What is “Scope of Practice?”  It is the description and definition of what a healthcare providers’ license empowers them to do within the delivery of health care within the jurisdiction of the agency issuing the license.  While the concept is more often applied to nurses, the fact is that all healthcare providers including physicians, nurse practitioners and physician assistance have a “scope of practice.”  As a physician, I am licensed by the State of Texas to practice Medicine and Surgery in the State.  However, my training and skills define what I can and cannot do.  For instance, I would not be allowed to post a case for the removal of a brain tumor, as I am neither trained nor skilled for such. 

Interestingly, while we commonly associate these limitations with surgery and specialty care as defined by training; in the 1990s, with the widespread advent of managed care, specialists who wanted to practice primary care or general practice, found that they required additional training because while they were skilled for special care of one area, they were not skilled for the broad skills required for primary care.  So, even specialists have a “scope of practice.”  As the demand for more and more healthcare increases and as many healthcare vocations press for broader privileges to be included in their “scope of practice,” pressure is brought upon incensing agencies and State legislatures to redefine “scopes of practices.” 

Inevitably, there is push back from responsible agencies and groups of healthcare providers against those pressing to broaden their authority.  Another area of discussion and sometimes conflict comes from the reorganization of teams within healthcare.   As the traditional model of healthcare, with a solo or a group of physicians not only leading healthcare but essentially performing all of the functions themselves,  morphs into a healthcare team, these tensions often come from agencies such as the Centers for Medicare and Medicaid (CMS) who want to define what one group or another can or cannot do.  This is enforced, of course, by what CMS will or will not pay for. And, in a punitive sense, the payer will often suggested the submission of a bill by one provider for work completed by another could be constituted as fraud subject to fines and penalties. . 

In 2013, CMS audits of hospital care in Southeast Texas began to raise questions about how nurses, both Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) were being used in the hospital to support medical care.  As a result of those discussions, SETMA wrote the Texas Nursing Board about RNs’ “scope of practice.” 

http://jameslhollymd.com/Letters/registered-nurse-texas-board-of-nursing-scope-of-practice -- this link is to SETMA’s April, 2013 letter to the Texas Nursing Board. The electronic copy allows the reader to use the links in the Index to Content.  As this letter  explained, SETMA thinks that RNs and particularly Certified Advanced Practice Nurses (CNPs) are greatly under-utilized and that their Scope of Practice is limited not by training but by long-standing traditions and even prejudices. As the Chief Executive Officer of a medium-size, multi-specialty practice in Beaumont, Texas, I requested clarification by the Texas Nursing Board of the scope of practice for registered nurses (RNs).  The motivation for this inquiry was a meeting held by Christus St. Elizabeth administrative staff with the assistance of consultant.  Baptist Hospital of Southeast Texas had a similar meeting in January, 2013  The purpose of these meetings was to define the limits to  the scope of practice by RNs which are credentialed by the hospital and who are employed by physicians to work in the hospital. 
  
The Context and Development of RNs working for Physicians in the hospital Index

In the 1970s, specialists, particularly cardiologists, began employing RNs to improve the transitions of care from the hospital.  The RNs completed medication lists, which were handwritten with directions for use and with explanations for why the medications were being prescribed.  This was a significant imprudent in the quality of care and in the safety of patient care.  Gradually, RNs began completing initial patient evacuations and daily progress notes and discharge planning and instructions.

As is still the case, no charges were submitted to CMS or to other insurance companies for the work of these RNs.  They were trained by the specialists and treatment guidelines were established for excellence of care and for patient safety.  As long as this process was practiced by the specialists no objections were raised.

Gradually, as the demand upon primary care increased and as the complexity of care increased, more and more primary care physicians employed RNs in similar capacities.  Again, no charges to CMS or other insurance companies were generated for the work of these nurses.  The nurses’ work accomplished:

• Improving of continuity, quality and immediacy of care
• Improving of the quality of life of the healthcare providers as their sharing of responsibly of care allowed for excellence of care and proper rest for the providers.

The Contradictions between healthcare Reform, Innovation and Regulations Index

Effective collaboration between members of the healthcare team has been a hallmark of healthcare innovation, particularly in regard to patient-centered medical home.  Physicians and nurses have increasingly become colleagues rather than employer/employee.   As a result of the “team approach” to healthcare, there has been an increasing public policy pressure to expand the RN scope of practice while protecting public safety, but there is also increasing bureaucratic pressure which is resisting this change because it does not fit the current model of care.

SETMA has addressed this and similar issues on multiple occasions including:

April 4, 2013 -- http://jameslhollymd.com/Your-Life-Your-Health/pdfs/The-Future-of-Collaboration-Between-Physicians-and-Nurses.pdf
January 24, 2013 -- http://jameslhollymd.com/Your-Life-Your-Health/pdfs/Inpatient-Team-Based-Care-Process-Analysis.pdf
October 28, 2010 -- http://jameslhollymd.com/Your-Life-Your-Health/pdfs/Re-Evaluating-the-Value-of-Members-of-the-Healthcare-Team.pdf

In the next several weeks, this column will address the “scope of practice” in more detail.