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Nurse Practitioners Call for Greater Independence

Relaxed rules could help medically underserved

Texas State Page February 2011

Alta Walter, a nurse practitioner in Waco, is one of the few in Texas who owns her own practice. Nurse practitioners want state restrictions relaxed so they can practice with less direct supervision from physicians. — Photo by Van Ditthavong

Nurse practitioner Alta Walter knows her patients. Often, she visits them where they live, developing relationships to the point where a simple nonverbal cue can tell her that something is wrong. She charges less than a physician, so her patients can visit her more often.

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"I use a lot of prevention and a lot of referrals [to physicians]," said Walter, 59, a nurse practitioner for a decade who specializes in geriatric patients.

A nurse practitioner is a registered nurse who has advanced education and clinical training in a health care specialty and can serve as a primary health care provider for children and adults.

Nurse practitioners are trained to provide a number of health care services, such as physical examinations, family planning services, diagnosing and treating acute and chronic illnesses, psychological counseling and health education. Nurse practitioners in Texas can prescribe medicine if they have an agreement with a physician. Under these agreements, they can prescribe certain, but not all, narcotics. They are barred from performing major surgery.

Walter is one of the few nurse practitioners in Texas who owns her own practice — Central Park Clinic in Waco. Under state rules, a physician visits Walter's clinic every couple of weeks to review a sample of her patient charts. Walter said she was lucky to find a "special doctor" who "understands what we do." Unfortunately, not all nurse practitioners in Texas are so lucky.

Texas is one of the strictest states in the country for nurse practitioners who want to open their own clinics, requiring them to find a physician with the willingness and time to follow a complex set of rules. Those rules include requiring the physician to delegate prescriptive authority, review patient charts, make on-site visits or practice within a certain geographical distance of the nurse practitioner. It's a system many nurse practitioners say is unnecessary and burdensome, especially in light of the state's considerable health access problem and the success of nurse practitioners in other states who practice without such direct physician supervision.

"It's really something that is limiting access to care and taking up physician and nurse time," said Lynda Woolbert, executive director of the Texas-based Coalition for Nurses in Advanced Practice. "There's no other state that has this type of very specific, site-based supervision."

Woolbert said she hopes to see legislative changes in which advanced practice nurses are granted diagnosing and prescribing authority solely from the state's Board of Nursing and not from a physician, such as in New Mexico.

Next: More independence for nurse practitioners? >>

A number of legislative attempts have been made to relax the rules governing nurse practitioners in Texas, but have yet to make it out of the legislature. The main opposition to such change is the Texas Medical Association, which supports the current rules, said Susan Bailey, the association's president. "We feel that it's important that [nurse practitioners] work as part of a team, supervised by physicians," Bailey said. "We understand there is a shortage of caregivers in Texas ... and we don't think that expanding prescribing authority for nurse practitioners is the way to address the shortage issue. We think it's a patient safety issue."

Thirty-five states and the District of Columbia allow nurse practitioners to work within their scope of training to prescribe and make diagnoses with high levels of autonomy — some allowing nurse practitioners to work fully independent of a physician, said Sandy McCoy, president of Texas Nurse Practitioners. With the overwhelming majority of Texas counties federally designated as completely or partially medically underserved, McCoy said, relaxing nurse practitioner rules could go far in filling the need for more primary care practitioners while reducing health care costs.

"The vast majority of Texas counties have some or all of their populations facing access-to-care problems," said Amanda Fredriksen, director of advocacy at AARP Texas. "We think that allowing advanced practice registered nurses to practice to the full extent of their training would help address that. We've got this whole cadre of health care professionals that we're not making the best use of."

A study published in the Journal of the American Medical Association in 2000 found no significant difference in health outcomes between patients treated by nurse practitioners and those cared for by physicians.

Susan Haynes, who works in a senior health clinic in the city of Round Rock, said that as a nurse practitioner she's able to spend more time getting to know and educating her patients. "Nurse practitioners treat people; doctors treat diseases," she said.

"I think if you turned us loose, you would see more of us setting out as entrepreneurs to start our own clinics," Haynes said.

Women's health nurse practitioner Connie Ryan, who founded Central Family Practice in Austin in 1998, said she hopes things change in Texas, so that more nurse practitioners are allowed to practice in areas that lack primary medical care. She said that while working collaboratively with a physician is important to her, being supervised by a physician is not necessary.

"I understand that physicians do not want to give up what they feel is their turf and their control over an increasingly uncontrollable medical environment," Ryan said. "But I also understand that nurse practitioners are capable of giving good, safe care within their scopes of practice."

Also of interest: State-by-state guide of nurse practitioners. >>

Kim Krisberg is a freelance writer based in Austin, Texas.

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