersonal skills, and technical skills. Previously, what had been evaluated was the ability to use knowledge in the context of taking care of patients. People are not equally competent in all skill dimensions. Critical thinking determines safe practice. The entry ability is what we call safe e.g. risk management. Can the nurse identify essential data indicative of acute changes in health status? If you recognize it, do you initiate actions that at least minimize the problem?
A study was conducted over 5 years of 58 acute care hospitals. A 10% sample was drawn representing 50,000 RNs with 6 months experience in their area of practice. The findings were as follows:
- 67% of the experienced nurses (at least 6 mos of experience) met at least safe practice.
- of the inexperienced nurses or new graduates, only 38% were considered safe. The manager makes a big difference to the degree to which she holds everyone accountable.
- of the unlicensed assistive personnel, 84% meet expectations.
It is not that we ought to ensure competence, it is how we ensure it. We need to measure and look at competence, not some surrogate that is not competence.
When determining a mechanism for continued competency, a balance should exist between nurses rights and client protection. Nurses have a right to draft prescriptions describing what is expected from them. An agency undertaking competency should recognize its own liability. What are the goals of competency? Is it for remediation? Then a needs assessment for strengths and weakness for practice should be developed. Is it for removal? Then patterns of behavior should be evaluated vs. a single incident. Is it to promote commitment to profession? Then consider professional mobility in practice. Is it for minimum safety? Then, should the nurse receive a limited practice license?
What are the evaluation points for continuing competency? Some states are looking at national licensure for clinical examination with state standardized educational requirements and state examinations to evaluate nurse juris prudence which is now omitted from the NCLEX.
To maintain current records for competency of RNs in the U.S. we could do the following:
- audits of total population
- trigger patterns of minor complaints, absence in reentry or change in specialty area, prior discipline or multiple jobs in a short period of time.
The Pew's Report on continuing competency in nursing states the following: (1) no assurance for continuing competency after initial licensure; (2) no demonstration of competency now required; (3) too much time on CEUs as best proxy for competency; (4) standards are inconsistent between states and professions.
The Pew's recommendations to the above: (1) standardize entry requirements; (2) change current practice acts to reflect initial continued competency; (3) built in evaluation mechanisms within Boards of Nursing; (4) provide uniform discipline processes that are cost effective and fair so one can exclude incompetent practitioners.
The Citizens Advocacy Center raised questions for continued competency to be considered when we make decisions:
- What techniques will be employed?
- How frequent?
- Should practitioners be given options to chose?
- Should it be a requirement of all?
- Who will pay?
- Should remediation be allowed?
- What relationship should exist between licensing and certifying organizations?
- What assurance can be given that recertification meets legal standards of fairness, reliability, nondiscrimination and accuracy?
E. Regulatory Systems -- Evolving Models
There are two different types of regulation: economic and social. Economic regulation covers sectors of our American economy. Examples are banking and electricity. It began during the "New Deal." Social regulation came about in the late 1960s.
Economic regulation takes the form of overt barriers to entry or exit, licensing, tariff, price and wage control. Many economic regulations have been repealed or reformed as these rules have made markets less competitive, lessened overall consumer welfare, and discouraged economic efficiency. Regulation affects our economy. Costs increase to comply with regulation which decreases workers wages. Regulation today is one of the most politically convenient ways to carry out public policy as it does not require a specific government expense. Costs are hidden and hard to measure and follow. We need to help the public understand the economic consequences of regulation by exposing these hidden costs. For example, let's look at electric companies.
The electric company is the last surviving monopoly in the U.S. Few have a choice as to who delivers their electricity. It is governed by outdated, overlapping, and confusing laws similar to the health industry. How was the electric company able to survive? It excluded new rivals on the market through competition and developed a notion of a needed monopoly power to justify intervention by state regulatory boards. The Public Utility Commission (PUC) was developed to protect this monopoly. The PUC provides an area with a price but guarantees these monopolies freedom from competition. Federal intervention failed as it hindered state and local new enterprise.
Free market vision is based on time tested principals of our economy. It increases consumer choices, innovations and competition. To deregulate correctly, the market needs to be a free market.
Proposals are slowly moving toward the Clinton Health Plan. The #1 underlying problem with health care is that the typical American family does not have the opportunity to choose their own health care insurance. The employer chooses the insurance and the insurance company works for employers to keep the cost down. When the consumer is dissatisfied, they cannot choose. Thus, we see a lot of mandates. Mandates are only a temporary solution. The unintended effects of mandates are the increased cost of health care. Insurance increases cost and is less accessible. Inappropriate medical stays have developed. There is a decreased incentive to find new and innovative services.
Our challenge is to stop Congress micro managing medicine. Americans want better access to higher quality lower cost care.
The primary reason for regulation is to advance and protect the public interest. Regulation promotes quality among health professions, equity among professionals and an emphasis on quality care. It has changed from a monopolistic focus to consumer driven focus. In Canada, health care is federally and provincially regulated. Health professionals are regulated by provincial issues. The Ontario Model, e.g., Regulated Health Profession Act (RHPA), was instituted in 1993. It is the first attempt to place expectations on 21 professions. Previously recognized and unrecognized professions were included. Midwives greatly benefited from this as now they are a bonafide health profession.
There are 6 major elements of the RHPA: (1) public participation and openness; (2) client relations; (3) entry into practice; (4) professional misconduct; (5) quality assurance programs; (6) scope of practice.
The RHPA is structured by a procedural code which describes how health professions are governed and a structural code which describes the structure of interaction between professions. Each profession has its own specific act. Regulations are developed here with specific parameters related to 6 major elements of the RHPA. The regulations are based on each professions template.
The RHPA has developed quality assurance programs for each profession which will begin in 1998. Their goals are to assure quality of practice for professionals and promote ongoing competence of members. Competence at entry level practice is very broad. With expertise, competence is more complex requiring self assessment of skills in the changing health care environment. There is a focus on the practice setting, peer feedback, self assessment, developing and implementing a learning plan, joining an organization, reading professional journals, or taking courses.
The RHPA has a scope of practice model with a focus on client outcomes vs. professional turf. It consists of 5 elements: (1) scope of practice which is a general statement of what the practice performs from LPN-RN; (2) 13 controlled acts are developed by regulators, and licensed authority is required to execute them; (3) authorized acts to each profession. Some professions overlap. Medicine does not have total control. (4) The risk of harm clause states that any professional, even an unregulated person, is liable. (5) Series of exceptions where unrecognized people can perform parts of a regulated act.
It was thought that the RHPA will increase consumer choices and flexibility, promote expansion of professional practice, assure recognition and acceptance and eliminate bureaucratic codes. The turf issue will continue until we all realize that we are all have overlapping competencies.
New practice methodologies and practice measures have brought licensure to the forefront. Telemedicine is an interactive long distance health care delivery system with the consumer in one location and the health care deliverer in another. It involves interstate commerce regulation by the federal government. In medicine, state licensing laws are seen as a barrier to telemedicine. If states continue to close boarders to telehealth practice, it invites the federal government to consider preemption of state laws or federal licensure.
There are disagreements regarding where telemedicine occurs. The Federation of State Medical Boards states that the patient is the location. The American Telemedicine Association states that it is where the practitioner is located. When telemedicine occurs within state boundaries it is widely accepted. It increases access to rural areas and brings specialized expertise to remote areas.
To cross state boundaries with telenursing we need a "harmonization approach." The first step is to believe that telenursing is nursing. These are licensed nurses using critical thinking, knowledge, judgment, and skills.
When discipline is required, it is the duty of the state to discipline or retrieve the license using full due process rights. The US Constitution, Article 4, Section 1, states, "Full faith and credit shall be given in each state to the public acts and judicial proceedings of every other state." The other discipline system is the torte system. This uses the consumer's state as the disciplining ruler. Under this system, it can be harder to monitor the nurse.
If we want to continue state licensure with the advancing technologies we must cooperate and share data.
Nursing regulations were developed to set standards. They determined who was and who was not qualified to practice nursing. The state boards of nursing developed their own boundaries and parameters for each particular state focusing on each state's needs. The current regulations need to change to accommodate the changes occurring in the USA. The catalyst here is telemedicine.
Telemedicine often crosses state boundaries. The HCFA estimates that telemedicine with cognitive care and quality people, can save $17 billion per year. Is this nursing? Some answer "yes" as it is an individual assessing a client using skills, knowledge, etc. Others say it is not nursing. It does not contain hands on care - just algorithms.
The NCSBN is recommending a hybrid tool for licensure using a format similar to a drivers license, a component of mutual recognition.
F. The Roles and Responsibilities of SNAs and State Licensing Boards
State Nurses Association
Significant differences occur among state nurses associations with regards to resources, styles and leadership. Recommendations for improvement of relations between State Boards and State Nurses Association are as follows:
- State Nurses Associations and State Boards need to understand each other.
- Need to be effective with legal resources.
- Know what the appointment process is for each state.
- National organizations must understand legal regulations of the profession at the state level.
- Openness to full exploration and discussion.
There is a lack of trust between State Boards and State Nurses Associations. This is attributed to a lack of understanding of what the other does. Boards have the legal ability to act. Associations are supported by volunteer members. There is a major difference in how each one executes their responsibilities. Boards represent RNs and LPNs. Associations advocate for one or the other. Both groups feel the need to define the scope of practice. The law mandates the board to do this. However, we need a collaborative working relationship between State Boards and State Nurses Associations in order to implement changes effectively.
Affara, FA, and Styles, MM (1992) Nursing Regulations: From Principle to Power. Geneva, The International Council of Nurses. Pp 97-101.
Report of the Task Force on Health Care Workforce Regulation (1995) Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century. San Francisco. Pew Health Professions Commission.
Safriet, BJ (1992) Health care dollars and regulatory sense: The role of advanced practice nursing. Yale Journal on Regulation 9:2. Summer.
Trilateral Initiative for North American Nursing. (1996). An Assessment of North American Nursing. Philadelphia: Commission on Graduates of Foreign Nursing Schools.
© 1997 Online Journal of Issues in Nursing
Article published November 6, 1997.