1. 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
2. Alabama APRN Update: Prescribing 2
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.
3. Alabama APRN Update: Prescribing 3
List of Figures
Figure 1: Lioce Advanced Practice Nursing Legislative Change Model……………….8
6. Alabama APRN Update: Prescribing 6
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
7. Alabama APRN Update: Prescribing 7
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
9. Alabama APRN Update: Prescribing 9
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,
10. Alabama APRN Update: Prescribing 10
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.
11. Alabama APRN Update: Prescribing 11
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
12. Alabama APRN Update: Prescribing 12
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
13. Alabama APRN Update: Prescribing 13
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
14. Alabama APRN Update: Prescribing 14
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
15. Alabama APRN Update: Prescribing 15
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
16. Alabama APRN Update: Prescribing 16
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
17. Alabama APRN Update: Prescribing 17
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
18. Alabama APRN Update: Prescribing 18
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
19. Alabama APRN Update: Prescribing 19
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
20. Alabama APRN Update: Prescribing 20
• 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
21. Alabama APRN Update: Prescribing 21
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.
22. Alabama APRN Update: Prescribing 22
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
23. Alabama APRN Update: Prescribing 23
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:
24. Alabama APRN Update: Prescribing 24
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
25. Alabama APRN Update: Prescribing 25
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
27. Alabama APRN Update: Prescribing 27
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.
28. Alabama APRN Update: Prescribing 28
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
29. Alabama APRN Update: Prescribing 29
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.
30. Alabama APRN Update: Prescribing 30
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
31. Alabama APRN Update: Prescribing 31
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.
32. Alabama APRN Update: Prescribing 32
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:
33. Alabama APRN Update: Prescribing 33
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
34. Alabama APRN Update: Prescribing 34
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)
35. Alabama APRN Update: Prescribing 35
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
36. Alabama APRN Update: Prescribing 36
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.
37. Alabama APRN Update: Prescribing 37
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
38. Alabama APRN Update: Prescribing 38
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
39. Alabama APRN Update: Prescribing 39
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.
40. Alabama APRN Update: Prescribing 40
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.
41. Alabama APRN Update: Prescribing 41
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
42. Alabama APRN Update: Prescribing 42
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
43. Alabama APRN Update: Prescribing 43
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.
44. Alabama APRN Update: Prescribing 44
• 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
45. Alabama APRN Update: Prescribing 45
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.
46. Alabama APRN Update: Prescribing 46
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
47. Alabama APRN Update: Prescribing 47
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.
48. Alabama APRN Update: Prescribing 48
(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:
49. Alabama APRN Update: Prescribing 49
“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.).
50. Alabama APRN Update: Prescribing 50
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
51. Alabama APRN Update: Prescribing 51
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.
52. Alabama APRN Update: Prescribing 52
References
Advance. (2009). State legislative update. Retrieved on May 3, 2010 from http://nurse-
practitioners.advanceweb.com/editorial/content/editorial.aspx?cc=212081&CP=1
Alabama Board of Nursing. (2009a). Administrative code: Advanced practice nursing. Ch. 610-
X-1, 2,5,6,9,10. Retrieved on May 2, 2010 from
http://www.alabamaadministrativecode.state.al.us/docs/nurs/index.html
Alabama Board of Nursing. (2009b). Advanced practice application: CRNP-CNM. Retrieved on
May 3, 2010 from http://www.abn.state.al.us/main/downloads/applications/AP
%20APPS/CRNP-CNM-Application.pdf
Alabama Board of Nursing. (2009c). Nurse practice act. Retrieved on May 8, 2010 from
http://www.abn.state.al.us/main/nurse-practice-act/article5.html
Alabama Board of Nursing. (2007). Advanced practice nursing: Standard protocol for CRNP and
CNM. Retrieved on April 13, 2010 from http://www.abn.state.al.us/main/Advanced
%20Practice/main-advanced.htm
Alabama Department of Public Health. (2010). About public health. Retrieved on April 10, 2010
from http://www.adph.org/administration/Default.asp?id=496
Alabama Department of Public Health. (2009). Annual report. Retrieved on April 18, 2010 from
from http://www.adph.org/administration/Default.asp?id=496
Alabama League of Women Voters. (2006). The Alabama Legislature: Facts and Issues.
Retrieved on May 2, 2010 from
http://www.lwval.org/legstudy/factsandissues/AL_Leg_F&I_whole.pdf
Alabama Legislative System Online. (2010). Retrieved on June 15, 2009 from
http://www.legislature.state.al.us/senate/senators/senateroster_alpha.html
53. Alabama APRN Update: Prescribing 53
American Academy of Nurse Practitioners. (2010). Alabama nurse practitioner: Practice
distribution map. Map presented at the American Academy of Nurse Practitioner Region
11 Leadership Meeting Orlando: FL.
American Academy of Nurse Practitioners. (2009a). Nurse Practitioner Facts. Retrieved on
September 10, 2009 from www.aanp.org
American Academy of Nurse Practitioners. (2009b). Position statement on nurse practitioner
prescriptive privilege. Retrieved on September 10, 2009 from www.aanp.org
American Academy of Nurse Practitioners. (2009c). Nurse practitioner prescriptive authority
map. Retrieved on September 10, 2009 from members only section from www.aanp.org
American College of Emergency Physicians. The National report card on the state of emergency
medicine; evaluating the emergency care environment state by state. Retrieved on July
20, 2009 from http://www.emreportcard.org/Alabama.aspx
American College of Physicians. (2009). Nurse practitioners in primary care. [Monograph].
Retrieved on July 10, 2009 from
http://www.acponline.org/advocacy/where_we_stand/policy/np_pc.pdf
America’s Health Rankings. Retrieved on July 30, 2009 from
http://www.americashealthrankings.org/2008/pdfs/al.pdf
Brown, S., & Grimes, D. (1993). Nurse practitioners and certified nurse-midwives: A meta-
analysis of studies on nurses in primary care roles. Washington, DC: American Nurse
Publishing.
54. Alabama APRN Update: Prescribing 54
Code of Alabama. (1975). Retrieved on May 2, 2010 from
http://alisondb.legislature.state.al.us/acas/CodeOfAlabama/1975/coatoc.htm
Coffey, S. (2009). Assessing the Impact of Limited Prescriptive Privileges by Florida's
Advanced Practice Nurses on Access to Care. Manuscript submitted for publication.
Cooper, R. (2004). Weighing the evidence for expanding physician supply. Annals of Internal
Medicine. 141(9), 705-714.
Conger, J.A., Spreitzer, G.M., & Lawler, E. E. (Eds.). (1999). The leader's change handbook: An
essential guide to setting direction and taking action. San Francisco:Jossey-Bass.
Controlled Substance. (n.d.) The People's Law Dictionary. (2005). Retrieved May 2, 2010 from
http://legal-dictionary.thefreedictionary.com/controlled+substance use code?
Health Resources and Services Administration (HRSA) available at
ftp://ftp.hrsa.gov/bhpr/workforce/scope1992-2000.pdf retrieved June 15, 2009.
Institute of Medicine. (2001) Committee on Quality in Healthcare in America. Crossing the
Quality Chasm. Washington, D.C.:National Academy Press 2001.
Joint Committee for Advanced Practice Nursing. (2010). Statistics summary of Collaborative
Practice Agreements. Qtr 2: FY10 (Available from the Joint Committee Meetings).
Lewin, K. (1951). Field theory in social science. New York: Harper & Row.
Lugo, N.R., O’Grady, E.T., Hodnicki, D.R. & Hanson, C.M. (2007). Ranking NP regulation:
Practice environment and consumer healthcare choice. The American Journal for Nurse
Practitioners 11, 8-24.
Medical Association of the State of Alabama. (2009). 2009-2010 Membership Roster:
Constitution and Bylaws. P.299-306. (Available from the Medical Association of the
55. Alabama APRN Update: Prescribing 55
State of Alabama, 19 South Jackson Street, Montgomery, Alabama 36102)
Medscape. (2009). U.S. nurse practitioner prescribing laws: A state-by-state summary. Clinical
Review. Retrieved on May 4, 2010 from
http://www.medscape.com/viewarticle/440315#MS
National Council of State Boards of Nursing. (2009). Changes in Healthcare Professions’ Scope
of Practice: Legislative Considerations. Retrieved on May 2, 2010 from
https://www.ncsbn.org/ScopeofPractice_09.pdf
National Council of State Boards of Nursing. (2005). Nursing Regulation and Interpretation of
Nursing Scopes of Practice. Retrieved on May 2, 2010 from
https://www.ncsbn.org/NursingRegandInterpretationofSoP.pdf
Pearson, Linda J. (2010). The Pearson report. Retrieved on May 5, 2010 from
http://www.pearsonreport.com/overview
Philips, S. (2009). Legislative update 2009:Despite legal issues APNs are still standing strong.
The Nurse Practitioner 34:1.
Prescott, P. (1993). Cost- effective primary care providers: An important component of health
care reform. International Journal of Technological Assessment in Health Care, 10(2),
255.
Safriet, B. (1994). Impediments to progress in healthcare workforce policy: License and practice
laws. Inquiry 31.
Schein, E. (1995). Kurt Lewin’s change theory in the field and in the classroom: Notes toward a
model of managed learning. Retrieved on July 5, 2009 from
http://www.entarga.com/orgchange/lewinschein.pdf
Sherwood, G., Brown, M., Fay, V. & Wardell, D. (1997). Defining nurse practitioner scope of
56. Alabama APRN Update: Prescribing 56
practice: Expanding primary care services . The Internet Journal of Advanced Nursing
Practice. 1:2. ISSN: 1523-6064. Retrieved on May 4, 2010 from
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijanp/vol1n2/scope.xml
The People's Law Dictionary. (2005). Controlled Substance. Retrieved May 2, 2010 from
http://legal-dictionary.thefreedictionary.com/controlled+substance
U.S. Census Bureau. (2010). State and county quick facts: Alabama. Retrieved on May 3, 2010
from http://quickfacts.census.gov/qfd/states/01000.html
U.S. Drug Enforcement Administration. (2010) DEA Mission Statement. Retrieved May 5, 2010
from http://www.justice.gov/dea/agency/mission.htm
Venning, P., Durie, A., Roland, M., Roberts, C., and Leese, B. (2000). Randomised controlled
trial comparing cost effectiveness of general practitioners and nurse practitioners in
primary care. BMJ. 320(7241) p. 1048–1053. PMCID: PMC27348. Retrieved on May 2,
2010 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/
57. Alabama APRN Update: Prescribing 57
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