Alabama APN Update: Precriptive privileges (for reference only)

Alabama APRN Update: Prescribing 1

Running head: ALABAMA APRN UPDATE: PRESCRIBING

Alabama Advanced Practice Registered Nurses

Practice Update: Prescribing Privileges

Lori Lioce, MSN, FNP-BC, NP-C, RDH

Samford University, Ida V. Moffett, School of Nursing

May 7, 2010

Abstract

The Advanced Practice Registered Nurses (APRNs) scope of practice was defined in 1996, in

statute in the Code of Alabama. Since 1996, there have been no changes in these statues, despite

the immense growth and evolution of the APRNs role throughout Alabama in providing primary

and specialty care. Recent legislative efforts to decrease barriers in delivering patient care have

yielded no positive results. Alabama is 1 of 2 states in the U.S. unauthorized to prescribe

controlled substances. This project describes APRN practice in Alabama, identifies barriers,

describes the need for controlled substance prescription privileges, and the process of seeking

those privileges. The project also details lessons learned from the process and presents a change

plan for accomplishing future legislative goals. The purpose of the project is to improve the

quality of health care by helping nurse practitioners develop, plan, educate, and implement a

change plan. This change plan can be used to add controlled substance prescriptive privileges to

the APRN Scope of Practice.


List of Figures

Figure 1: Lioce Advanced Practice Nursing Legislative Change Model……………….8


Table of Contents

Abstract......................................................................................................2

Background........................................................................................................................9

Definitions...................................................................................................10

Problem...........................................................................................................................12

Intended improvement ...............................................................................12

Significance of the problem..............................................................................................20

Patient Care................................................................................................20

Nursing practice.........................................................................................21

Project Purpose..........................................................................................22

Theoretical Framework...............................................................................22

Related Concepts.......................................................................................22

Definition of Project Terms .........................................................................23

Specific Theories Related to Capstone Project...........................................23

Relationship of Concepts and Theories......................................................25

Assumptions or Presuppositions....................................................................27

Relevant Variables......................................................................................28

Review of the Literature..............................................................................30

Setting.......................................................................................................35

Institution and Unit .....................................................................................35

Purpose.....................................................................................................35


True Leaders..............................................................................................36

Population..................................................................................................37

Detailed Plan for Project..............................................................................37

Resources...................................................................................................38

Budget.......................................................................................................39

Timeline....................................................................................................39

Evaluation Plan..........................................................................................40

Results.......................................................................................................41

Evaluation of the timeline for the project shows the revisions, in orange, for the time line. The

legislative drafts took longer than expected due to the ongoing negotiations. Bill sponsors were unwilling to

commit their support for a bill that was not fully supported by MASA. Introduction of the bill was delayed

due to inadequate sponsorship and support in the legislature. .....................................................42

.........................................................................................................................................42

Lessons Learned..............................................................................................................44

Limitations......................................................................................................................45

Plans for Dissemination...................................................................................................50

Recommendations for Future Research............................................................................50

Conclusion.................................................................................................51

References..................................................................................................52

Appendices

54


Alabama Advanced Practice Registered Nurses

Practice Update: Prescribing Privileges

How can Advanced Practice Registered Nurses (APRNs) in Alabama effect legislation

that will change the scope of practice laws in Alabama? The answer to this question has proven

difficult for APRNs as a result of multiple practice barriers. Despite the growing number of

APRNs in the state and the rapid evolution of their professional role, limitations in scope of

practice and the scope’s absence in the Code of Alabama have created barriers to delivering care

in Alabama. APRNs are educated and nationally certified to provide primary care. This capstone

project describes current APRN practice and the state of prescribing for APRNs. Further, a

focused change plan is developed to expand prescribing privileges to include controlled

substances, specifically, limited schedule II through V, regulated by the Alabama Board of

Nursing (ABON).

Background

There are approximately 157,782 APRNs practicing in the United States today. The

number of APRNs has doubled since 1999 from 76,306 APRNs. This ranks Alabama as one of

the three slowest growing states for the profession with a rate of 47% growth (Pearson, 2010).

APRNs have been educated and trained to provide primary care across the country since 1965

(American Academy of Nurse Practitioners (AANP), 2009). Ninety-two percent of APRNs

maintain national certification (AANP, 2009a). APRNs have prescriptive authority in all 50

states and write over 513 million prescriptions each year (AANP, 2009a). Presently, 48 states

authorize APRNs to prescribe controlled substances. Alabama and Florida are the only two states

in the country restricted from providing these prescriptions for their patients’ care (AANP,


2009a; Pearson, 2009). Moreover, 15 states and D.C. require no physician involvement in any

aspect of prescribing (Pearson, 2009, map 2).

This capstone project proposes expansion of the APRN prescribing privileges to include

limited controlled substances in schedule II and schedules III-V. The change plan eliminates one

of the barriers to delivering appropriate care, increases access to care when the physician is not

in the office, decrease the wait time for patients for pain relief, and provides increased quality of

care for the patients in Alabama. APRNs currently have controlled substance prescribing

schedules II-V, with varying rules, in 40 states (AANP. 2009).

Definitions

An advanced practice registered nurse (APRN) has completed a master’s degree or higher

in the field of nursing. They have received additional educational preparation in advanced

pharmacology, advanced pathophysiology, and advanced health assessment. They have had over

600 post-baccalaureate hours of supervised clinical practice that includes the above skills.

APNs conduct comprehensive health assessments aimed at health promotion and disease

prevention. They also diagnose and manage common acute illnesses, with referral as

appropriate, and manage stable chronic conditions in a variety of settings. APNs titles

include Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, and

Certified Nurse Anesthetist. Independent practitioners are capable of solo practice with

clinically competent skills and are legally approved to provide a defined set of services

without assistance or supervision of another professional (Sherwood, Brown, Fay &

Wardell (1997).

APRNs, for the purpose of this study, include nurse practitioners and certified nurse-

midwives. Under existing law in Alabama, APRNs are titled as Certified Registered Nurse

Practitioners (CRNP), when in collaborative practice.


A controlled substance is legally defined as:

A drug, which has been declared by federal or state law to be illegal for sale or use, but

may be dispensed under a… prescription. The basis for control and regulation is the

danger of addiction, abuse, physical and mental harm (including death), the trafficking by

illegal means, and the dangers from actions of those who have used the substances (The

People’s Law Dictionary, 2005, n.p.).

Drugs are assigned to one of five schedules by the Drug Enforcement Agency (DEA).

The DEA is “the federal agency responsible for enforcing laws and regulations governing

narcotics and controlled substances; their goal is to immobilize drug trafficking organizations”

(The Peoples Law 2005, n.p.). Their mission is to “enforcement of the provisions of the

Controlled Substances Act as they pertain to the manufacture, distribution, and dispensing of

legally produced controlled substances (U.S. Drug Enforcement Administration, 2010, p.8)”

A certifying board “promulgates rules and charge reasonable fees to defray expenses

incurred in registration and administration of the provisions of this article in regard to the

manufacture, dispensing or distribution of controlled substances within the state” (Code of

Alabama, 1975, Sec. 20-2-50). Certifying boards currently include: The State Board of Medical

Examiners, the State Board of Health, the State Board of Pharmacy, the State Board of Dental

Examiners, the State Board of Podiatry, and the State Board of Veterinary Medical Examiners

(Sec. 20-2-2). The certifying board is responsible for granting and withdrawing the Qualified

Alabama Controlled Substances Certificate (QACSC). The process for both is defined in the

rules and regulations of the administrative code by the certifying body and should include, fees,

monitoring, investigating complaints and abuse, and discipline.

A Qualified Alabama Controlled Substances Certificate is required from the applicant’s


regulatory board in the state of Alabama before application can be made to the DEA for a

controlled substance prescribing number. The BME rules for physician assistant prescribing,

adopted in December 1, 2009 are found in Appendix A.

Problem
Under existing law, a CRNP may prescribe legend drugs. Legend drugs are defined as

“any drug, medicine, chemical, or poison bearing on the label the words, caution, federal law

prohibits dispensing without prescription," or similar wording indicating that such drug,

medicine, chemical, or poison may be sold or dispensed only upon the prescription of

a licensed medical practitioner” (Code of Alabama, 1975, Sec 34-23-1). Legend drugs include

medications such as attention deficit disorder (ADD) stimulants, antibiotics, diabetic insulin,

heart, cholesterol, and blood pressure medications. Patients’ treatment should not be delayed or

undertreated when qualified providers are providing their care.

The significant underutilization of Advanced Practice Nurses (APRNs) continues to limit

patient care. Numerous gaps in policy and the healthcare system have been identified in the

literature and unnecessary restrictions on APRNs limit access to care for patients who are

underserved or receive no medical care at all (Institute Of Medicine (IOM), 2001; Safriet, 1994).

Intended improvement

The proposed legislative change expands APRN prescribing privileges by adding

controlled substance, schedules II-V, to the scope of practice. This practice change increases the

quality of care delivered to patients. Concurrently, it eliminates one of the current barriers for

APRNS to practice in Alabama.

National

Alabama is ranked 51st in country for restrictive APRN regulation, consumer choice and

practice environment (study included the District of Columbia). The ranking of 51st earns


Alabama an “F” for severely limiting patient’s choice. Alabama received the lowest number of

points in the United States, 5 out of 30, for patient’s access to prescriptions (Lugo, O’Grady,

Hodnicki & Hanson, 2007).

Scopes of practice restrictions are barriers to increased quality of care (IOM, 2001;

Safriet, 1994). With shortages of physicians expected to reach 200,000 in 15 years, states are

looking to expanding scopes of practice for APRNs to provide primary care (ACP, 2009;

Cooper, 2004). Scope of practice barriers decrease access to care for Alabama citizens and rank

Alabama in the bottom ten states for healthcare access in the United States (America’s Health

Rankings, 2007).

The American College of Physicians (ACP) released a policy monograph in 2009

recognizing nurse practitioners as primary care providers, equal in safety to physician

counterparts, and endorsed efforts to support healthcare collaboration. The monograph’s

executive summary supports that APRNs be regulated and certified solely by boards of nursing.

Further, the ACP stated “anticipated and actual shortages of primary care physicians have led

policy makers to consider the roles of nurse practitioners in improving access to primary care

health care services” (American College of Physicians (ACP), 2009, p. 2).

According to the American Academy of Nurse Practitioners, 48 states authorize APRNS to

prescribe controlled substances and recognized by the DEA. Only six states are restricted to

schedules III-V, and two states, Alabama and Florida restricted to legend drugs only, as shown

on the map in Appendix B (2009a). These facts negate any reasonable explanation for

maintaining the current statutory or regulatory barriers in Alabama that may limit prescribing

privileges for APRNs. The facts support the need for legislative change.

The Pearson report utilizes a national map to display the state of nurse practitioner


prescriptive practice. The map summary clearly shows 15 states with “absolutely no requirement

for any physician involvement” and 38 states with a written requirement for physician

involvement. (Pearson, 2010, maps 2).

The American College of Emergency Physicians (American College of Emergency

Medicine (ACEM), 2008) report card ranks Alabama 38th with a “D-” for access to emergency

care. This ranking included the following areas of study: quality and patient environment, access

to care, liability, public health and prevention and disaster preparedness. Alabama received the

lowest ranking as 44th with an “F” in the public health and injury prevention study (Appendix C).

The study further recommends Alabama improve “access to care by expanding its health care

workforce (ACEM, 2008, p.17).”

The AANP’s national position statement on nurse practitioner prescriptive privileges

states:

Four decades of research conclude that nurse practitioners provide safe, cost-effective,

high-quality healthcare. Prescribing medications and devices is essential to the nurse

practitioners practice. Restrictions on prescriptive authority limit the ability of the nurse

practitioners to provide comprehensive health care services (AANP. 2009b, n.p.).

Further research suggests state boards of nursing should be the sole regulatory authority for nurse

practitioner practice and prescriptive privileges (AANP, 2009b; ACP, 2009; NCSBN, 2009).

Regional

Alabama and Florida remain the only two states without controlled substance privileges.

There have been no regional studies identified in this literature search. The search included the

following key words: nurse practitioner, advanced practice nurse, Alabama, southern regional,

prescriptive privileges, prescriptive authority, prescribing.

In Mississippi, the 2009 legislative session removed the joint regulation/promulgation of


nurse practitioners recognizing the Board of Nursing as the sole regulatory authority (Appendix

D). Mississippi is now the 48th state under sole regulatory authority of the state Board of Nursing.

House Bill 1260 eliminated the Board of Medical Licensure and the requirement for supervision

by a physician for insurance reimbursement. Mississippi APRNs are “authorized for controlled

substance prescribing privileges, schedules II-V, as separately approved by the BON” (Medscape,

2009, n.p.).

In Georgia, “authority to prescribe is evidenced by inclusion on the prescription of the

prescriber's title and as outlined in the prescriber's collaborative practice agreement.

All prescriptions must show collaborating physician's name. Authority to prescribe controlled

substances includes Schedule III-V (Medscape, 2009, n.p.).”

Tennessee requires:

• A state issued certificate, including certificate of fitness to prescribe and

identification number on file with state.

• All prescriptions must show collaborating physician's name.

• Authority to prescribe controlled substances includes Schedule II-V as

outlined in the collaborating physician's supervisory rules and the prescriber's

prescriptive formulary (Medscape, 2009, n.p.).

In Florida, “authority to prescribe is evidenced by inclusion on the prescription of the

prescriber's title, and as outlined in the prescriber's collaborative practice agreement. Authority to

prescribe controlled substances is not granted (Medscape, 2009, n.p.). In 2008, Florida’s Senate

committee tabled the controlled substance prescribing bill and ordered an investigation of need

for prescriptive privileges to a task force. The report resulted in firm support for controlled

substance prescribing for APRNs in 2009 (Advance, 2009). Florida nurses now have Senatorial


evidence to support change in practice and improve patient care and have proposed legislation

for prescriptive legislation.

0Regionally, the states of Mississippi, Tennessee, and Georgia all have controlled substance

prescribing authority. Florida is moving forward with the legislative battle due to the

legislative task force report being complete and supportive of the need for controlled

substance prescribing. This leaves Alabama as the most restrictive practice environment

with the least progress in the legislative environment.

Local

There are approximately 1820 CRNPs in the state of Alabama with 2033 collaborative

practice covering different 4,426 practice sites. A summary table and break down of these

numbers are included in Appendix E (Joint Committee, 2010, p. 9A). A map representing the

distribution of the practice sites and residential sites of the CRNPs is found in Appendix FD

AANP, 2010). The map demonstrates the practice locations are lightly scattered in the rural

areas.

Alabama has 60 of 67 counties declared as underserved for primary care as displayed on

the map in Appendix G (Health Resources and Services Administration (HRSA), 2009).

Furthermore, Alabama is in the top five states for death related to diabetes, obesity, heart disease,

and strokes (Alabama Rural Health Association, 2007). The state is number one in the number of

deaths caused by stroke or other cerebrovascular disease according to the State Health Facts

website (2005). At present, APRN practice is limited, access to care is decreased, and treatment

is delayed.

APRNs are required to have the patient wait; locate a physician who may verbally order

controlled substance medications based on the APRNs assessment and diagnosis. The APRN

may refer the patient to another provider. Referral for redundant services, just to obtain a


prescription increases the cost for the patient.

The Coffey study (2009), completed in Florida, examined and attempted to tabulate

valuable APRN time required to obtain a signature/approval for a controlled substance

prescription. The study then extrapolated the time into number of patient visits lost by limited

prescribing privileges. There were 994 respondents of which 862 surveys were complete, valid,

and analyzed. Significantly, yielding 8.69 additional patient visits could be completed per week.

The numbers were applied to the approximate 83% of the Florida APRNs that expressed a need

in practice for the privilege to provide 67,047 patient visits per week. That is 3.5 million more

patient visits per year in Florida. The study effectively and efficiently supports removing the

barrier to practice. The study supports expanded scope of practice, for the APRN, would yield a

significant increase in access to patient care without adding additional primary care providers.

Similar results can be extrapolated for Alabama.

The American College of Emergency Medicine (American College of Emergency

Medicine (ACEM), 2008) reports Alabama as among the lowest rates of emergency physicians

(6.7 per 10,000 people) and board certified emergency physicians (3.9 per 10,000 people).

ACEM (2008) also reports Alabama has the lowest rate of physicians accepting Medicare (1.8

per 100 beneficiaries) which leads to significant deficiency in accessing care for the population.

The need for change is overwhelmingly evident. Expanded controlled substance prescriptive

privileges will make a difference in these areas by improving the quality and quantity of care

delivered in these areas.

Prescribing controlled substances is currently authorized on military bases in Alabama.

Theses sites are covered under federal regulations/rules, though the CRNP still maintains state

credentialing. APRNs practicing under military base guidelines and have been allowed to


prescribe scheduled medications for over 20 years (anonymous, personal communication, 2010).

Military hospitals and health care facilities employ APRNs and are an excellent example of the

successful use of APRNs and controlled substance prescribing in Alabama.

Licensing

CRNPs are credentialed and regulated under rules set forth by the Alabama Board of

Nursing. CRNPs are required to practice under protocols approved by a Joint Committee

(Appendix H). The Joint Committee is composed of three physicians from the State Board of

Medical Examiners (BME) and three nurses appointed by the Alabama Board of Nursing

(ABON, 2009c, Sec. 34-21-87). APRNs are restricted, in Alabama, from using the title CRNP if

they are not currently engaged in an approved collaboration agreement with a physician (ABON,

2009c, Sec. 34-21-90 1975).

Scope of Practice

The APRNs scope of practice, also known as the nurse practice act, Article 5, has not been

updated in the Code of Alabama since July 26, 1995, Appendix I (ABON, 2009c). The APRN

role has evolved as practice has expanded. The ABON Administrative Code defines the rules and

regulations set forth by the Joint Committee (ABON, 2009a). According to those rules, CRNPs

in Alabama are:

responsible and accountable for the continuous and comprehensive management of a

broad range of health services for which the CRNP is educationally prepared and for

which competency is maintained” and “may work in any setting consistent with the

collaborating physician's areas of practice and function within the CRNP's specialty scope of

practice. The CRNP's scope of practice shall be defined as those functions and procedures for

which the CRNP is qualified by formal education, clinical training, area of certification and


experience to perform (ABON, 2007, p. 1).

Further, the CRNP functions are defined by the ABON in the standard protocol for CRNPs. The

protocol authorize the scope of practice, is abbreviated as follows:

1. Perform complete, detailed and accurate health histories, review patient records,

develop comprehensive medical and nursing status reports, and order laboratory,

radiological and diagnostic studies

2. Perform comprehensive physical examinations and assessments, including bimanual

pelvic examination

3. Formulate medical and nursing diagnoses and institute therapy or referrals

4. Institute emergency measures and emergency treatment

5. Plan and initiate a therapeutic regimen that includes ordering legend drugs

6. Arrange inpatient admissions and discharges at the direction of the collaborating

physician; perform rounds

7. Interpret and analyze patient data

8. Provide instructions and guidance regarding health care and health care promotion to

patients/family/significant others.

9. In addition to functions/procedures within the scope of RN practice, perform or assist

with laboratory procedures and technical procedures, which include but are not

limited to the following:

• Biopsy of superficial lesions
• Suturing of superficial lacerations
• Management and removal of arterial and central venous lines
• Debridement of wounds
• Aspiration, incision and drainage of superficial lesions
• Foreign body removal
• Initial x-ray interpretation, with subsequent required physician
interpretation


• Cast application/removal
• Wet mount microscopy and interpretation of vaginal swab
• Microscopic urinalysis

Additional duties requested for the CRNP (i.e., diagnostic or therapeutic procedures

requiring additional training) as provided in ABN Administrative Code Chapter 610-

X-5-.10 (3) (ABON, 2007, p. 1).

The full collaborative practice rules may be found in Appendix J.

Continuing Education Requirements

APRNs in Alabama are required to maintain national certification and collaborative

practice with a physician to be recognized as a certified registered nurse practitioner (CRNP) in

Alabama. Additionally, 24 hours of continuing education is mandatory for license renewal every

two years. For APRN license renewal, six of hours must be in pharmacology (ABON, 2009c).

Current prescriptive regulation for APRNs in the state is summarized as follows:

CRNPs practicing under protocols may prescribe legend drugs that are included in the

formulary recommended by the Joint Committee and adopted by the BON and the

BOME. The drug type, dosage, quantity and number of refills are authorized in an

approved protocol signed by the collaborating physician and the CRNP. Written

prescriptions must adhere to the standard recommended doses of legend drugs as

identified in the Physician’s Desk Reference or Product Information Insert, not to exceed

the recommended treatment regimen periods (Pearson, 2009, p. 8).

The collaborative practice prescriptive formulary for the CRNP is found in Appendix K.

Significance of the problem

Patient Care

Primary care provider shortages began and were predicted over a decade ago in Alabama.

The provider shortages have decreased access to care in Alabama. The National Council of State


Boards of Nursing (NCSBN) succinctly states:

It is critical to review scope of practice issues broadly if our regulatory system is going to

achieve the recommendations made by both the Institute of Medicine and the Pew Health

Commission Taskforce on Healthcare Workforce Regulation. These reports urge

regulators to allow for innovation in the use of all types of clinicians in meeting

consumer needs in the most effective and efficient way, and to explore pathways to allow

all professionals to provide services to the full extent of their current knowledge, training,

experience and skills (2009, p.4).

Currently, evidence demonstrates limited prescribing creates the following issues for

patients: (a) patients must do without needed pain medication, (b) creates time delays to find a

physician to prescribe needed medications (Coffey, 2009). Eliminating these prescriptive barriers

would improve care by giving patients what they need when they need it, thus, improving the

quality, decreasing time to provide care, and cost of the care they receive. Examples of

medications that are on the scheduled formulary are: Lomotil (used to treat diarrhea), cough

suppressants, pain medications (for pneumonias, bronchitis, injuries, muscle strain), or Concerta

(used to treat attention deficit disorders).

Nursing practice

APRNs currently have the responsibility to diagnose and assess pain, disease, primary

and acute illness, yet no authority to treat it appropriately (ABON, 2009a, p). As practice evolves

and scope of practice increases changes must be to update the statutes. Alabama has never

changed the scope of practice since it was placed in statue 15 years ago. The number of CRNPs

in Alabama has not grown equivalently with the number of students graduating our programs

each year. This is attributed to the attrition rate as they go to practice across state lines.

Project Purpose

The purpose of the project is to improve quality of health care in Alabama. This project

proposes to improve the quality of health care by helping nurse practitioners develop, plan,

educate, and implement a change plan. This change plan can be used to add controlled substance

prescriptive privileges to the APRN Scope of Practice. This project will provide a theoretically

based planned step-by-step resource for implementing proposed scope of practice changes to

improve quality of care for Alabamians.

Theoretical Framework

The proposed framework for change incorporates Lewin’s Change Theory (Lewin, 1951)

and Conger’s Organizational Change Theory (Conger, Spreitzer, & Lawler, 1999). Interaction of

the related concepts of change, professional advocacy, and participants are demonstrated in the

Lioce Advanced Practice Nursing Legislative Change Model. The assumptions and variables are

indentified along with operational definitions for related concepts.

Evolution of primary care has created a paradigm shift in the role of the advanced practice

nurse. This includes an expanded role for the advanced practice registered nurse (APRN).

Therefore, the focus of this capstone project is legislative change in the APRN scope of practice,

for the state of Alabama. Particularly, to obtain APRN controlled substance prescriptive

privileges for schedules II-V. This change will improve quality of care for Alabamians. Change

will be implemented using the following concepts for planned change.

Related Concepts

The theoretical framework recommended by this author to support this capstone project

includes the following major concepts: (a) legislative change in APRN scope of practice, (b)

participants, and (c) professional advocacy. Definitions are included to clarify these concepts.

Lewin’s (Schein, 1995) and Conger’s (Conger et al., 1999) change theories will be used as


the theoretical guide to successful change and implementation of the expansion of scope of

practice. Legislative change will require a bill to be submitted and passed through the legislature

to amend the Alabama Administrative Code. Implementation of professional advocacy

responsibility will be incorporated into the theoretical framework.

Definition of Project Terms

The terms are operationally defined as follows, for this capstone project:

1. Professional Advocacy - empowerment of the nurse to advocate for the professional role

objectives while championing social justice in healthcare.

2. Participants - nurses, legislators, voters, healthcare consumers.

3. Change - legislative change in scope of practice of the APRN and change in perception

of the APRN role.

Specific Theories Related to Capstone Project

To provide a clear understanding of the complexity of change to impact practice in

Alabama, integration of theories were necessary to create the theoretical framework proposal.

Specifically, blending of Lewin’s (1951) and Conger’s (Conger, Spreitzer, & Lawler, 1999)

change theories. The framework incorporates Lewin’s (Schein, 1995) steps to change;

unfreezing, changing, and refreezing, while utilizing Conger’s 8 steps to organizational change

to fully encompass the state organizations and clearly identify the path to change (Conger et al.,

1999).

The following is proposed for implementing planned change and should be used to

advocate for incremental practice changes in Alabama. The major premises of change that will

be used are identified by Conger (et al., 1999). The steps for change are detailed in the first

column and the strategies for successful implementation are listed in the second column.

Conger’s (1999) steps Strategies for implementation:


to change:
1. Establishing a sense Educating the APRNs, the public, and legislators on:
of urgency • The shortage of providers
• Barriers to practice for APRNs
• Comparison of Alabama to other states and the positive effect
and progress APRNs have made
• The healthcare crisis
• Utilizing handouts, town hall meetings, electronic
communication etc. see Appendix L.
2. Forming a powerful • Escalate efforts to build and unite APRNs across the state
guiding coalition through website, email, state and local meetings
• Utilize existing coalitions, Health Care for Alabama, Alabama
Nurses Coalition, Alabama State Nurses Association, and the
American Academy of Nurse Practitioners
3. Creating a vision • Draft initial bill for prescriptive privilege change, Appendix M.
•
• Encourage professional advocacy in the nursing community
4. Communicating the • Increase public relations
vision • Increase APRN grassroots efforts (i.e. phone tree, email and
volunteers)
• Communicate the vision through the organizations
• Utilize their public relations advocates
• Create and publish an update on APRNs in Alabama for
dissemination and presentation (capstone project)
5. Empowering others to • Engage the NPAA legislative committee
act on the vision • Empower and invite colleagues
• Publicize need for active participation at state and regional
APRN group meetings
• Increase education in APRN programs on responsible
professional advocacy (not optional)
6. Planning for and • Publicize bill
creating short-term • Obtain sponsors for bill
wins • Create more nurse leaders by role modeling and mentoring to
continue the advocacy for change
7. Consolidating • Annual evaluation of progress toward passing legislation
improvements and • Continue to create urgency in nurses to participate in process
producing still more • Continue evidence based research
change • Plan next incremental change (Resolution Appendix N)
8. Institutionalizing new • Publish and publicize accomplishments (Appendix O)
approaches • Continue training new APRN leaders for advocacy

Applying these steps to legislative change to obtain prescriptive privileges will have


greater success when merged with Lewin’s change theory of unfreezing, implementing change,

and refreezing (Schein, 1995). An overview of the blended theories would include: (a)

unfreezing of: the legislators to act, current beliefs held by legislators, physicians, APRNs in

Alabama, and motivating nurses to be active. Strategies for (b) change include: a recommitment

to professional advocacy for APRNs, education on current prescriptive practices in the United

States/evidenced-based practice dissemination. Strategies to (c) refreeze the change would

include: continued evidence-based education and research for APRNs, with dissemination,

mentoring new leaders, and continuing to advocate for the nursing profession.

Further explanation, for clarity of Lewin’s theory (Schein, 1995) is explained in stages.

Stage one is the unfreezing stage. Disconfirmation of the present prescribing conditions is

demonstrated by the proposal for change. In Alabama, this has already taken place.

Disconfirmation produces anxiety for the APRN. This anxiety is motivating the APRN to

advocate for improved patient care. In stage two, the change agents must prioritize change and

continually evaluate. The evaluation is based on patient needs and trial and error in the

legislative process efforts. The final stage is stage three, refreezing. This stage includes

controlled substance schedule II-V education and prescribing authority for APRNs in Alabama.

This stage could include additional pharmacology or prescribing education and licensing to

increase the APRNs knowledge of current prescribing trends and reinforce the change.

Relationship of Concepts and Theories

Figure 1. Lioce APRN Legislative Change Model


The Lioce APRN Legislative Change Model demonstrates the target audience of

participants/adult learners in the background circles. The overlay model of rectangles reflects the

theories guided by the central focus of legislative practice change to provide a visualization of

the theoretical framework.

Assumptions or Presuppositions

The following assumptions are made:

1. There is a need for schedule II-V controlled substance prescriptive privileges in Alabama.

2. Having controlled substance prescriptive privilege will improve the quality of care in

Alabama.

3. APRNs are nationally certified licensed primary care providers and demonstrate

competency through continuing education and certification.

4. Changes in scope of practice are required in the evolving healthcare delivery systems.

5. Overlapping scopes of practice are common among healthcare providers.


6. Scope of practice regulation is intended to protect the public not a particular profession.

7. Patient’s pain is delayed and undertreated related to restricted practice.

8. Practice barriers increase the attrition rate of APRNs. APRNs are being educated in

Alabama and leaving to practice in other states with less restrictive environments.

9. Nurse practitioners are safe prescribers and collaboration is necessary to provide

comprehensive care of patients.

Relevant Variables

Five variables must be taken into consideration: (a) the legislative system, (b) the Alabama

Board of Nursing (ABON), (c) the Board of Medical Examiners (BME), (d) the Medical

Association of the State of Alabama (MASA) and (e) the joint committee. The legislative system

in Alabama is difficult to navigate and effect change. Politics can prevent effective, efficient, and

equitable policies from being introduced. Therefore, drafting a piece of legislation with immense

support and agreement will be a priority.

The Alabama Board of Nursing is supportive of change (G. Lee, personal communication,

May 2009). The board’s priority is protecting the public and serves a vital function for the state

(Alabama Board of Nursing, 2009). The ABON will be responsible for implementation and

regulation of any scope of practice changes made in the legislature.

The Board of Medical Examiners (BME) and the Medical Association of the State of

Alabama (MASA) are not supportive of change to APRN practice. they are the certifying body.

This means the BME would have the power to grant and remove the Qualified Alabama

Controlled Substance pretificates QACSC), set rules, fees, and regulations (L. Dixon, D.

Whitaker, K. Aldridge, personal communications, March 2010). This increases the regulation to

providing care by requiring the APRN to be certified by one board and licensed by another. Thus

creating conflict that inhibits the legislators from introducing controversial legislation.omplicates


th

Current practice for APRNs in Alabama is regulated through a joint committee. The Joint

Committee is granted powers in Article 5 of the Nurse Practice Act and became effective in

April 17, 2001(ABON, 2010, Sec. 34-21-82). The joint committee is comprised of three nurses

and three physicians. The committee approves nurse practitioners collaborative practice,

including specific protocols, within which the nurse practitioner must work and may prescribe an

approved formulary (Code of Alabama, 1975, 34-21-85). Alabama is one of seven states with

joint regulatory authority in the U.S. The majority of states are licensed and regulated by the

Board of Nursing. There are a few exceptions, of states that are regulated through an Advanced

Practice Boards or joint committees (AANP, 2009d; Pearson, 2010). The nursing profession

must continue to evolve with the healthcare changes and needs of our patients and advocate for

continued sole regulation through the Board of Nursing.

Further barriers identified are: (a) lack of participation by APRNs in professional

advocacy, (b) lack of pursuit and use of personal connections to the legislators, (c) apathy, burn-

out and low participation in professional nursing organizations in this state (C. Stewart, R.

Brown, C. Cooke, personal communication, May 2009). The Nurse Practitioner Alliance of

Alabama currently has approximately 1000 members out of the almost 1820 licensed nurse

practitioners in the state (A.Keller, personal communication, May 2010). The Alabama State

Nurses Association (ASNA) has less than 3% of the 65,000 nurses in Alabama as members, (J.

Decker, personal communication, May, 22, 2009). Collegial efforts to teach professional

advocacy must be revisited and increased. Efforts to collaborate and increase communication

with each of these organizations are a priority and are continually advocated for by the nursing

leaders in the Alabama.

Review of the Literature

The following databases were systematically reviewed for the period of 1980 through

2010: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, Cochrane,

EbscoHost, and PubMed. Search parameters included English language, peer reviewed scholarly

articles utilizing the following terms interchangeably: prescriptive authority, prescribing,

scheduled drugs, controlled substances, advanced practice registered nurse, certified registered

nurse practitioner, nurse practitioner, and Alabama.

Literature review supports the need for expanded scope of practice (ACP, 2009; ACEM,

2008; AANP, 2009c). The Institute of Medicine stated “state practice acts that limit non-

physician providers, e-health and multidisciplinary teams act as a barrier to innovative

healthcare” (IOM, 2001, n.p.). Barbara Safriet (1994) further states “regulations that are barriers

serve no useful purpose and contribute to our health care problems by preventing the full

deployment of competent and cost effective providers who can meet the needs of a substantial

number of consumers” (p. 315).

National regulatory boards have been discussing expanding scopes of practice since the

1990s and formally documented their opinions in this study. Changes in Healthcare Professions

Scope of Practice: Legislative Considerations (National Council of State Boards of Nursing

(NCSBN), 2009) was developed in 2006 by six national regulatory boards, including medical,

nursing, occupational therapy, social work, and pharmacy in the United States. This monumental

document plainly states that “lost among the competing arguments and assertions [regarding

changes in scopes of practice] are the most important issues of whether the proposed change will

protect the public and enhance consumers’ access to competent healthcare services (p. 5).” The

paper further supports scope of practice changes by stating:

We believe it is critical to review scopes of practice broadly if our regulatory system is


going to achieve the recommendations made by both the Institute of Medicine and the

Pew Health Commission Taskforce on Healthcare Workforce Regulation. These reports

urge regulators to allow for innovation in the use of all types of clinicians in meeting

consumer needs in the most effective and efficient way, and to explore pathways to allow

all professionals to provide services to the full extent of their current knowledge, training

experience and skills (NCSBN, 2009, p. 5).

The national boards urge legislators that “overlapping scopes of practice are a reality in a rapidly

changing healthcare environment” (p. 16). Specifically agreed upon in this document is “if a

profession can provide supporting evidence in these areas, the proposed changes in the scope of

practice should be adopted (p. 11).”

In 2003, Representative Robert Bentley (District 63) requested The Nurse Practitioner

Task Force study the utilization of Nurse Practitioners in Alabama and included nursing leaders

and educators in Alabama. Four co-chairs led and organized subcommittees. This included an

Educational Subcommittee comprised of the states nursing experts; faculty, deans, and directors

of the nursing schools in the state. The Practice Subcommittee included; experts in the advanced

practice field, nursing consultants, and regulators. The study, stimulated by the shortage in

primary care providers, identified in 2003 is the only one of record in Alabama and resulted in

“A Proposal to Increase the Utilization of Nurse Practitioners in Underserved Alabama” (Nurse

Practitioner Task Force, 2004). The study results indicated that in 2003:

1. 61 of 67 counties were federally classified with primary care practitioner shortages

2. 60% of the people in Alabama live in rural areas

3. 58 of 67 counties are designated as underserved in Primary Care by Department of

Health & Human Service and the Bureau of Primary Care Health.


4. Disparities between urban and rural health contrast

5. 80% of physicians practice only in urban areas (p. 5-6)

The results identified the majors barriers to practice and identified the “CRNP as having no

authority to prescribe controlled substances as restrictive rules governing collaborative practice”

(p.10) were identified and presented to Representative Robert Bentley in January of 2004, the

ABON and the Joint Committee in May 2004. Five recommendations for change were a result

of the research. To date, two of the five recommendations have been partially met, by the state or

federal government, “allocation of resources to nurse practitioner programs to retain and recruit

faculty to expand the number of graduates” and to provide incentives for CRNPs to work in

medically underserved areas” (Nurse Practitioner Task Force Proposal, 2004, p. 11). There have

been no advances on three recommendations that dealt with reimbursement, expansion of

practice, and establishing the Advanced Practice Nursing Committee. “Proposed changes in

scopes of practice that are supported by one profession but opposed by other professions may be

perceived by legislators and the public as ‘turf battles’. These turf battles are often costly and

time consuming for the regulatory bodies, the professions, and the legislators involved (NCSBN,

2009, p. 8).”

The National Council of State Boards of Nursing stated:

Important issues for consideration by legislators and regulatory bodies when establishing

or modifying a profession’s scope of practice are that the primary focus …is public

protection.

In defining a profession’s scope of practice, the goal of public protection can be realized

when legislative and/or regulatory bodies include the following critical factors in their

decision-making process:


1. Historical basis for the profession, especially the evolution of the profession

advocating a scope of practice change,

2. Relationship of education and training of practitioners to scope of practice

3. Evidence related to how the new or revised scope of practice benefits the public, and

the capacity of the regulatory agency involved to effectively manage modifications to

scope of practice changes (NCSBN, 2009, p. 15).

Synthesis of the literature review supports the following answers to these critical factors.

Factor one: APRNs have been providing high quality, safe effective primary care for over 40

years. In the U.S., multi-disciplinary studies supports the APRN scope of practice has advanced

since statues were implemented in 1995. The American College of Physicians’ Policy

Monograph supports the evolution and in the monograph’s executive summary that Nursing

Board should regulate Nursing and that Boards of Medicine should regulate physicians and

physician’s assistants (AANP, 2009; ACP, 2008; Alabama Code, 1975; Brown & Grimes, 1993).

Factor two: APRNs are prepared with advanced health assessment, advanced

pharmacology, advanced pathophysiology, and over 600 hours of supervised clinical training in

the practice setting post baccalaureate. APRNs are nationally board certified in their primary care

or other specialty area and must maintain that certification supported by 1000 practice hours

every five years nationally and 24 continuing education hours every two years in Alabama for

licensure renewal (ABON, 2009a; ABON, 2009c; AANP, 2009; NCSBN, 2009)

Factor three: The north, east, and western states have decades of patient treatment

outcome and safety data. The Southern states have similar data but have been resistant to change

laws to authorize the practice, yet seem satisfied in the APRNs safety and competency, enough

to become business partners, profit share, be employed by, and fill in for each other; as long as


they are not practicing independently. Studies demonstrate an increased level of patient

satisfaction with treatment outcomes equal to primary care physicians, including prescribing

controlled substances (AANP, 2009; Coffey, 2009; Phillips, 2009; Safriet, 1994).

Factor four: Boards of Nursing have successfully and responsibly set rules and

regulations for controlled substances for 48 states. The ABON can efficiently and effectively add

regulate APRN controlled substance prescriptive privileges. Some states have added an

Advanced Practice Council to their Board of Nursing . This council with their advanced

knowledge of the APRN scope of practice would be prepared to regulate APRN issues and

prescribing. Rules and regulation are determined after the legislation is passed and could

incorporate and advanced practice board (NCSBN, 2009).

Overlapping scopes of practice are a reality in a rapidly changing healthcare

environment. The criteria related to who is qualified to perform functions safely without

risk of harm to the public are the only justifiable conditions for defining scopes of

practice and restraining qualified professionals from providing care (NCSBN, 2009, p.

15).

The American Academy of Nurse Practitioner’s position on prescribing supports

unlimited prescribing authority. AANP is a certifying body for APRNs. Their position is

supported with descriptions of the extensive education, training, 40 years of research, and ability

to save money by providing cost-effective care without the limitation in practice. The position

statement is included as Appendix P (2009b, n.p.)

Other barriers were identified by the literature review as follows: (a) collaborative

practice requirement; which decreases the ability of the APRNs to practice in rural areas (b) lack

of primary care provider designation in statue, effecting reimbursement of services; and (c)


multiple individual policy barriers related to fractional reimbursement, direct reimbursement,

radiology ordering, receiving physical therapy orders, signing of death certificates, or prescribing

handicap parking permits; and (d) exclusion of actual prescriber on prescription bottles, the

APRNs name is not listed even if they are primary prescriber; this decreases evaluation data on

prescribing. Presently, the collaborating physicians name is placed on the label (AANP, 2009c).

Setting

The setting addressed is the State of Alabama’s legislature. The evaluation of this

environment is a vital first step before attempting to influence policy change for APRNs. The

purpose is to clarify the environment in order to effectively make legislative practice changes.

Institution and Unit

The Alabama Legislature is located in Montgomery, Alabama. It is housed in the State

House on Union Street across from the Capitol. They utilize the fifth through eighth floors of the

building.

According to the League of Women Voters study, The Alabama Legislature Facts and

Issues (2006), the legislature has thirty formal meeting days in a regular session to complete in

105 calendar days between January and May. The typical meeting schedule is Tuesday and

Thursdays with Wednesdays reserved for committee meetings.

There are 105 House members and 35 senate members. In the Senate, there are 21

democrats, 13 republicans and one vacant seat. Democratic affiliation represents the majority at

present. In the House, there are 62 democrats and 42 republicans.

Purpose

The purpose of the legislature is as follows:

“Legislatures engage in three principal functions: policymaking, representation, and

oversight. The first, policymaking, includes enacting laws and allocating funds. In their


second function, legislators are expected to represent their constituents, the people who

live in their district, in two ways. At least in theory, they are expected to speak for their

constituents in the state, to do ‘the will of the public’ in designing policy solutions. In

another representative function, legislators act as their constituents' facilitators in state

government. The oversight function, evaluating the performance of the state bureaucracy,

is one that legislatures have taken on recently” (Alabama League of Women Voters,

2006, n.p.).

True Leaders

Senate and House members vote to elect their own leaders. In the Senate, this is known

as the President Pro Tempore. Historically, these powers belonged to the Lt. Governor but were

transferred in 1999, related to political party changes (Alabama League of Women Voters,

2006). The true leader of the Senate is the President Pro Tempore, though the title “President of

the Senate” remains with the Lieutenant Governor. In the House, there are two leadership

positions, Speaker of the House and Speaker Pro tempore. These are both elected by a majority

vote in the house.

The true leaders of the Alabama legislature are selected members who represent large

groups, large campaign funds, or votes. These are not necessarily the committee heads or leaders

of the Senate or House, but in many cases can correlate to positions of power. There are key

members, who are not in positions of leadership. It is important to obtain key leader support to

gain the support of the majority. Using this informal leadership is key to passing legislation.

Identification of the key players and persons in favor with these key politicians is crucial to

successfully pass legislation. Uniting the key politicians throughout the state is vital to increase

the quality of care.

Population

The citizens of Alabama are the target population of the proposed change. Increasing the

scope of practice for nurse practitioners in Alabama will directly result in increased quality of the

healthcare provided to the community populations. The current estimate for the population in

Alabama is 4,708,708. Race is distributed with 71% White, 26.4% Black, 2.9% Hispanic/Latino,

1% Asian, and .05% American Indian (U.S. Census Bureau, 2010).

Detailed Plan for Project

Legislation proposed during the 2009 legislative session will be used as a draft and and

sd include a plain language summary. This legislation will include wording to obtain controlled

substance prescriptive privileges schedules II-V. Target date for revision will be January 5, 2010,

so the bill may be disseminated for comments and sponsors. Sponsorship for legislation will be

simultaneous with development of legislation and will be finalized mid February 2010.

Efforts are directed to introduce the bill into the House of Representatives by March 2.

This allows time during the session to secure a passing vote in the health committee and be

introduced on the floor. The legislative session ends in June 2010 and evaluation and revision of

the strategic plan and objectives will be accomplished at that time. This project will compliment

the efforts of the NPAA and ASNA. Collaboration with the leaders of both organizations has

already been established along with the additional resources listed under the qualification section

of this document.

The specific approach will be:

• Develop a strategic plan for lobbying and educating legislators. This will be

accomplished with colleagues, mentors, and twenty nurse practitioners on the

NPAA steering committee from across the state. Feedback and evaluation from

Samford University doctoral capstone project committee will be utilized along


with re-evaluation annually.

• Begin a public relations campaign to educate the public and legislators about

nurse practitioners.

• Developing an appropriate piece of legislation to implement the proposed

change. The legislative committee and executive committee of NPAA drafted

legislation last year. Participation in revision for new legislation from November

2009 to January 2010.

• Identifying and obtaining sponsors in the legislature by working with individuals

in the nursing profession and executive members of AANP, NPAA, and ASNA

to obtain sponsors for the legislation in both the House and the Senate. Travel to

the Capitol will be required for face-to-face meetings.

• Introduce legislation. Pass legislation through the House and/or Senate Health

committees to be introduced on the floor.

Resources

The resources available for completion of this capstone project will be many of the state

and nations leaders in the nursing profession:

1. Becky Patton, ANA President

2. Mary Behrens, ANA PAC Chair

3. Rose Gonzales, ANA Government Affairs

4. Carol Stewart, MSN, FNP, past president NPAA

5. Joe Decker, Executive Director, ASNA

6. Cindy Cooke, Region 11, Director AANP, NPAA past president

7. Dr. Richard Brown, Alabama representative to AANP, UAB Faculty


8. Dr. Poole, Capstone Advisor, Samford University, Ida Moffet School of Nursing

9. Dr. Nena Sanders, Dean, Capstone Advisor, Samford University, Ida Moffet School of

Nursing

10. Dr. C. Fay Raines, AACN President, Dean, University of Alabama Huntsville, College of

Nursing

Budget

Expenses for the implementation of the plan are estimated to be approximately $5,662

(Appendix Q). This includes:

• $3,217 covers mileage for 15 visits to the Alabama Legislature in Montgomery from

Huntsville

• $420 for educational/lobbying materials on nurse practitioner role, practice and scope of

practice for 140 legislators

• $600 per diem for 15 days ($40 daily)

• $1,425 for 15 nights lodging expenses (roundtrip 6 hour drive from Huntsville)

Timeline

This indicates the proposed timeline for the project plan implementation.


Evaluation Plan

The project will be evaluated at the end of the 2010 legislative session based on

progress toward the following outcomes: (a) drafting appropriate legislation (b) obtaining 10 key

sponsors for APN legislation in the House and the Senate (c) passing proposed legislation out of

the health committee and into the House/Senate (d) successful passage of legislation. Samford

University, Ida Moffet School of Nursing, doctoral committee will complete additional

evaluation, in May 2010. The results from these evaluations and assessments will be shared with

the leadership of AANP, NPAA, and ASNA for the continued effort toward practice

improvement. The strategic plan will be annually reviewed annually to incorporate the outcomes/

research until the goal is reached.

The research derived from this experience and participation will be utilized in a capstone

project for the University of Samford in Birmingham, Ida Moffet School of Nursing. The

information will be widely disseminated by email to the nurse practitioner regional groups in

Alabama. The abstract will be submitted for poster presentation at the 2010 AANP, ASNA, and

NPAA annual conferences for continued practice improvement.

Results

The 2010 legislative session was convened on Tuesday January 12, 2010 and adjourned

on April 22, 2010. This completed the 30 legislative days in 105 calendar days as required by the

Code of Alabama. This marks the end of the quadrennial and begins a new one. Elections will be

held this year and will be monumental in restructuring the legislature. The Alabama Code

convenes the legislature on the second Tuesday in January 2011. They may meet up to 10

consecutive calendar days for reorganization of the House and Senate following elections. The

legislature will reconvene the first Tuesday of March for the first year of the quadrennial to begin

the thirty-day session (1975, Sec. 29-1-4).

The sponsor did not introduce the bill as written. He asked that the two professional

organizations come to an agreement and set up a meeting between the MASA lobbyist and

NPAA president. The sponsor was not available to the Alliance to negotiate the bill or mediate

negotiations. Negotiations continued for ten weeks with face-to-face meeting and several

revisions of the bill.

The following goals were set and are evaluated as follows:

Goal Evaluation

(a) Draft appropriate legislation Goal met.

(b) Obtain10 key sponsors for APN Goal not met.
legislation in the House and the Senate Barriers to introduction of controversial bills during
an election year not anticipated from legislators.
A sponsor was not obtained in the Senate until the
last 5 days of the session.
House Sponsor introduced the HB688 and was
under the impression it had mutual agreement by other


parties. Sponsor recommended we negotiate with
MASA to reach agreement on a bill. Eight weeks of
negotiation yielded no agreement with MASA
lobbyist.

(3) Pass proposed legislation out of the Goal not met.
health committee and into the HB688 was opposed by the NPAA. The bill
House/Senate requested the BME to be the certifying body for
CRNP/CNM prescriptive privileges.

(4) Successful passage of legislation Goal not met.

Evaluation of the timeline for the project shows the revisions, in orange, for the time line. The legislative

drafts took longer than expected due to the ongoing negotiations. Bill sponsors were unwilling to commit their

support for a bill that was not fully supported by MASA. Introduction of the bill was delayed due to inadequate

sponsorship and support in the legislature.

Discussion


Many successes were noted through this project. As of May 2010, we have already

secured a sponsor in the House and the Senate with 3 additional sponsors. Plans are underway

for introduction of the bill early in the 2011 session. Several new task forces have been formed to

address changes for a new strategic plan and build alliances . Educational efforts have resulted in

two articles being published and two interviews scheduled with local television stations in

Montgomery and Huntsville. New leaders have emerged throughout the state to advocate for

these important changes. Positive lessons were noted and the plan for success will undergo

revisions through a think tank to be sponsored with AARP this fall.

The negotiations with MASA and discussion with the BME revealed no willingness to

alter their bottom line of the BME as the certifying board. There was no interest in what the

evidence demonstrated or the qualifications of the nurse practitioners. The bill was offered and

refused by the BME and MASA. This was strong evidence that collaboration on controlled

substances is not possible between the existing leadership of the organizations and APRNs. If

Alabama is going to continue to operate under collaborative practice, collaboration must be

improved.

Elections are held in November this year and will be monumental in restructuring the

legislature. Recommendations for legislative session 2011 are as follows:

• Educate APRNs on importance of elections this year.

• Strategic planning must begin every May for next session and be

continually evaluated.

• Strengthen grassroots communication with APRNs .

• President should attend and meet with regional groups to increase

communication and visibility of NPAA and unite the members.


• Establish more regional groups to cover to include all APRNs; increase

website information for members to participate in the interim.

• Establish alliances with community partners continually and communicate

frequently.

• Identify policy changes outside the legislature that could impact delivery

of care.

• Establish a timeline for education and media coverage.

• Obtain sponsors the summer preceding the legislative session.

• Meet regularly throughout the year with legislators.

• Negotiate only with the decision makers not the lobbyist.

• Meet with all opposition.

• Establish an endorsement process for NPAA based on the ANA PAC

(Appendix R).

• Establish a pictorial representation for NPAA to represent, inspire, and

united symbol across the state (Appendix S)).

• Train good leaders and followers and strive for excellence.

• Re-evaluate.

•

•

•

Lessons Learned

Research from this project revealed advanced practice nursing in this state has been

significantly underfunded. APRN primary care pilot projects are virtually non-existent. APRNs


are crossing state lines to practice in states with fewer barriers. A significant educational deficit

is noted in the general public and legislators regarding the role/scope of practice of APRNs.

Individuals and organizations do not have to write the bill themselves. They can secure a

legislative sponsor and a list of the items they would like to change and the legislative reference

service will write the bill for the sponsor. This saves time for the organization or individual to

implement change. I learned once the bill is given to the legislator it is no longer “your” bill.

Legislators can change the bill any way they would like, without informing you, or providing

you a copy. Lobbyists are paid a salary to either get legislation passed, or keep it from getting

passed. Negotiations must be completed between the decision makers of the organizations. If

decision makers are not willing to talk, there will be no true negotiation.

The effort is worth the potential success. The experience of working on the controlled

substance bill provided an immersed learning experience. Politics is complicated. APRNs have

to be willing to continue to pursue alternatives for professional progress to be made. There are

advocates and alliances that share interests. Finding and building those alliances is foundational

work that takes several years to develop, but the collaboration and progress you make will be

tremendous.

Negotiations give you great insight to the needs of all parties. Willingness to discuss issues

without confrontational speech and body language opened many doors and allowed free

exchange of information. Being knowledgeable and prepared with the facts earns respect and

builds coalitions.

Limitations

Limitations were noted in the amount of time APRNs could implement the recommended

strategies. The need for staff persons within the NPAA organization was recognized and

suggested to carry out the daily communication required for executing the planned change.


Limitations were also noted in finances. NPAA does not charge any dues; rather the regional

groups charge a small fee to fund their regional meetings and organization functions. NPAA

relies on donations by individuals and regional groups. The budget for this project will limit

future use of the plan unless a policy for reimbursement is implemented for the executive

officers. A comprehensive strategic planning meeting for growth of NPAA has been addressed

and is planned for 2010. Broader educational events and projects are a priority to increase the

outreach efforts. Nurse Practitioners work long hours and are dedicated to their patients and

teaching responsibilities, therefore cannot spend large amounts of time lobbying for changes.

Bias was noted throughout the legislature to not get involved if the legislation was

controversial. Several comments were made about talking to “the nurse practitioner group” with

unfavorable reactions by the legislature. Legislators overwhelming felt the NPAA should obtain

the opposition’s agreement prior to introducing the bill. In the end, the NPAA agreed to disagree

with the MASA lobbyist and the BME physicians on what was best for the patients in Alabama

and the nursing profession.

Additionally, the project analysis revealed organizational structures in Alabama with

conflicting responsibilities. These state boards should maintain some degree of separation to

effectively fulfill the function and mission ethically. The lack of separation of public boards of

health and private professional associations creates a roadblock in progress in those fields. This

limitation must be addressed. The overlapping structures of three organizations are referenced

herein for clarity in advancing future legislation and for future research.

The Medical Association of the State of Alabama (MASA) annually elects a Board of

Censors, from the medical societies, to be the governing body for the organization (Medical

Association of the State of Alabama (MASA), 2010). The mission of the organization is stated in


their constitution, as “The Medical Association of the State of Alabama exists to serve, lead, and

unite physicians in promoting the highest quality of healthcare through advocacy, information,

and education.” The constitution further lists five objectives. The fifth objective states “(5) to

combine the influence of the member of the medical profession of the state for the purpose of

protecting their legitimate rights and of promoting the health of the people” (2010, p. 299).

The MASA constitution (MASA, 2009) and the Code of Alabama (1975) and 540X1.07,

[2009]), designate the MASA Board of Censors as board members for the Board of Medical

Examiners (Code of Alabama 540X1, 1975) and for the Alabama Department of Public

Health/State Board of Health (MASA Bylaws, 2010; Code of Alabama 420-1-5). The MASA

Board of Censors, therefore, is responsible both legally and ethically to fulfill all three boards

functions and objectives.

The Code of Alabama (1975, 540-1-.07) sets out the function of the BME as follows:

The Board is authorized to:

(a) Adopt and promulgate rules and regulations and to do such other acts as may

be necessary to carry into effect the duties and powers which accrue to the Board

under laws now in force or which may hereafter be in force.

(b) Issue certificates of qualification to the Medical Licensure Commission for

applicants meeting the statutory qualifications for licensure.

(c) Commence and maintain proceedings to restrain the unlawful practice of

medicine.

(d) Serve as the certifying board for physicians applying for an Alabama

Controlled Substances Certificate.

(e) Carry out the provisions of law relating to assistants to physicians.


(f) Administer and/or approve an examination in certain specified branches of

medical learning.

(g) Keep complete records of all examinations held by the Board.

(h) Keep complete minutes of all the Board's proceedings.

(i) Keep records of all reports of claims or actions for negligence in the

performance of a licensee's professional services and review the reports annually.

(j) Approve, jointly, with the Alabama Board of Nursing, qualified applicants for

collaborative practice as Certified Registered Nurse Practitioners and Certified

Nurse Midwives.

(k) Record and maintain a permanent file on all professional corporations

incorporated by physicians and osteopaths.

(l) Administer and enforce the provisions of the Controlled Substance Therapeutic

Research Program.

(m) Furnish all personnel and facilities necessary to administer and enforce the

provisions of law relating to the Medical Licensure Commission.

(n) Employ investigators, attorneys, agents and other employees necessary to aid

the Medical Licensure Commission in the administration and enforcement

The Code of Alabama states:

The Board of Censors of the Medical Association of the State of Alabama, as constituted

under the laws now in force, or which may hereinafter be in force, and under the

constitution of said association, as said constitution now exists or may hereafter exist, is

constituted the State Board of Medical Examiners (1975, Section 540x1.01).

The Alabama Department of Public Health’s website displays the following statements:


“Alabama law designates the State Board of Health as an advisory board to the state in all

medical matters, matters of sanitation and public health. The Medical Association, which meets

annually, is the State Board of Health.” Further it states, the “purpose of the Alabama

Department of Public Health is to provide caring, high quality and professional services for the

improvement and protection of the public’s health through disease prevention and the assurance

of public health services to resident and transient populations of the state regardless of social

circumstances or the ability to pay (2010, n.p.).” The description of the ADPH responsibility

purports that it “serves the people of Alabama by assuring conditions in which they can be

healthy (2010).”

Alabama law additionally states:

The Board functions through the State Committee of Public Health as constituted by Code

of Ala. 1975§2224, which is composed of 12 members of the Medical Association of the

State of Alabama and the chairman of each of four councils provided for by statute. The

16 members function under the leadership of a chairman and a vice chairman, [who are]

elected by the membership for a term of four (4) years. (1975, Section 540x1.01, #2).

This committee is authorized to employ a State Health officer who is empowered to act on

behalf of the State Committee of Public Health when the committee is not in session.

(ADPH, 2010, n.p.).

More than 130 years ago, medical leaders in Alabama advocated constitutional authority

to oversee matters of public health. The purpose of the authority was to preserve and

prolong life; to plan an educational program for all people on rules, which govern a

healthful existence; and to determine a way for enforcing health laws for the welfare of all

people (ADPH, 2009, n.p.).


In reflecting on the purpose of these three boards, comparing the Alabama Code and

revisions, and analyzing the organizations missions and functions, it is apparent they are

intended for completely separate functions. One is a private, dues paying member only

association with lobbyist advocating for a profession, MASA. Two are public boards. The ADPH

and BME were established to protect the public. The BME was established to license, regulate,

and discipline physicians.

The public boards should be comprised of a balanced group of healthcare and scientific

representatives. Currently, there is not diverse professional leadership nor does it appear to

demonstrate the legislative checks and balances, to ensure the welfare of the public, these boards

are intended, both ethically and fundamentally, to provide. It is apparent that governance of the

BME by board members of MASA presents a conflict of interest. Research demonstrates

significant structural changes including separation, balance, and oversight should be mandated to

these state boards.

Plans for Dissemination

A poster presentation and power point modules have been prepared and the abstract

submitted for the ASNA September annual convention as a 4-hour Legislative workshop.

Current presentations are scheduled for May 11, 2010, at the Ida V. Moffet School of Nursing,

and the NPAA Annual convention May 13 in Florida. Future dissemination will be through

travel to regional NPAA meetings, state nurses’ publications, newspaper and TV interviews,

literature dissemination to the legislators, article submissions and abstracts submitted to AANP

and NSNA.

Recommendations for Future Research

Further research is indicated to eliminate barriers in providing primary care. Research

should address the following; primary care provider designation, reimbursement policies for all


primary care providers, state medical organizations overlapping structure, sole regulation by the

Board of Nursing (as in 48 other states) and collaborative practice requirements preventing care

to rural areas. Questions directing future research in Alabama must include maximizing the use

of APRNs and other providers.

Conclusion

Continuation of this project is recommended for historical and future progress of the

nursing profession. The interventions were successful in building alliances and educating

legislators and the public. The impact will be greater in dissemination of the results. Successful

change in the scope of practice for APRNs by attaining controlled substance prescriptive

privileges schedule II-V, will improve the quality of care provided by APRNs in Alabama and

the length of time patients are in pain. This prescriptive privilege expansion increases access to

care and authorizes appropriate treatment for patient’s pain relief. The elimination of one of the

barriers that restrict practice is positive incremental change. It is made possible with

participation, education, and advocacy. The patients in the State of Alabama are paying the price

for the barriers to providing quality care. To truly address the primary care shortage, barriers

such as collaborative practice, reimbursement and primary care designation in statue will need to

be addressed. APRNs must vote, be proactive, present at the decision tables, or other professions

will make decisions for our profession alone. Nurses should continue to advocate for their

patients needs as part of their professional responsibility. It is time to decrease the barriers in

Alabama to allow full scope of practice for APRNs to improve the quality and community health

of the Alabama citizens. APRNs can help solve the primary care shortage with increased

utilization.

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Appendices

Appendix Description

A BME Physician Assistant Summary Rules

B AANP State Prescriptive Authority Map (2009)

C ACEM Alabama Emergency Medicine Report Card

D AANP Map State Regulatory Authority 2010

E Joint Committee CRNP Summary Table

F AANP Map: Alabama APRN Practice Sites

G HRSA State Map Underserved Areas

H AL CRNP Standard Protocol

I Alabama Nurse Practice Act

J ABON CRNP Collaborative Practice Rules

K AL CRNP Prescriptive Formulary

L Handouts/Marketing

M Draft CRNP Controlled Substance Bill

N Draft Resolution

O Media Success

P AANP Position Statement on Prescribing

Q Lioce Budget (Balanced)

R Draft Endorsement Process

S Draft Emblem/Symbolization for APRNs


Appendix A


Appendix A (cont’d)

Alabama APN Update: Precriptive privileges (for reference only)

Alabama APN Update: Precriptive privileges (for reference only)

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