HISTORY OF ADVANCED PRACTICE NURSING IN TENNESSEE
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Tennessee Nurses Association
History of Advanced Practice Registered Nursing in Tennessee
The 1969 Tennessee Medical Association (TMA)-Tennessee Nurses Association (TNA)-Tennessee Hospital Association (THA) Joint Practice Statement endorsed the expanding role of Registered Nurses (RNs) in hospital coronary care units.
1) Vanderbilt University established the first master’s program to prepare nurse practitioners (NPs) in Tennessee.
2) NPs were safely practicing and writing prescriptions as a delegated medical act in urban and rural areas in many different settings.
The U.S. Department of Health, Education and Welfare recommended that states enact amendments to their medical practice acts to codify the authority of physicians to delegate medical tasks to health personnel working under their supervision.
A TMA bill passed to amend the medical practice act to include a section to authorize delegation of medical acts stating: “Nothing in this chapter shall be construed as to prohibit service rendered by a physician’s trained assistant, registered nurse, or licensed practical nurse if such service is rendered under the supervision, control, and responsibility of a licensed physician.”
The Board of Nursing promulgated Administrative Rule 32 stating that RNs functioning in an expanded role who manage the medical aspects of a patient’s care must have written medical protocols jointly developed by the nurse and the sponsoring physician(s). [Board of Nursing Rule 1000-1-.04(3)(b)]
The 1976 TMA/TNA Joint Practice Statement stated that jointly developed medical protocols should outline delegated medical tasks and drug management to be used in patient care.
The Board of Pharmacy attempted to promulgate rules to authorize filling prescriptions written by NPs. The attorney general refused to approve the proposed rules stating there was no statutory authority for the rules. A group of plaintiffs, including the Primary Care Association, obtained a temporary restraining order to keep the Board of Pharmacy from enforcing their warning, and NPs continued to write prescriptions. TNA’s bill to authorize NPs to prescribe was introduced and passed the Senate
TNA’s bill passed to authorize NPs to write prescriptions under MD supervision and medical protocols, signing both the NP’s and supervising MD’s names, and, as amended in the House Health Committee, limiting prescribing privileges to sites approved by the Primary Care Advisory Board. [TCA 63-7-123]
TMA’s bill passed to change the delegatory clause in the Medical Practice Act to: “Nothing in this chapter shall be so construed as to prohibit service rendered by a physician assistant, registered nurse, or licensed practical nurse if such service is rendered under the supervision, control, and responsibility of a licensed physician. TCA [TCA 63-6-204(b)]
A bill passed to transfer from the Board for Healing Arts to the Board of Nursing the authority to issue a certificate of fitness to NPs to write and sign prescriptions and/or issue drugs. [TCA 63-7-123(a)]
TNA helped lobby a McWherter administration bill that passed to mandate Medicaid reimbursement for certified nurse midwives (CNMs). [TCA 71-5-107 (a) (22)]
The Black Health Care Commission initiated a bill to issue a temporary certificate of fitness to prescribe to first-time writers. TNA drafted an amendment to rewrite the bill and the bill passed. [TCA 63-7-123(c)]
1) TNA’s bill passed to mandate Medicaid reimbursement for the services of certified pediatric and certified family NPs just prior to the implementation of TennCare. [TCA 71-5-107(a)(23)]
2) TNA negotiated with TennCare officials to change “primary care physicians” to “primary care providers” and include NPs in all TennCare/MCO contracts as primary care providers.
1) TNA’s bill passed to delete the site approval process and allow NPs with a Certificate of Fitness and medical protocols to write prescriptions in any setting with medical supervision. [TCA 63-7-123]
2) Bill sponsored by the Black Caucus passed for private insurance reimbursement for certified nurse midwives. There was no action on the bill until TNA urged sponsors to move the bill and rallied the CNMs to help TNA lobby for its passage. [TCA 56-7-2407]
1) TNA’s bill passed granting the Board of Nursing the authority to jointly adopt all Board of Medical Examiners’ rules for supervising MDs. This legislation was necessary to halt imminent approval by the Board of Medical Examiners of lengthy and unreasonable proposed rules for supervising MDs that would have severely restricted NP practice and shut down clinics. [TCA 63-7-123(d)]
2) TNA’s bill passed to grant privileged communications between client and certified psychiatric mental health clinical specialists with same protections accorded to patient–psychiatrist. [TCA 63-7-125]
1)TNA’s bill passed to delete the requirement to mail copies of Protocols to the Primary Care Advisory Board. Protocols were to be maintained at the practice site. Copies of Formularies, by category, would be mailed to the Primary Care Board.
2) TNA’s bill passed to add advanced practice nurses (APNs) to the list of health care providers reimbursed by private insurers. [TCA 56-7-3408]
TNA’s bill passed to authorize prescription of controlled drugs, Schedules II, III, IV, and V. [TCA 63-7-123(b)(2)]
An Administration bill passed to sunset the Primary Care Advisory Board and require that copies of the formularies be mailed to the Board of Nursing. [TCA 63-7-123(b)(1)]
1) New rules for MDs who supervise NPs who prescribe were jointly adopted by the Board of Medical Examiners and the Board of Nursing. [Medical Board Rules 0880-6]
2) NPs began to receive DEA numbers to prescribe, dispense, administer and procure Schedules II-V controlled drugs.
3) TNA’s bill passed to prohibit discrimination against APNs based on license or class of providers with respect to participation, referral, or reimbursement in managed care if services provided are covered by the health insurer.
The Board of Medical Examiners proposed a strident set of rules to prohibit MDs from contracting for supervision with NP clinic owners or being employed by any entity providing services to persons who were not clearly identifiable as patients of the physician. The rules would have also adversely affected university owned clinics and health department clinics. TNA rallied the NPs, educators and others organizations who supported the practice of NPs to present testimony in opposition to the rule. There was no supporting testimony at the hearing. The Medical Board voted to table the rules and convene a joint medicine and nursing task force to further study the proposed rules. The task force did not materialize.
TNA’s bill passed to protect the title “Advanced Practice Nurse” and initials “APN” and grant the privilege to apply (“may” apply) for a certificate to practice as an APN. Sections of the original bill that attempted to remove the requirement for physician supervision were deleted as a compromise with TMA in order to gain title protection. [TCA 63-7-126]
1) At the request of the Board of Nursing, TNA proposed a bill that passed to change “may” apply to “shall” apply for a certificate to practice, making it mandatory for all APNs to hold a certificate in order to practice as an APN.
2) TNA’s bill passed to “deem” the prescription to be that of the NP rather than the MD and to require only the signature of the NP. The section in the original bill to attempt to replace “supervision” with “medical consultation and referral” was deleted from the bill as a compromise with TMA to gain ownership of the NP’s prescriptions.
1) TNA lobbied heavily against TMA’s proposed bill that attempted to delete all requirements in the law for the Board of Nursing’s “joint” adoption of the Board of Medical Examiners’ rules for supervising physicians, and the bill was taken off notice.
2) A bill passed relative to requirements for legible handwritten, typed, or computer-generated prescriptions. [TCA 63-7-123(b)(3)(B) and (C)] Public Chapter 678
3) Protection of the title “Nurse”. Public Chapter 573
1) Enacted legislation allows the composition of the Board of Nursing to increase by adding two Advanced Practice Nurses. Public Chapter 387
2) “Soft landing Safety Net” enacted for TennCare disenrollees allowed for; increase staffing and support in county health clinics and federal qualified health clinics; incentive for primary care providers, etc. Public Chapter 474
Nursing Loan Scholarship – 25 % loan forgiveness per year to candidates in master’s and doctoral program when upon completion enter into teaching or administrative positions. Public Chapter 882
1) Legislation enacted requires an insurer to notify a health care provider of the results of credentialing and insurer intends to contract with provider within 90 days, addresses other provisions relating to credentialing. Public Chapter 365
2) Established “The Tennessee Nurse Home Visitor Program”. Amends TCA Title 4; Title 63; Title 68 and Title 71. Public Chapter 530
3) TNA addressed and was successful in thwarting attempts made by the Tennessee Medical Association (TMA) in their effort to have introduced drastic, undocumented and unnecessary proposed APN supervisory rule changes.
4) Attorney General Opinion No. 07-116 – states that a physician in active clinical practice lawfully may enter into an independent contractor arrangement with a certified nurse practitioner, advanced practice nurse or physician.
1) Enacted legislation included Advanced Practice Nurses to those health care providers who may be members and holders of professional limited liability companies (PLLC). Public Chapter 747
1) Enacted legislation authorized Advanced Practice Nurses to certify disability or deafness to the department of revenue for the purpose of obtaining disabled license tags and also authorized Advanced Practiced Nurses to perform physical examinations of police officers. Public Chapter 264
1) Attorney General Opinion No. 10-22: Confirmed that the Board of Nursing has statutory authority to issue certificates of fitness to prescribe to Advanced Practice Nurses (Nurse Practitioners, Certified Nurse Anesthetists, Clinical Nurse Specialists and Certified Nurse Midwives).
2) Enacted legislation requires that all written, printed, or computer-generated orders for a Schedule II controlled substance prepared by a podiatrist, dentist, physician, surgeon, optometrist, osteopathic physician, Advanced Practice Nurse, or physician assistant be written legibly, printed, or computer-generated as a separate prescription order; requires on handwritten prescriptions that quantity be written in letters or numbers instead of both letters and numbers. Public Chapter 795
3) Under this legislation, a Level 2 adult care home provider serving residents with traumatic brain injury must hold a current professional license or employ a resident manager who holds a current professional license as a physician, Nurse Practitioner, Registered Nurse, licensed rehabilitation professional or licensed mental health professional who is trained and experienced in the care and rehabilitation of residents with traumatic brain injury. Public Chapter 642
4) TNA, CRNA and PA were successful in defeating legislation which would require advanced practice nurses and physician assistants who perform certain invasive pain management techniques involving the spine to do so under certain direct supervision by a physician.
1)TNA introduced legislation to make consistent throughout TN Code the term Advance Practice Registered Nurse where applicable was not acted on due to opposition and misunderstanding of intent. – Amends TCA Title 49; Title 53; Title 56; Title 63 and Title 71.
2)Enacted legislation requires every person licensed or registered to practice one of the healing arts, must keep an original or copy of the person’s license or certificate of registration displayed in the office or place in which the person practices, in a conspicuous place, and to place and keep placed in a conspicuous place at the entrance of the person’s office, a sign in intelligible lettering and not less than one inch in height, containing the name of such person immediately followed by the recognized abbreviation indicating the professional degree, if any, held by such person, and containing immediately below the person’s name, in equal size lettering, the word or words. Public Chapter 75
3)As enacted, regulates pain management clinics and requires that such clinics apply for certification as such a clinic with the department of health. Requires the Commissioner of Health, in consultation with the Board of Medical Examiners, the Board of Nursing, the Board of Osteopathic Examination and the Committee on Physician Assistants to promulgate necessary rules. Public Chapter 340
4) TNA in partnership with the TN Association of Nurse Anesthetists and the TN Academy of Physician Assistants, lobbied heavily against legislation seeking to limit the scope of practice of Advanced Practice Registered Nurses and Physician Assistants in Tennessee, by requiring those who perform certain invasive pain management procedures do so under direct supervision by physicians licensed in Anesthesiology, Neurological Surgery, Orthopedic Surgery, Physical Medicine and Rehabilitation. The bill was referred to 2011 Summer Study Committee of the House Health Subcommittee.
1) Despite TNA’s continued opposition and expert testimony, Interventional pain Management legislation was enacted as Public Chapter 961. The enactment of the law specifies any Advanced Practice Registered Nurse shall only perform invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves or block of major peripheral nerves in any setting not licensed under Title 68, Chapter 11 under the direct supervision of a licensed Tennessee physician who is actively practicing spinal injections and has current privileges to do so at a facility licensed pursuant to Title 68, Chapter 11. The supervising physician may only practice interventional pain management if the licensee is either:
- Board certification through the American Board of Medical Specialties (ABMS); American Board of Physician Specialties (ABPS); American Association of Physician Specialties (AAPS) in one of the following medical specialties:
- Neurological surgery
- Orthopedic surgery
- Physical medicine and rehabilitation
- Radiology; or
- Any other board certified physician who has completed an ABMS subspecialty board in pain medicine or completed an ACFME fellowship
2) Hormone Replacement Therapy legislation was enacted as Public Chapter 836 which specifies that hormone replacement therapy shall be performed by a Tennessee licensed physician or delegated by such physician to a Certified Nurse Practitioner.
3) TNA lobbied heavily against legislation which if passed, would have eliminated requirement that the board of medical examiners and the board of nursing jointly adopt rules to regulate supervision of nurse practitioners. The bill also would have deleted provision of existing code which grandfathers in advanced practice nurses prior to May 22, 2002. This bill failed in the Senate Health and General Welfare Committee.
1) Public Chapter 254 authorizes Nurse Practitioners or Clinical Nurse Specialist to issue a POST under certain circumstances and revises definition of POST.
2) Public Chapter 396 prohibits Nurse Practitioner from prescribing schedule II, III and IV controlled substances unless such prescription is specifically authorized by the formulary or expressly approved after consultation with the supervising physician before initial issuance. Nurse Practitioner may only prescribe or issue a schedule II or III opioid listed on the formulary for a maximum of a non-refillable 30-day course of treatment unless specifically approved after consultation with supervising physician. Drugs are listed on formularies by category, not individual drug name.
1) Public Chapter 590 allows for Advanced Practice Registered Nurses to be exempt from subpoena to trial but may be subject to subpoena to deposition.
2) Public Chapter 898 changes the Consumer Right- to- Know statue, requiring Advance Practice Registered Nurse who holds a certificate of fitness to keep the name of the current supervising physician updated within the information maintained by the Department of Health (DOH). The act requires DOH to allow a supervising physician to at any time, to review, accept and update the existence of a supervisory relationship between the physician and Advance Practice Registered Nurse.