By Judy Collins, RN, MS, WHNP-BC, FAAN and Diane Hanna, RN, MS, FNP-BC
January – December 1991
- The Task Force on the Access and Barriers to the Services of Nurse Practitioners (established 1989), made the following recommendations to the Committee of the Joint Boards of Nursing and Medicine:
- The Task Force endorsed continued joint regulation of NP’s by the BOM and BON.
- Consider the need for definition and delineation of the scope of practice of NP’s.
- Include the definition of “collaboration” in statute or regulation.
- That state entities include explicitly the collaborative primary health care practices of physicians and NP’s and CNM’s in any program/initiative designed to address the resolution of problems related to the provision of primary health care services.
- That all hospitals and other health care entities be encouraged to review their bylaws to ensure that the use of the competence and expertise of primary care NP’s, CNM’s, and CRNA’s is facilitated to the maximum degree consistent with state law and regulation.
- That limited prescriptive authority be granted to NP’s, consistent with the regulations to be established by the Committee of the Joint Boards of Nursing and Medicine.
The Committee of the Joint Boards adopted recommendations #1-5. The sixth recommendation was lost on a tie vote when the nurse members voted “yes” and the physician members voted “no”.
(Despite the collaborative practice of many physicians and NP’s throughout the Commonwealth, there was still a strong division on this issue between the formal representatives of the medical and nursing communities. One NP colleague recalls an angry physician at a public meeting waving a prescription pad saying “you’ll never get this!”)
- Introduction of Prescriptive Authority Legislation to the 1991 General Assembly (January 1991)
House Bill 1402 (Del. Mary Marshall) and its companion Senate Bill 606 (Sen. Elliot Schewell) “To Enact Changes in the Medical Practice Act and Drug Control Act to authorize Schedule VI Prescriptive Authority for NP’s and CNM’s” were introduced into the 1991 General Assembly Session.
- Mark Rubin is now engaged as the VNA/VCNP lobbyist.(Tracking a bill day to day in the General Assembly became a full-time endeavor without internet technology. Updated copies of the bills, as amended, could be obtained from the “bill room” in the basement of the General Assembly Building.)
- VCNP members testified at public hearings, contacted their representatives in the House and Senate, and attended sub-committee and full committee meetings when the bill was taken up – sometimes addressing specific questions/concerns related to NP practice and the proposed legislation.(Without email technology available, the phone tree had to be activated for important legislative updates to the VCNP membership and guidance related to key legislative contacts. NP’s in the Richmond area frequently were called on to make last minute trips to critical House and Senate Committee and Sub-Committee meetings . . . this sometimes entailed frantic last minute child care arrangements, too!)
- Judy Collins, NP and Clementine Pollok, RN, PhD represented the Board of Nursing at committee hearings and other meetings to address questions and support the passage of the bill.
- Outside of the General Assembly, there were lively discussions during Board of Health meetings about the role of nurse practitioners in improving access to primary care services and the related prescriptive authority legislation. After much discussion, the Board of Health endorsed the NP Prescriptive Authority legislation at its January 1991 meeting.
- The legislation for the 1991 session was also supported by the Joint Commission on Health Care for all Virginians, chaired by Sen. Stanley Walker as well as the Virginia Health Planning Board.
- Several updates on the NP prescriptive authority legislation appeared in the Richmond Times-Dispatch as well as other local television and radio news media.
- During the annual Virginia Nurses Association Legislative Day in January, over 800 nurses marched to the State Capitol and met Del. Mary Marshall on the capitol steps. She gave an inspirational speech charging those nurses present to visit their legislators and seek their support of the prescriptive authority legislation for NP’s. In doing so, they would be supporting increased access to primary care services, especially in underserved settings where many NP’s worked. Following her speech, nurses could be seen in every corner of the General Assembly Building making their legislative visits. That afternoon, a call was received by Mark Rubin from the Medical Society of Virginia – the physicians were ready to negotiate.
- As the bill continued to move through the House and Senate, there were intensive negotiations between the MSV lobbyists (Madeline Wade and Sandy Kramer) and the VCNP lobbyists (Mark Rubin and Leslie Herdegen). At one point, the MSV proposed compromise legislation giving the Board of Medicine sole regulatory authority over NP prescriptive practices. In the end, compromise language from the MSV was agreed to where the number of prescribing NP’s a physician could supervise in a private practice setting was two. In a public practice setting, a physician could supervise the prescriptive practice of up to four NP’s.(The ratios agreed to in this legislation raised many questions later such as why were they adopted and did they promote a two tiered level of health care? As Mark Rubin paced from one end of the General Assembly Building speaking with the MSV and then returned to the other end of the hall to speak with VCNP representatives, it became clear that some form of compromise was the only way to keep the bill alive at the 11th hour. As the VCNP hoped, these disparate ratios were eliminated with legislative action during a subsequent General Assembly Session. Politics is the art of compromise!)
- HB 1402 (Marshall) and SB 606 (Schewell) were passed by the 1991 General Assembly
- The bill was signed into law by Governor Wilder on April 2, 1991.
- A reception to celebrate our success as well as recognize and thank our supporters was held on May 3, 1991 in conjunction with the Mid-Atlantic NP Conference held in Richmond.
- Total expenses for the prescriptive authority legislative effort were estimated at $25,000. $15,000 was underwritten by the VCNP legislative budget and generous contributions from the VNA and the VA Clinical Nurse Specialists. The balances of funds needed for the effort were collected from contributions by the regional NP councils and individual NP donations.
Following our legislative victory for prescriptive authority, the next phase of the journey became the development of regulations:
- The Joint Boards of Nursing and Medicine appointed an advisory committee to develop proposed regulations to implement the statute. Members of this Advisory Committee were:Judy Collins, NP, Chairman of Advisory Committee (BON)
Thomas Wash, MD, Vice-Chairman of Advisory Committee (BOM)
Pat Williams, RN (BON)
Sharon Bailey, NP (appointed by BON)
Gerald Bechamps, MD (BOM)
David Branch, MD (BOM)
Susan Shlifer, MD (appointed by both Boards)(This Advisory Committee was comprised of 3 nursing representatives, 3 physician representatives and one additional member jointly agreed upon by both Boards. There was some discussion about the joint appointee as the initial MD recommendation from the BOM did not have experience with NP’s. After further discussion, the above committee members were agreed upon. As in all phases of the regulatory process, the devil is in the details and the players are critical to the outcomes!)
- On 9/30/91 and 10/15/91 two important meetings were held at the MSV headquarters with representatives from the VCNP, the MSV, their respective lobbyists, and a CNM representative* to discover whether there was any common ground for agreement as to which Schedule VI drugs might be listed in an overall formulary for NP prescribing privileges. The goal was to select an acceptable list of Schedule VI meds and operate by exclusions rather than inclusions. Reference material for these discussions included the Code of Virginia, the approved formulary for NP’s in North Carolina, and the AHFS Pharmacologic-therapeutic classification. In ensuing discussions, the group agreed that the use of these drugs should be guided by the clinical protocol and not precluded by a restrictive formulary. After much thoughtful discussion, the group recommended that all Schedule VI meds be included in the formulary with the exception of radioactive drugs, ophthalmic steroids, ophthalmic aminoglycosides, and barbiturates. (VCNP representatives in attendance included Linda Hancock, NP, Diane Hanna, NP, Karen Saunders, NP, and Mark Rubin, esq.; Mary Ellen Bouchard, CNM served as the nurse-midwife representative.)
(Significant work and negotiations transpired here. After all of our struggles in the prescriptive privileges journey, it was hard to believe we were sitting around the Board Room table inside the posh MSV headquarters!)