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3 Transforming Practice Key Message #1: Nurses should practice to the full extent of their education and training. Patients, in all settings, deserve care that is centered on their unique needs and not what is most convenient for the health professionals involved in their care. A transformed health care system is required to achieve this goal. Transforming the health care system will in turn require a fundamental rethinking of the roles of many health profession- als, including nurses. The Affordable Care Act of 2010 outlines some new health care structures, and with these structures will come new opportunities for new roles. A number of programs and initiatives have already been developed to target necessary improvements in quality, ac- cess, and value, and many more are yet to be conceived. Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses. 

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 THE FUTURE OF NURSING The Affordable Care Act of 2010 (ACA) will place many demands on health professionals and offer them many opportunities to create a system that is more patient centered. The legislation has begun the long process of shifting the focus of the U.S. health care system away from acute and specialty care. The need for this shift in focus has become particularly urgent with respect to chronic condi- tions; primary care, including care coordination and transitional care; prevention and wellness; and the prevention of adverse events, such as hospital-acquired infections. Given the aging population, moreover, the need for long-term and palliative care will continue to grow in the coming years (see Chapter 2). The increase in the insured population and the rapid increase in racial and ethnic mi- nority groups who have traditionally faced obstacles in accessing health care will also demand that care be designed for a more socioeconomically and culturally diverse population. This chapter examines how enabling nurses to practice to the full extent of their education and training (key message #1 in Chapter 1) can be a major step forward in meeting these challenges. The first section explains why transforming nursing practice to improve care is so important, offering three examples of how utilizing the full potential of nurses has increased the quality of care while achiev- ing greater value. The chapter then examines in detail the barriers that constrain this transformation, including regulatory barriers to expanding nurses’ scope of practice, professional resistance to expanded roles for nurses, fragmentation of the health care system, outdated insurance policies, high turnover rates among nurses, difficulties encountered in the transition from education to practice, and demographic challenges. The third section describes the new structures and op- portunities made possible by the ACA, as well as through technology. The final section summarizes the committee’s conclusions regarding the vital contributions of the nursing profession to the success of these initiatives as well as the overall transformation of the health care system, and what needs to be done to transform practice to ensure that this contribution is realized. Particular emphasis is placed on advanced practice registered nurses (APRNs), including their roles in chronic disease management and increased access to primary care, and the regulatory bar- riers preventing them from taking on these roles. This is not to say that general registered nurses (RNs) should not have the opportunity to improve their practice and take on new roles; the chapter also provides such examples. THE IMPORTANCE OF TRANSFORMING NURSING PRACTICE TO IMPROVE CARE As discussed in Chapter 2, the changing landscape of the health care system and the changing profile of the population require that the system undergo a fun- damental shift to provide patient-centered care; deliver more primary as opposed to specialty care; deliver more care in the community rather than the acute care setting; provide seamless care; enable all health professionals to practice to the

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 TRANSFORMING PRACTICE full extent of their education, training, and competencies; and foster interprofes - sional collaboration. Achieving such a shift will enable the health care system to provide higher-quality care, reduce errors, and increase safety. Providing care in this way and in these areas taps traditional strengths of the nursing profession. This chapter argues that nurses are so well poised to address these needs by virtue of their numbers, scientific knowledge, and adaptive capacity that the health care system should take advantage of the contributions they can make by assuming enhanced and reconceptualized roles. Nursing is one of the most versatile occupations within the health care workforce.1 In the 150 years since Florence Nightingale developed and promoted the concept of an educated workforce of caregivers for the sick, modern nursing has reinvented itself a number of times as health care has advanced and changed (Lynaugh, 2008). As a result of the nursing profession’s versatility and adaptive capacity, new career pathways for nurses have evolved, attracting a larger and more broadly talented applicant pool and leading to expanded scopes of practice and responsibilities for nurses. Nurses have been an enabling force for change in health care along many dimensions (Aiken et al., 2009). Among the many in- novations that a versatile, adaptive, and well-educated nursing profession have helped make possible are • the evolution of the high-technology hospital; • the possibility for physicians to combine office and hospital practice; • lengths of hospital stay that are among the shortest in the world; • reductions in the work hours of resident physicians to improve patient safety; • expansion of national primary care capacity; • improved access to care for the poor and for rural residents; • respite and palliative care, including hospice; • care coordination for chronically ill and elderly people; and • greater access to specialty care and focused consultation (e.g., incon - tinence consultation, home parenteral nutrition services, and sleep ap- nea evaluations) that complement the care of physicians and other providers. With every passing decade, nursing has become an increasingly integral part of health care services, so that a future without large numbers of nurses is impos- sible to envision. 1 This discussion draws on a paper commissioned by the committee on “Nursing Education Policy Priorities,” prepared by Linda H. Aiken, University of Pennsylvania (see Appendix I on CD-ROM).

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 THE FUTURE OF NURSING Nurses and Access to Primary Care Given current concerns about a shortage of primary care health professionals, the committee paid particular attention to the role of nurses, especially APRNs, 2 in this area. Today, nurse practitioners (NPs), together with physicians and physi- cian assistants, provide most of the primary care in the United States. Physicians account for 287,000 primary care providers, NPs for 83,000, and physician assis- tants for 23,000 (HRSA, 2008; Steinwald, 2008). While the numbers of NPs and physician assistants are steadily increasing, the numbers of medical students and residents entering primary care have declined in recent years (Naylor and Kurtz- man, 2010). The demand to build the primary care workforce, including APRNs, will grow as access to coverage, service settings, and services increases under the ACA. While NPs make up slightly less than a quarter of the country’s primary care professionals (Bodenheimer and Pham, 2010), it is a group that has grown in recent years and has the potential to grow further at a relatively rapid pace. The Robert Wood Johnson Foundation (RWJF) Nursing Research Network commissioned Kevin Stange, University of Michigan, and Deborah Sampson, Boston College, to provide information on the variation in numbers of NPs across the United States. Figures 3-1 and 3-2, respectively, plot the provider-to-primary care doctor of medicine (MD) ratio for NPs and physician assistants by county for 2009.3 The total is calculated as the population-weighted average for states with available data. Between 1995 and 2009, the number of NPs per primary care MD more than doubled, from 0.23 to 0.48, as did the number of physician assistants per primary care MD (0.12 to 0.28) (RWJF, 2010c). These figures suggest that it is possible to increase the supply of both NPs and physician assistants in a rela- tively short amount of time, helping to meet the increased demand for care. In addition to the numbers of primary care providers available across the United States and where specifically they practice, it is worth noting the kind of care being provided by each of the primary care provider groups. According to the complexity-of-care data shown in Table 3-1, the degree of variation among primary care providers is relatively small. Much of the practice of primary care—whether provided by physicians, NPs, physician assistants, or certified nurse midwives (CNMs)—is of low to moderate complexity. 2 APRNs include nurse practitioners (NPs), certified nurse midwives (CNMs), clinical nurse spe- cialists (CNSs), and certified registered nurse anesthetists (CRNAs). When the committee refers to NPs, the term denotes only NPs. 3 To get a sense of the size and proportion of the NP workforce across the country, Stange and Sampson computed the ratio of the total number of licensed NPs to the total number of primary care MDs, physician assistants, and NPs in a given area. The physician assistant share was computed similarly. These computations are for proportion and growth analysis purposes only; they are not to suggest that all NPs or physician assistants are providing primary care.

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 TRANSFORMING PRACTICE 1 or more 0.50-0.99 0.25-0.49 0.00-0.24 No primary care MDs in county Data unavailable FIGURE 3-1 Map of the number of NPs per primary care MD by county, 2009. SOURCE: RWJF, 2010a. Reprinted with permission from Lori Melichar, RWJF. 1 or more 0.50-0.99 0.25-0.49 0.00-0.24 No primary care MDs in county Data unavailable FIGURE 3-2 Map of the number of physician assistants per primary care MD by county, 2009. SOURCE: RWJF, 2010b. Reprinted with permission from Lori Melichar, RWJF.

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0 THE FUTURE OF NURSING TABLE 3-1 Complexity of Evaluation and Management Services Provided Under Medicare Claims Data for 2000, by Practitioner Type Low Complexity Moderate Complexity High Complexity Practitioner Type (%) (%) (%) Primary care physician 55 34 11 Nurse practitioner 57 35 9 Physician assistant 59 34 7 Certified nurse midwife 77 19 4 NOTES: For evaluation and management services, low-complexity services are defined as those re- quiring straightforward or low-complexity decision making; moderate-complexity services are those defined as requiring a moderate level of decision making; and high-complexity services are defined as those requiring a high level of decision making. SOURCE: Chapman et al., 2010. Copyright © 2010 by the authors. Reprinted by permission of SAGE Publications. Nurses and Quality of Care Beyond the issue of pure numbers of practitioners, a promising field of evidence links nursing care to a higher quality of care for patients, includ- ing protecting their safety. According to Mary Naylor, director of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initia - tive (INQRI), several INQRI-funded research teams have provided examples of this link. “[Nurses] are crucial in preventing medication errors, reducing rates of infection and even facilitating patients’ transition from hospital to home.” 4 INQRI researchers at The Johns Hopkins University have found that sub- stantial reductions in central line−associated blood stream infections can be achieved with nurses leading the infection control effort. Hospitals that adopted INQRI’s intensive care unit safety program, as well as an environment that sup- ported nurses’ involvement in quality improvement efforts, reduced or eliminated bloodstream infections (INQRI, 2010b; Marsteller et al., 2010). Other INQRI researchers linked a core cluster of nurse safety processes to fewer medication errors. These safety processes include asking physicians to clarify or rewrite unclear orders, independently reconciling patient medica- tions, and providing patient education. A positive work environment was also important. This included having more RNs per patient, a supportive management structure, and collaborative relationships between nurses and physicians (Flynn et al., 2010; INQRI, 2010a). 4 Personal communication, Mary Naylor, Marian S. Ware Professor in Gerontology, Director of New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, June 16, 2010.

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1 TRANSFORMING PRACTICE Examples of Redesigned Roles for Nurses Many examples exist in which organizations have been redesigned to better utilize nurses, but their scale is small. As Marilyn Chow, vice president of the Patient Services Program Office at Kaiser Permanente, declared at a public forum hosted by the committee, “The future is here, it is just not everywhere” (IOM, 2010b). For example, over the past 20 years, the U.S. Department of Veterans Af- fairs (VA) has expanded and reconceived the roles played by its nurses as part of a major restructuring of its health care system. The results with respect to quality, access, and value have been impressive. In addition, President Obama has lauded the Geisinger Health System of Pennsylvania, which provides comprehensive care to 2.6 million people at a greater value than is achieved by most other or- ganizations (White House, 2009). Part of the reason Geisinger is so effective is that it has aligned the roles played by nurses to accord more closely with patients’ needs, starting with its primary care sites and ambulatory areas. The following subsections summarize the experience of the VA and Geisinger, as well as Kaiser Permanente, in expanding and reconceptualizing the roles of nurses. Because these institutions also measured outcomes as part of their initiatives, they provide real-world evidence that such an approach is both possible and necessary. Of note in these examples is not only how nurses are collaborating with physicians, but also how nurses are collaborating with other nurses. Department of Veterans Affairs In 1996, Congress greatly expanded the number of veterans eligible to receive VA services, which created a need for the system to operate more ef- ficiently and effectively (VHA, 2003). Caring for the wounded from the wars in Afghanistan and Iraq has further increased demand on the VA system, particularly with respect to brain injuries and posttraumatic stress disorder. Moreover, the large cohort of World War II veterans means that almost 40 percent of veterans are aged 65 or older, compared with 13 percent of the general population (U.S. Census Bureau, 2010; VA, 2010). Anticipating the challenges it would face, the VA began transforming itself in the 1990s from a hospital-based system into a health care system that is fo- cused on primary care, and it also placed emphasis on providing more services, as appropriate, closer to the veteran’s home or community (VHA, 2003, 2009). This strategy required better coordination of care and chronic disease manage- ment—a role that was filled by experienced front-line RNs. More NPs were hired as primary care providers, and the VA actively promoted a more collaborative professional culture by organizing primary care providers into health teams. It 5 See http://www1.va.gov/health/.

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2 THE FUTURE OF NURSING also developed a well-integrated information technology system to link its health professionals and its services. The VA uses NPs as primary care providers to care for patients across all settings, including inpatient and outpatient settings. In addition to their role as primary care providers, NPs serve as health care researchers who apply their find- ings to the variety of settings in which they practice. They also serve as educators, some as university faculty, providing clinical experiences for 25 percent of all nursing students in the country. As health care leaders, VA NPs shape policy, fa- cilitate access to VA health care, and impact resource management (VA, 2007). The results of the VA’s initiatives using both front-line RNs and APRNs are impressive. Quality and outcome data consistently demonstrate superior results for the VA’s approach (Asch et al., 2004; Jha et al., 2003; Kerr et al., 2004). One study found that VA patients received significantly better health care—based on various quality-of-care indicators6—than patients enrolled in Medicare’s fee-for- service program. In some cases, the study showed, between 93 and 98 percent of VA patients received appropriate care in 2000; the highest score for comparable Medicare patients was 84 percent (Jha et al., 2003). In addition, the VA’s spending per enrollee rose much more slowly than Medicare’s, despite the 1996 expansion of the number of veterans who could access VA services. After adjusting for dif- ferent mixes of population and demographics, the Congressional Budget Office determined that the VA’s spending per enrollee grew by 30 percent from 1999 to 2007, compared with 80 percent for Medicare over the same period. Geisinger Health System The Geisinger Health System employs 800 physicians; 1,900 nurses; and more than 1,000 NPs, physician assistants, and pharmacists. Over the past 18 years, Geisinger has transformed itself from a high-cost medical facility to one that provides high value—all while improving quality. It has borrowed several restructuring concepts from the manufacturing world with an eye to redesigning care by focusing on what it sees as the most critical determinant of quality and cost—actual caregiving. “What we’re trying to do is to have [our staff] work up to the limit of their license and . . . see if redistributing caregiving work can increase quality and decrease cost,” Glenn Steele, Geisinger’s president and CEO, said in a June 2010 interview (Dentzer, 2010). Numerous improvements in the quality of care, as well as effective in- novations proposed by employees, have resulted. For example, the nurses who 6 Quality-of-care indicators included those in preventive care (mammography, influenza vaccina- tion, pneumococcal vaccination, colorectal cancer screening, cervical cancer screening), outpatient care (care for diabetes [e.g., lipid screening], hypertension [e.g., blood pressure goal <140/90 mm Hg], depression [annual screening]), and inpatient care (acute myocardial infarction [e.g., aspirin within 24 hr of myocardial infarction], congestive heart failure [e.g., ejection fraction checked]). 7 See http://www.geisinger.org/about/index.html.

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3 TRANSFORMING PRACTICE used to coordinate care and provide advice through the telephone center under Geisinger’s health plan suspected that they would be more effective if they could build relationships with patients and meet them at least a few times face to face. Accordingly, some highly experienced general-practice nurses moved from the call centers to primary care sites to meet with patients and their families. The nurses used a predictive model to identify who might need to go to the hospital and worked with patients and their families on creating a care plan. Later, when patients or families received a call from a nurse, they knew who that person was. The program has worked so well that nurse coordinators are now being used in both Geisinger’s Medicare plan and its commercial plan.8 Some of the nation’s largest for-profit insurance companies, including WellPoint and Cigna, are now trying out the approach of employing more nurses to better coordinate their pa- tients’ care (Abelson, 2010). As a result, an innovation that emerged when a few nurses at Geisinger took the initiative and changed an already well-established program to deliver more truly patient-centered care may now spread well beyond Pennsylvania. Geisinger was also one of the very first health systems in the coun- try to create its own NP-staffed convenient care clinics9—another innovation that reflects the organization’s commitment to providing integrated, patient-centered care throughout its community. Kaiser Permanente10,11 As one of the largest not-for-profit health plans, Kaiser Permanente provides health care services for more than 8.6 million members, with an employee base of approximately 165,000. Kaiser Permanente has facilities in nine states and the District of Columbia, and has 35 medical centers and 454 medical offices. The system provides prepaid health plans that emphasize prevention and consolidated services designed to keep as many services as possible in one location (KP, 2010). Kaiser is also at the forefront of experimenting with reconceptualized roles for nurses that are improving quality, satisfying patients, and making a difference to the organization’s bottom line. Nurses in San Diego have taken the lead in overseeing the process for patient discharge, making it more streamlined and efficient and much more effective. Discharge nurses now have full authority over the entire discharge process until home health nurses, including those in hospice and palliative care, step in to take over the patient’s care. They have created efficiencies relative to previous 8 Personal communication, Bruce H. Hamory, Executive Vice President and Chief Medical Officer Emeritus, Geisinger Health System, April 27, 2010. 9 Personal communication, Tine Hansen-Turton, CEO, National Nursing Centers Consortium, and Vice President, Public Health Management Corporation, August 11, 2010. 10 See https://members.kaiserpermanente.org/kpweb/aboutus.do. 11 Personal communication, Marilyn Chow, Vice President, Patient Care Services, Program Office, Kaiser Permanente, August 23, 2010.

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4 THE FUTURE OF NURSING processes by using time-sensitive, prioritized lists of only those patients who are being discharged over the next 48 hours (instead of patients who are being dis- charged weeks into the future). Home health care nurses and discharge planners stay in close contact with one another on a daily basis to make quick decisions about patient needs, including the need for home health care visitation. In just 3 months, the number of patients who saw a home health care provider within 24 hours increased from 44 to 77 percent (Labor Management Partnership, 2010). In 2003, Riverside Medical Center implemented the Riverside Proactive Health Management Program (RiPHM)™, an integrated, systematic approach to health care management that promotes prevention and wellness and coordinates interventions for patients with chronic conditions. The model strengthens the patient-centered medical home concept and identifies members of the health care team (HCT)—a multidisciplinary group whose staff is centrally directed and physically located in small units within the medical office building. The team serves panel management and comprehensive outreach and inreach functions to support primary care physicians and proactively manage the care of members with chronic conditions such as diabetes, hypertension, cardiovascular disease, asthma, osteoporosis, and depression. The expanded role of nurses as key mem- bers of the HCT is a major factor in RiPHM’s success. Primary care manage- ment nurse clinic RNs and licensed practical nurses (LPNs) provide health care coaching and education for patients to promote self-management of their chronic conditions through face-to-face education visits and telephone follow-up. Using evidence-based clinical guidelines, such as diabetes and hypertension treat-to- target algorithms, nurses play important roles in the promotion of changes in chronic conditions and lifestyles, coaching and counseling, self-monitoring and goal setting, depression screening, and the use of advanced technology such as interactive voice recognition for patient outreach. Through this model of care, nurses and pharmacists have become skilled users of health information technology to strengthen the primary care−based, patient-centered medical home. Nurses use disease management registries to work with assigned primary care physicians, and review clinical information that addresses care gaps and evaluate treatment plans. RiPHM has provided a strong foundation for the patient-centered medical home. By implementing this program and expanding the role of nurses, Riverside has sustained continuous improve- ment in key quality indicators for patient care. Guided care is a new model for chronic care that was recently introduced within the Kaiser system. Guided care is intended to provide, within a primary care setting, quality care to patients with complex needs and multiple chronic conditions. An RN, who assists three to four physicians, receives training in such areas as the use of an electronic health record (EHR), interviewing, and the par- ticulars of health insurance coverage. RNs are also provided skills in managing chronic conditions, providing transitional care, and working with families and community organizations (Boult et al., 2008).

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 TRANSFORMING PRACTICE The nurse providing guided care offers eight services: assessment; planning care; monitoring; coaching; chronic disease self-management; educating and supporting caregivers; coordinating transitions between providers and sites of care; and facilitating access to community services, such as Meals-on-Wheels, transportation services, and senior centers. Results of a pilot study comparing surveys of patients who received guided care and those who received usual care revealed improved quality of care and lower health care costs (according to insur- ance claims) for guided care patients (Boult et al., 2008). Summary The VA, Geisinger, and Kaiser Permanente are large integrated care systems that may be better positioned than others to invest in the coordination, education, and assessment provided by their nurses, but their results speak for themselves. If the United States is to achieve the necessary transformation of its health care system, the evidence points to the importance of relying on nurses in enhanced and reconceptualized roles. This does not necessarily mean that large regional corporations or vertically integrated care systems are the answer. It does mean that innovative, high-value solutions must be developed that are sustainable, eas- ily adopted in other locations, and rapidly adaptable to different circumstances. A website on “Innovative Care Models” illustrates that many other solutions have been identified in other types of systems.12 As patients, employers, insurers, and governments become more aware of the benefits offered by nurses, they may also begin demanding that health care providers restructure their services around the contributions that a transformed nursing workforce can make. As discussed later in the chapter, the committee believes there will be numerous opportunities for nurses to help develop and implement care innovations and assume leadership roles in accountable care organizations and medical homes as a way of providing access to care for more Americans. As the next section describes, however, it will first be necessary to acknowledge the barriers that prevent nurses from practicing to the full extent of their education and training, as well as to generate the politi- cal will on the part of policy makers to remove these barriers. BARRIERS TO TRANSFORMING PRACTICE Nurses have great potential to lead innovative strategies to improve the health care system. As discussed in this section, however, a variety of histori- cal, regulatory, and policy barriers have limited nurses’ ability to contribute to widespread transformation (Kimball and O’Neil, 2002). This is true of all RNs, including those practicing in acute care and public and community health set- tings, but is most notable for APRNs in primary care. Other barriers include 12 See http://www.innovativecaremodels.com/ and http://www.rwjf.org/reports/grr/057241.htm.

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12 THE FUTURE OF NURSING Hansen-Turton, T., A. Ritter, H. Begun, S. L. Berkowitz, N. Rothman, and B. Valdez. 2006. Insurers’ contracting policies on nurse practitioners as primary care providers: The current landscape and what needs to change. Policy, Politics, & Nursing Practice 7(3):216-226. Hansen-Turton, T., A. Ritter, and R. Torgan. 2008. Insurers’ contracting policies on nurse practitioners as primary care providers: Two years later. Policy, Politics, & Nursing Practice 9(4):241-248. Harris Interactive. 2008. New WSJ.com/Harris Interactive study finds satisfaction with retail- based health clinics remains high. http://www.harrisinteractive.com/NEWS/allnewsbydate. asp?NewsID=1308 (accessed August 6, 2010). Hatem, M., J. Sandall, D. Devane, H. Soltani, and S. Gates. 2008. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews (4):CD004667. Hayes, L. J., L. O’Brien-Pallas, C. Duffield, J. Shamian, J. Buchan, F. Hughes, H. K. Spence Las- chinger, N. North, and P. W. Stone. 2006. Nurse turnover: A literature review. International Journal of Nursing Studies 43(2):237-263. HHS (Department of Health and Human Services. 2009. CMS and ONC issue regulations proposing a definition of ‘meaningful use’ and setting standards for electronic health record incentive program. http://www.hhs.gov/news/press/2009pres/12/20091230a.html (accessed September 29, 2010). Hogan, P. F., R. F. Seifert, C. S. Moore, and B. E. Simonson. 2010. Cost effectiveness analysis of anesthesia providers. Nursing Economic$ 28(3):159-169. Hooker, R., and L. Berlin. 2002. Trends in the supply of physician assistants and nurse practitioners in the United States. Health Affairs 21(5):174-181. Horrocks, S., E. Anderson, and C. Salisbury. 2002. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 324(7341):819-823. HRSA (Health Resources and Services Adminsitration). 2004. Supply, demand, and use of licensed practical nurses. Rockville, MD: HRSA. HRSA. 2006. The registered nurse population: Findings from the National Sample Survey of Regis- tered Nurses, March 2004. Rockville, MD: HRSA. HRSA. 2008. The physician workforce. Rockville, MD: HRSA. HRSA. 2010. The registered nurse population: Findings from the 200 National Sample Survey of Registered Nurses. Rockville, MD: HRSA. Hughes, F., S. Clarke, D. A. Sampson, J. A. Fairman, and E. M. Sullivan-Marx. 2010. Research in support of nurse pracitioners. In Nurse practitioners: Evolution and future of advanced practice. 5th ed., edited by E. M. Sullivan-Marx, D. O. McGivern, J. A. Fairman, and S. A. Greenberg. New York: Springer. Pp. 65-92. Huijbregts, P. A. 2007. Chiropractic legal challenges to the physical therapy scope of practice: Anybody else taking the ethical high ground? Journal of Manual & Manipulative Therapy 15(2):69-80. Hunt, E., S. Sproat, and R. Kitzmiller. 2004. The nursing informatics implementation guide, edited by K. Hannah and M. Ball. New York: Springer-Verlag. INQRI (The Blog of the Interdisciplinary Nursing Quality Research Initiative). 2010a. Interrupt- ing a nurse can lead to errors. http://inqri.blogspot.com/2010_07_01_archive.html (accessed September 29, 2010). INQRI. 2010b. Lessons learned from  states on building successful HAI reporting programs. http://inqri.blogspot.com/2010/08/lessons-learned-from-9-states-on.html (accessed September 29, 2010). IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. IOM. 2003. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press. IOM. 2004. In the nation’s compelling interest: Ensuring diversity in the health care workforce. Washington, DC: The National Academies Press.

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1 TRANSFORMING PRACTICE ANNEX -1 STATE PRACTICE REGULATIONS FOR NURSE PRACTITIONERS TABLE 3-A1 State-by-State Regulatory Requirements for Physician Involvement in Care Provided by Nurse Practitioners Physician Quantitative Involvement Requirements for Requirement (for On-Site Oversight Physician Chart Maximum NP-to- State Prescription) Requirement Review Physician Ratio Alabama MD Collaboration 10% of the time 10% of all charts, 1 MD - 3 full-time Required all adverse NPs or max. total outcomes of 120 hours/week Alaska None None No N/A Arizona None None No N/A Arkansas MD Collaboration None No None stated Required California MD Supervision None No 4 prescribing NPs Required - 1 MD Colorado None (although None No 5 NPs - 1 MD; preceptor and board may waive mentoring restriction period required for prescribing during the first 3,600 hours of prescriptive practice) Connecticut MD Collaboration None No None stated Required Delaware MD Collaboration None No None stated Required Florida MD Supervision None No 1 MD - no more Required than 4 offices in addition to MD’s primary practice location (If MD provides primary health care services) continued

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1 THE FUTURE OF NURSING TABLE 3-A1 continued Physician Quantitative Involvement Requirements for Requirement (for On-Site Oversight Physician Chart Maximum NP-to- State Prescription) Requirement Review Physician Ratio Georgia MD Delegation None All controlled 4 NPs - 1 MD Required substance Rx w/in 3 mos of issuance of Rx, all adverse outcomes w/in 30 days of discovery, 10% of all other charts at least annually Hawaii MD Collaboration None No None stated Required* Idaho None None No N/A Illinois MD Delegation At least once per Yes, periodic None stated Required month (no duration review required for specified) Rx orders Indiana MD Collaboration None Yes, at least 5% None stated Required random sample of charts and medications prescribed for patients Iowa None None No N/A Kansas MD Collaboration None No None stated Required Kentucky MD Collaboration None No None stated Required Louisiana MD Collaboration None No None stated Required Maine None (although None No N/A supervision by a physician or nurse practitioner is required for first 24 months of NP practice) Maryland MD Collaboration None Yes (percentage None stated Required left to MD & NP discretion)

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1 TRANSFORMING PRACTICE TABLE 3-A1 continued Physician Quantitative Involvement Requirements for Requirement (for On-Site Oversight Physician Chart Maximum NP-to- State Prescription) Requirement Review Physician Ratio Massachusetts MD Supervision None Yes (for Rx only None stated Required - once every 3 months, percentage left to MD & NP discretion) Michigan MD Delegation None No None stated Required Minnesota MD Delegation None No None stated Required Mississippi MD Collaboration At least once every Yes - a None stated Required 3 months representative sample of either 10% or 20 charts, whichever is less, every month Missouri MD Delegation NP must first Yes - once every 2 3 FTE NPs - 1 Required practice for at weeks MD least one month at same location of collaborating MD, after which time MD must be on-site once every 2 weeks Montana None None 15 or 5% of charts, None stated whichever is less, reviewed quarterly (may be reviewed by MD or NP peer) Nebraska MD Collaboration None No None stated Required Nevada MD Collaboration Part of a day, once Yes (percentage 3 NPs - 1 MD Required a month left to MD & NP discretion) New None None No N/A Hampshire New Jersey MD Collaboration None Yes - periodic None stated Required review (percentage left to MD & NP discretion) New Mexico None None No N/A continued

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10 THE FUTURE OF NURSING TABLE 3-A1 continued Physician Quantitative Involvement Requirements for Requirement (for On-Site Oversight Physician Chart Maximum NP-to- State Prescription) Requirement Review Physician Ratio New York MD Collaboration None Yes at least once 4:1 NPs to Required every 3 months physicians (only (percentage left applies if more to MD & NP than 4 NPs discretion) practice off-site) North MD Supervision None Yes (for initial None stated Carolina Required 6 months of collaboration, must be review and countersigning by MD w/in 7 days of NP-patient contact & meetings of NP-MD on weekly basis for first month, & then at least monthly for next 5 months) North Dakota MD Collaboration None No None stated Required Ohio MD Collaboration None Yes - periodic 3 NPs - 1 MD Required review (annually, percentage left to MD & NP discretion) Oklahoma MD Supervision None No 2 FTE NPs or max Required 4 PT NPs - 1 MD Oregon None None No N/A Pennsylvania MD Collaboration None Yes (percentage 4 NPs - 1 MD Required left to MD & NP discretion) Rhode Island MD Collaboration None No None stated Required South MD Delegation None No 3 NPs - 1 MD Carolina Required South Dakota MD Collaboration No less than one Yes (percentage 4 NPs - 1 MD Required half day a week or left to MD & NP 10% of the time discretion) Tennessee MD Supervision Once every 30 20% of all charts None stated Required days (no duration every 30 days specified)

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11 TRANSFORMING PRACTICE TABLE 3-A1 continued Physician Quantitative Involvement Requirements for Requirement (for On-Site Oversight Physician Chart Maximum NP-to- State Prescription) Requirement Review Physician Ratio Texas MD Delegation For sites serving 10% of all charts 3 NPs or FTE Required medically - 1 MD (for underserved alternative populations: at practice sites, 4 least once every 10 - 1; can be waived days (no duration up to 6 - 1) specified). 10% for designated alternative practice sites. Utah MD Collaboration None No None stated Required** Vermont MD Collaboration None Yes (percentage None stated Required left to MD & NP discretion) Virginia MD Supervision MD must Yes - periodic 4 NPs - 1 MD Required “regularly practice” review (percentage at location where left to MD & NP NP practices discretion) Washington None None No N/A West Virginia MD Collaboration None Periodic and None stated Required joint review of Rx practice (no percentage specified) Wisconsin MD Collaboration None No None stated Required Wyoming None None No None stated NOTES: For the purposes of this chart, “collaboration” includes all collaboration-like requirements (such as “collegial relationship,” etc.). FTE = full-time equivalent; MD = medical doctor; NP = nurse practitioner; PT = part time; Rx = prescription. * This requirement will be altered pending new rules in 2011. ** For controlled substance schedules II-III only. SOURCE: NNCC, 2009. Reprinted with permission from Tine Hansen-Turton, NNCC. Copyright 2009 NNCC. REFERENCE NNCC. 2009. NNCC’s state-by-state guide to regulations regarding nurse practitioner and physi- cian practice 200. http://www.nncc.us/research/ContractingToolkit/contractingtoolkitgrid.pdf (accessed December 6, 2010).

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