• Collaborative practice requirement divides nursing, medical communities

    Family nurse practitioner Kathy Lenz files paperwork at her clinic at Central Missouri Healthcare Associates in Boonville, Missouri on Tuesday, April 21.  Lenz has worked as an advanced practice registered nurse for 10 years.

    Family nurse practitioner Kathy Lenz files paperwork at her clinic at Central Missouri Healthcare Associates in Boonville, Missouri on Tuesday, April 21. Lenz has worked as an advanced practice registered nurse for 10 years.

    By Jacqueline LeBlanc and Micheala Sosby

    Kathy Lenz is an advanced practice registered nurse (APRN) in Boonville, Missouri, but sometimes her patients mistakenly call her “Dr. Kathy.” She makes sure to correct them.

    “I tell them, ‘You don’t see a doctor, you see a nurse practitioner,’” Lenz said. “They don’t realize it, they just know that there’s somebody there that’s going to help them.”

    Just like Lenz’s role in the health care system is unclear to some of her patients, it’s being called into question by many Missouri lawmakers and health professionals.

    That same confusion surrounding what APRNs are and how they work has led many politicians and health professionals to question their role in Missouri’s health care system. Missouri is one of 12 states with restricted practice of APRNs.

    Under restricted practice laws, nurses can’t practice independently and must enter a collaborative practice agreement with a physician.  APRNs can also only practice within 30 miles of their collaborating physician, or 50 miles if the area in which they provide services is considered a Health Professional Shortage Area. While APRNs are required to collaborate with a physician in order to practice independently, physicians are not required to take on an APRN and can only collaborate with no more than three nurses.

    “I see a lot of really, really sick people who haven’t had health care in a long time,” Lenz said. “If my collaborator is out of town and my second person isn’t available, then I can’t by law see these people.”APRN0423

    “The mileage restriction is my biggest problem.”

    Frances Atkins practiced talk therapy in her hometown of Higginsville, Missouri.  As a talk therapist, Atkins counseled patients through a range of psychotherapies by talking.  However, in 2009 the State Board of Nursing informed her their interpretation of talk therapy was different than it had been. In order for her to continue her talk therapy practice she would have to abide by the collaborative practice agreement.

    “I’d been led to believe that it was okay, I wouldn’t be doing anything different than a social worker would do or a psychologist would do,” Atkins said.  “I was in this no-man’s land.”

    Atkins knew that this was her calling, and she was confident that she would be able to find a physician to collaborate with so she could continue her practice.

    However, the search for a psychiatrist who fit the distance requirement was not as easy as Atkins originally thought.

    “All this time I was looking for a doctor and I was sure I was going to find a doctor and I’d be back in business. And three years later I was not back in business,” Atkins said.  “So I had an empty office.”

    After three years and asking 26 different psychiatrists to collaborate with her, Atkins finally found someone willing to work with her, but she would have to leave Higginsville since this psychiatrist was not within 50 miles of her old office.

    While Atkins appreciates the work she does with her physician and believes that she would still collaborate with him regardless of the restrictions, some nurses think otherwise.  Christine Hurt, a family nurse practitioner in Tipton, Missouri, believes that she wouldn’t have a collaborator if it weren’t required. That’s not to say that the relationship isn’t valuable.

    “If it weren’t required by law I probably wouldn’t have a collaborating physician,” Hurt said.   “That doesn’t mean that I wouldn’t collaborate. I think collaborating is just a smart thing to do whether you’re a nurse practitioner or a physician.”

    While the relationship is valuable, both Atkins and Hurt agree that these restrictions impose unnecessary requirements,which ultimately limits healthcare for patients. Marilyn Rantz and Gina Oliver, professors at the Sinclair School of Nursing, conducted a study that examined the difference in care and health outcome for patients in states with and without APRN restrictions.  They found that states that had restrictions actually impeded the quality and access to healthcare.

    “The bigger issue is there’s no scientific foundation for these restrictions,” Rantz said.

    When a category F5 tornado struck Joplin, Missouri in 2011, APRNs like Oliver couldn’t travel to Joplin to provide care for victims because of the geographic proximity and collaborative practice regulations.

    “There were many of us who wanted to go down and help, but we were unable to do that because of the state restrictions,” Oliver said.  “We could go down and help clear debris but we couldn’t use our expertise as a health care providers to go down and assist the physicians and the advanced practice nurses who were in this crisis situation and could’ve used some help.”

    However, proponents in favor of the restrictions believe that because APRNs do not receive the same amount of training or knowledge from nursing school like they would in medical school.  Dr. Dan Purdom, a family practice physician and president of the Missouri Academy of Family Physicians, said that restrictions like the distance and collaborative practice requirements are necessary.

    “I think the distance and having a relationship between the nurse practitioner and the physician, I think that’s really important,” Purdom said.  “I can tell you that having worked with nurse practitioners in rural areas, if you get much more than 15 miles away, it’s very difficult to maintain the relationships we need for good patient care and safety.”

    Psychiatric nurse practitioner Frances Atkins laughs during a counseling session with one of her patients at her clinic in Boonville, Missouri on Tuesday, April 21.  Atkins uses a combination of counseling and medication to treat her patients.

    Psychiatric nurse practitioner Frances Atkins laughs during a counseling session with one of her patients at her clinic in Boonville, Missouri on Tuesday, April 21. Atkins uses a combination of counseling and medication to treat her patients.

    He said that instead of lifting the requirements, the medical community should encourage more physicians and nurse practitioners to practice in rural areas in order to prevent problems like the situation in Joplin.

    “The false assumption that some people get is that somehow nurse practitioners will fill this void when primary care physicians haven’t,” Purdom said.  “ And really what we’re seeing is that nurse practitioners are gravitating toward urban areas and specialty care as much as physicians are.”

    Though, for APRNs like Atkins, rural underserved areas are the communities that they wish to help, which would be easier if the restrictions were lifted.

    “Even though there are barriers to care for our clients, that’s where a nurse’s heart lies,” Atkins said.  “We go into nursing not to get rich, it’s a service. It’s not so much about us having freedom as it is about patients having care.”

    Supervising editor is Kaileen Gaul. Faculty Editor is Judd Slivka.

    ----------Posted on April 28, 2015 by in Student Work

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