State May Limit APN Specialties
By Glen Fest
September 20, 2004
The Texas Board of Nurse Examiners is expected to rule next month on a controversial proposal that would limit licensure of advanced practice nursing specialties to a selection of general health care categories — and refrain from recognizing APN subspecialties such as emergency department, oncology, and palliative care.
The state’s plan to narrow the number of recognized specialties rises from concerns about patient safety, and whether APNs or clinical nurse specialists in these subspecialties have a wide-enough breadth of general practice expertise. Plus, the board is concerned with the ability to ascertain new branches of subspecialization (such as diabetes management) as they mushroom each year.
Although the specializations being dropped make up a small percentage of advanced practice nurses in the state, opponents are worried that the plan will starve the state of high-demand APN specialties, which many hospitals are clamoring for nursing schools to promote and fill.
The board of examiners plans an Oct. 20 hearing in Austin the day before voting on the measure, which contains a grandfather clause that will retain recognition for current APNs, and permit licensure to students enrolled in recognized APN and CNS specialties.
“At the national level, advanced practice nursing has been the subject of discussion among regulators for many years,” says Kathy Thomas, executive director of the state board of nurse examiners. “Some people are prepared too narrowly in some of these programs, and that has impact on scope of practice.”
The plan would restrict advanced practice nurses and clinical nurse specialists to a handful of general practice categories — acute care adult, family, pediatric, and others — and eliminate recognized specialties such as perinatal, school nurse, maternal child health, emergency, and oncology. The proposed change also would eliminate subspecialties of recognized practices, such as pediatric acute and pediatric critical care for clinical nurse specialists.
Critics say the proposal is far too sweeping and threatens to drive APNs out of the state upon graduation.
“My greatest concern is it’s going to deprive the people of Texas the expertise we now enjoy,” says Patricia Starck, RN, DSN, nursing school dean at the University of Texas Health Science Center at Houston. The nursing school feeds a number of oncology and emergency department advanced practice nurse graduates to regional hospitals, including the University of Texas M.D. Anderson Cancer Center.
Among the proposal’s opponents to speak out against the rule change is Ken Shine, executive vice chancellor of health affairs for the University of Texas system and former president of the Institute of Medicine. Shine led the IOM when it issued its landmark 1999 study on the prevalence of patient deaths due to medical errors.
“You can’t say I don’t have a major interest in quality of care and patient safety,” Shine says. He labeled the proposal “counterproductive” to the gains made by Texas nursing schools in graduating advanced practice nurses for areas of critical shortage, particularly emergency department and oncology. “I think the nature of health care is increasingly specialized,” Shine says, where treatment is the focus of specialized teams and “an advanced practice nurse is coordinating the care in specialized management.”
According to the board, several advanced practice nurses and clinical nurse specialists in the past two years have requested practice licensure for newer areas like ophthalmology, forensic nursing, and diabetes management. Such a narrow field of expertise for nurse practitioners leaves them unprepared to identify treatments or make proper referrals outside their expertise, the board says.
Examiners also cite disciplinary cases of advanced practice nurses conducting work outside their area of preparation — such as a psychiatric/mental health APN practicing thoracic oncology.
Shine has invited 27 nursing school deans across the country to convene in Austin later this month to discuss the board’s upcoming vote.
Shine and Starck said the board of nurse examiners is overstepping its authority by issuing rules and decisions that shape nursing school curriculum — which they argue is the domain of the Texas Higher Education Coordinating Board.
“What the board says is that everybody needs to be a generalist first,” Starck says. “Then they can do a post-master’s for that specialty. Well, that’s more time and more money, and a post-master’s course is not as in-depth as a full program. Also, it puts a burden on hospitals to do this specialty training.”
Thomas said regulators are put in the position of being the “tail wagging the dog” in terms of curriculum, but stresses that the board has to consider how to derive standards from an area (advanced practice nursing) where requirements nationwide are varied.
“That standard is not being set by another entity, so it falls to the board to evaluate it,” Thomas says.
“But I think having this discussion of state rules is a good thing. It encourages dialogue, and I hope in the end, consistent with our end will do the best thing for the public.”
The Texas Board of Nurse Examiners will vote in October whether to amend the scope of practice for advanced practice nurses and clinical nurse specialists. The proposal would restrict advanced nursing practice to the following recognized areas:
Advanced Nurse Practitioner:
Acute Care Adult
Acute Care Pediatric
Adult
Family
Gerontological
Neonatal
Pediatric
Psychiatric/Mental Health
Women’s Health
Clinical Nurse Specialist:
Adult Health/Medical-Surgical
Community Health
Critical Care
Gerontological
Pediatric
Psychiatric/Mental Health
Texas Board of Nurse Examiners