By Judy Collins, RN, MS, WHNP-BC, FAAN and Diane Hanna, RN, MS, FNP-BC
- Task Force Interim Study Report on Limited Prescriptive Authority states “No other issue generated evidence so credible and persuasive that restrictive policies should be reexamined as the issue of limited prescriptive authority for nurse practitioners. That evidence has determined the following conclusion and recommendation:”
Current restrictions on the ability of nurse practitioners to prescribe a limited range of medication in Virginia inhibit the delivery of safe, accessible, cost-effective quality care.
The Task Force recommends that limited prescriptive authority be granted to nurse practitioners, consistent with regulations to be established by the Committee of the Joint Boards of Nursing and Medicine for the Certification of Nurse Practitioners.
“This recommendation is based upon extensive testimony, comment, and expert opinion, as well as review of the experience of thirty-four states in which nurse practitioners currently have legislative authority to prescribe.”
- Based upon this recommendation from the Task Force and the ground swell of support from many arenas, the VCNP moved forward to propose a bill for Limited Prescriptive Authority for Schedule VI drugs for NPs and CNMs. (The CRNAs ask to be exempt due to potential issues related to non-Schedule VI pre-op medications ordered in the hospital for their practice vs. written prescription.)
- HB768 was introduced by Delegate Mary Marshall, a senior, well- respected member of the House of Delegates.
- The VCNP engaged the services of Mark Rubin of the Shuford, Rubin and Oksman Law firm, the VNA lobbyist, to assist with the passage of HB768. Unfortunately, Mr. Rubin had a conflict of interest with another client and he referred us to another lobbyist to assist with the bill. VCNP started “passing the hat” at every meeting and making request for donations from members and regions to raise money for the lobbyist!!!
- HB 768 was scheduled for the first hearing in the Health, Welfare and Institutions Health Standards Sub-Committee chaired by Delegate David Brickley. Dr. Clementine Pollok, President of the BON, several NPs from a variety of settings and supportive physicians were scheduled to testify. Delegate Marshall had a meeting with the House Appropriations which conflicted with the Sub- Committee Meeting. She contacted Delegate Brickley and he agreed to wait and hear HB768 the next week in the Sub-Committee. So, those scheduled to testify were called and told not to come, but reschedule for next week
- Judy Collins had returned from the General Assembly, after the decision was made to hear the bill the next week, to her office across the street at MCV/VCU. She received a panic phone call from a VDH colleague saying that HB768 was being heard in the Sub-Committee and being “torn apart” by the MSV. Judy called Delegate Marshall’s Legislative Assistant and she quickly got Delegate Marshall out of the Appropriations Committee while Judy ran across the street to the General Assembly to the Sub-Committee Room. Delegate Marshall rushed in with a red face and declared that in all her years in the General Assembly she had never been so double- crossed and treated in this fashion!!!
- Alas, it was too late to save the original intent of the bill since votes had passed on the amendments. The amendments had taken away prescriptive authority for NP’s and placed the language in a section of the law that permitted NPs to “scribe a prescription” for the physician to sign–thus a secretarial role!!!!
- A debriefing was held in Delegate Marshall’s office with the lobbyist and some NP leaders who could return to the General Assembly. A decision was made to carry the bill over into the 1991 session as opposed to rewriting the drastically amended bill that had come out of the sub-Committee. This was a case of “know when to hold the and when to fold them’!!! (Multiple phone calls were made late into the evening letting VCNP members know what happened and the game plan for the next year!!)
- The next morning the amended HB768 was to be heard in the full HWI Committee, chaired by Delegate Sam Glasscock. House Room C Committee Room was packed with physicians, many in lab coats and their lobbyists. However, there was absence of many NPs who were called and told to stay at work and care for their patients. When the amended HB768 was reported out of Sub-Committee by Delegate Brickley, Delegate Marshall was invited to the podium to discuss her bill.
- Delegate Marshall asked the HWI Committee to carry the bill over to the 1991 Session of the General Assembly. Chairman Glasscock asked Delegate Marshall since it was early in the session; did she not want to try for a compromise on the bill? Delegate Marshall stated, “It will take a lot of light in dark places to fix the bill” so we will be back with the legislation next year. (Note: The physicians, physician groups and their lobbyist were stunned!!!)
- Members of the 1990 General Assembly approved Senate Joint Resolution No. 24 requesting that the final report of the Task Force be submitted to the Senate Committee on Education and Health and the House Committee on Health Welfare and Institutions during the 1991 General Assembly.
- VCNP members “dusted themselves off” and developed a positive strategy to move forward with a goal during the year to have an NP and collaborating physician in each political district meet with each member of the House of Delegates and Senate to educate them about the bill, the need for limited prescriptive authority with a focus on NPs providing improved access to care for patient and their families.
March 1990 – December 1990
- Following the decision to pull HB 768 during the 1990 General Assembly Session with a plan to re-introduce prescriptive authority legislation during the 1991 session, VCNP spent the rest of the year educating legislators about the NP role and building coalitions for support.
- VCNP developed legislative packets for NP’s and their collaborating physicians to use during visits with legislators from their home districts. Legislative visits with all 140 members of the General Assembly were coordinated. VCNP members Terry Tempkin, Susan Lawless, Bonnie Atkins, Mary Nottingham, Diane Hanna, and Judy Collins were instrumental in this effort. (Legislative packets and mass mailings meant late night envelope stuffing and often hand-addressing parties for NP volunteers . . . complimentary pizza provided!)
- Extensive work was done via US mail, phone chains, conference calls and local VCNP meetings to rally the NP community’s involvement in the legislative effort.(There was no FAX or email technology available at this point in time. Conference calls were costly and often covered out-of-pocket by those participating.)
- Mark Rubin (lobbyist) and Judy Collins, NP were featured on a video that was sent to each VCNP regional chair. This video served as an educational tool to prepare NP’s and their collaborating physicians for legislative visits with their delegates and senators.
- Lisa Baker, MD who was serving as an intern in the Secretary of Health and Human Resources office provided additional guidance and technical assistance in moving the prescriptive authority legislation forward.(It was strategically important to have an MD in the meetings with the MSV and VCNP to discuss all sides of the issue.)
- Clinical nurse specialists raised $500. for the VCNP legislative efforts. VNA pledged to donate additional legislative funds.(The political and financial support of the nursing community was key to our success. VNA’s financial and in-kind support was critical!)
- Physician’s Assistants expressed an interest in tagging onto the NP prescriptive authority legislation. VCNP believed that adding another provider group to the legislation could potentially cause confusion at this point in the process. PA’s lobbied for and attained prescriptive authority one year after the NP legislation was passed.
- At the Mid-Atlantic NP Conference in Roanoke (April 1990), Judy Collins, NP and Alan Tempkin, MD were recognized for their outstanding work on the NP Task Force and House Bill 768.
- The Virginia Health Planning Board (members appointed by the Governor; this Board’s work was staffed by the Department of Health) was also involved in the study of the NP prescriptive authority issue through their Task Force on Alternative Providers in Underserved Areas. This Task Force released a status report on their work on 6/19/90 covering the background of Nurse Practitioners and Physician Assistants, Current Delivery Settings of NP’s and PA’s, and Issues Related to the Practice of NP’s and PA’s. A Draft Discussion Paper addressing the utilization, distribution and reimbursement of these providers along with Barbara Coomb’s report “Review of State Laws Affecting the Use of Allied Health Professional in Underserved Areas” was provided to task force members in August 1990 as background for further discussion and recommendations.(The issue of primary care access for underserved populations continued to drive the policy discussions related to utilization of mid-level providers and barriers to their practice. These discussions entailed in-depth analysis of many related policy issues.)
- Judy Collins, NP was appointed to the state Board of Nursing (BON) by Governor Wilder. She was the first advanced practice nurse on the BON. This positioned her to provide critical education and guidance on NP prescriptive authority and other key advanced practice issues to members of the BON as well as the Joint Boards of Nursing and Medicine on which she also served.
- Diane Hanna, NP was re-appointed to the state Board of Health by Governor Wilder. This positioned her to provide critical education about NP prescriptive authority and key advanced nursing practice issues to members of this regulatory and policy-making board which is charged to “protect and promote the health of all Virginians”.
- A special prescriptive authority study group reporting to the Secretary of Health and Human Resources was formed. It was comprised of physicians (including a past president and the president-elect of the MSV as well as a former chair of the BOM), nurse practitioners, hospital administrators and a pharmacist. The group was convened to iron out any perceived difficulties with the concept of Rx authority for NP’s. The committee made several unanimous recommendations and one by a divided vote. The unanimous recommendations were, in summary:
- To support the granting of limited prescriptive authority to NP’s.
- The authority would be limited at its broadest to schedule VI drugs and limited further by NP/MD jointly developed written prescriptive protocols.
- The Joint Boards of Nursing and Medicine would govern prescriptive practices.
- The current practice of CRNA’s would neither be expanded nor limited by this legislation.
The only recommendation which was not arrived at by unanimous consent involved the scope of Rx authority for NP’s. The Subcommittee recommended that the authority be statewide while the physicians on the subcommittee wanted to limit the authority to only those NP’s employed by public health agencies and non-profit providers.
- In a random survey conducted by the Virginia Department of Health Professions, two-thirds of the physician respondents supported limited prescriptive authority for NP’s.