Monitoring and investigating certified registered nurse practitioners in pain management

Journal of Law, Medicine and Ethics

Volumn 31, Issue 1, 2003, Pages 101-118

  Lazarus, Jean B ^a   Downing, Belinda ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ANALGESIC AGENT;

ARTICLE; CERTIFICATION; DRUG CONTROL; EDUCATION; HUMAN; LEGAL ASPECT; LEGAL LIABILITY; LICENSING; NURSE PRACTITIONER; NURSING; PAIN; PRESCRIPTION; QUESTIONNAIRE; STANDARD; UNITED STATES;

ALABAMA; ANALGESICS; DRUG AND NARCOTIC CONTROL; HUMANS; LIABILITY, LEGAL; LICENSURE, NURSING; NURSE PRACTITIONERS; NURSING; PAIN; PRESCRIPTIONS, DRUG; QUESTIONNAIRES; SPECIALTY BOARDS;

EID: 0041708464     PISSN: 10731105     EISSN: 1748720X     Source Type: Journal    
DOI: 10.1111/j.1748-720X.2003.tb00061.x     Document Type: Review

References (96)

1. American Society of Law, Medicine & Ethics, Mayday Pain Project, at 〈http://www.aslme.org/research/mayday_rfp_021601.php〉 (last visited March 1, 2001).
2. Titles vary for nurse practitioners from state to state. In Alabama, the registered nurse who has successfully completed an approved nurse practitioner master's degree in nursing, been certified by a national board acknowledged by the Alabama Board of Nursing, been recommended for approval for collaborative practice by the Joint Committee on Advanced Nursing Practice of the Alabama Boards of Nursing and Medical Examiners, and been confirmed by the Board of Nursing may use the title "certified registered nurse practitioner" (CRNP). This is what is meant by use of the term "nurse practitioner" in this article.
3. S. Isaac and W.B. Michael, Handbook in Research and Evaluation, 2nd ed. (San Diego: Edits publishers, 1981). The action research design is described as being relevant to actual situations in the work world, and providing a framework for problem-solving and new developments. For this project, data were obtained from applications for collaborative practice, literature and case law searches, interviews with investigators from the Alabama Boards of Nursing and Medical Examiners, e-mail questionnaires to other boards of nursing and mail questionnaires to a sample of Alabama certified registered nurse practitioners. The questionnaires were subjected to outside evaluation for content validity. Confidentiality of individual responses was imposed. Data were analyzed using qualitative and quantitative methods. Chi-square was applied to determine associations between selected variables. Respondents did not consistently answer all questions; therefore, analysis of data allowed for missing cases.
4. B.R. Furrow, "Pain Management and Provider Liability: No More Excuses," Journal of Law, Medicine & Ethics, 29, no. 1 (2001): 28-51, at 28.
5. A.M. Martino, "In Search of a New Ethic for Treating Patients with Chronic Pain: What Can Medical Boards Do?," Journal of Law, Medicine & Ethics, 26, no. 4 (1998): 332-49, at 332.
6. D.E. Joranson et al., "Pain Management and Prescription Monitoring," Journal of Pain and Symptom Management, 23 (2002): 231-38, at 231.
7. Several other experts have addressed undertreatment of pain, including S.H. Johnson, "Disciplinary Actions and Pain Relief: Analysis of the Pain Relief Act," Journal of Law, Medicine & Ethics, 24, no. 4 (1996): 319-27, available at 〈http://www.painandthelaw.org/aslme_content/24-4c/24. 4c. html〉.
8. N.O. Hester et al., "Symptom Management Outcomes, Do They Reflect Variations in Care Delivery Systems?," Medical Care, 35, suppl. (1997): NS69-83, at NS69.
9. Id. at NS77-78.
10. Furrow, supra note 4, at 29.
11. D.E. Hoffmann, "Pain Management and Palliative Care in the Era of Managed Care: Issues of Health Insurers," Journal of Law, Medicine & Ethics, 26, no. 4 (1998): 267-89.
12. Hester et al., supra note 7, at NS69.
13. Joranson et al., supra note 6, at 231.
14. S.I. Peine, ed., Drug Enforcement Administration, "Security of Confidential Information and Patient Confidentiality," Diversion and Abuse of Prescription Drugs: A Closer Look at State Prescription Monitoring Programs (April 2000), available at 〈http://www.deadiverson.usdoj.gov/pubs/program/ rx_monitor inex.html〉. In this portion of the report, reference is made to concerns about access to personal information and medical records. Three acts now pending were named: S. 573, "Medical Information Privacy and Security Act"; S. 578, "Health Care Personal Information Nondisclosure Act of 1999"; and S. 881, "Medical Information Protection Act of 1999."
15. E. Spratley et al., Health Resources and Services Administration, The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses (Rockville, Maryland: U.S. Department of Health and Human Services, 2000), available at 〈http://bhpr.hrsa.gov/healthworkforce/ rnsurvey/rnss1.htm〉.
16. L. Crawford et al., 2001 Licensure and Examination Statistics (Chicago: National Council on State Boards of Nursing, 2002).
17. This citation and the statistics were provided by the National Council of State Boards of Nursing by e-mail on April 15, 2002. E-mail communications on both April 5, 2002 and April 15, 2002 conveyed that their numbers of advanced practice nurses varied from those in the Health Resources and Services Administration (HRSA) report, The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses (supra note 14). While the number of nurse practitioners was similarly accounted for by both organizations (approximately 87,000 for the National Council to 88,000 for HRSA), the overall figures varied considerably (approximately 138,000 for the National Council to 196,000 for HRSA). The variance is due to a number of factors, including dates of data collection, sources of data collection, classifications of practice areas, and various attrition factors (e.g., death, license and/or certification lapse, change of profession). The data from the National Council were collected from the fifty-five jurisdictions that legally authorize advanced practice nursing, whereas the HRSA data were collected from an adjusted sample of registered nurses throughout the United States. The American Academy of Nurse Practitioners stated by e-mail on April 5, 2002 that their 2001 data show approximately 80,000 nurse practitioners recognized to practice in the United States. The term "recognized" has meaning relative to authority to practice, not just educational preparation to practice.
18. This statistic was provided by the National Council of State Boards of Nursing by e-mail on April 15, 2002.
19. National Council of State Boards of Nursing, Profiles of Member Boards 2000 (Illinois: National Council of State Boards of Nursing, 2001): at 251.
20. B.J. Safriet, "Health Care Dollars and Regulatory Sense: the Role of Advanced Practice and Nursing," Yale Journal of Regulation, 9, no. 2 (1992): 417-88.
21. Furrow, supra note 4, at 28.
22. American Academy of Pain Management, What Is Pain Management?, at 〈http://www.aapainmanage.org/aapm/whatis. html〉 (last visited September 12, 2001).
23. An EBSCO Host Academic search was conducted by the Alabama Public Library Service in Montgomery on December 18, 2001. Thirty-one articles referenced prescriptive authority for pain management by professionals such as pharmacists, psychologists, and advanced practice nurses.
24. Joint Commission on Accreditation of Health Care Organizations (JCAHO), Pain Management Standards for 2001 (2002).
25. J.B. Mann, A. Permaloff, and G. Howard, "Consumers' Perceptions of Competence," Educational Proceedings of the Annual Meeting of the National Council of State Boards of Nursing, Inc., Atlanta, Georgia, July 27, 1999. The Alabama Board of Nursing's 26quot;Accountability Model" was first presented in a research report to the Board of Nursing on July 14, 1999.
26. D.B. Brushwood, "From Confrontation to Collaboration: Collegial Accountability and the Expanding Role of Pharmacists in the Management of Chronic Pain," Journal of Law, Medicine & Ethics, 29, no. 1 (2001): 69-93.
27. F.M. Lewis and M.V Batey, "Clarifying Autonomy and Accountability in Nursing Service, Part 2," Journal of Nursing Administration, 12, no. 10 (1992): 10-15,
28. in K.A. Roper and G. Russell, "The Effect of Peer Review on Professionalism, Autonomy, and Accountability" Journal of Nursing Staff Development, 13, no. 4 (1997): 198-206.
29. N.L. Chaska, "Avoiding the Fatal 'By-Pass Operation' in Facilitating Accountability," in N.L. Chaska, ed., The Nursing Profession Tomorrow and Beyond (Thousand Oaks, California: Sage Publishers, 2001): 825-39, at 827.
30. Joranson et al., supra note 6, at 232.
31. Id. at 233.
32. Additionally, forty-four states have adopted state pain policies through laws and regulations. See D.E. Joranson et al., 2001 Annual Review of State Pain Policies: A Question of Balance (Madison: Pain & Policy Studies Group, University of Wisconsin Comprehensive Cancer Center, 2002), available at 〈www.medsch.wisc.edu/painpolicy/publicat/01annrev/contents. htm〉.
33. L.Y. Kelly and L.A. Joel, Dimensions of Professional Nursing (New York: McGraw-Hill, 1995): at 467.
34. National Council of State Boards of Nursing, supra note 17, at 1.
35. National Council of State Boards of Nursing, Nursing Regulation, at 〈http://www.ncsbn.org/public/regulation/ regulation_index.htm〉 (last visited April 11, 2002).
36. G.D. Sherwood et al., "Defining Nurse Practitioner Scope of Practice: Expanding Primary Care Services," The Internet Journal of Advanced Nursing Practice, 1, no. 2 (1997), at 〈http:// 216.39.195.244/ostia/index.php?xmlFilePath=journals/ijanp/ vol1n2/scope. xml〉.
37. M.L. Gray, "Advanced Practice Nursing Roles: Preparation and Scope of Practice," in N.L. Chaska, ed., The Nursing Profession Tomorrow and Beyond (Thousand Oaks, California: Sage Publishers, 2001): 515-26, at 517.
38. Crawford et al., supra note 15.
39. C. Curtis, The ABC's of Advanced Practice Nursing, Wild Iris Medical Education Website, available at 〈http:// www.nursingceu.com/NCEU/courses/ advpraccc/〉 (last visited April 3, 2002).
40. Id.
41. W.Y. Carson, American Nurses Association, 2000 Prescriptive Authority Chart (revised February 1, 2000), available at 〈http://www.nursingworld. org/gova/charts/dea.htm〉.
42. Spratley et al., supra note 14.
43. Gray, supra note 33, at 518.
44. Curtis, supra note 35.
45. Crawford et al., supra note 15.
46. Curtis, supra note 35.
47. P.A. Kalish and B.J. Kalish, The Advance of American Nursing (Boston: Little, Brown and Company, 1978): at 660.
48. Sherwood et al., supra note 32.
49. Gray, supra note 33, at 520.
50. National Advisory Council on Nurse Education and Practice, Report to the Secretary of Health and Human Services: Federal Support for the Preparation of the Nurse Practitioner Workforce through Title VIII (Rockville, Maryland: U.S. Department of Health and Human Services, Health Resources and Services Administration, 1997): at 14-15.
51. See also Crawford et al., supra note 15.
52. Safriet, supra note 18, at 417.
53. Gray, supra note 33, at 517.
54. Sermchief v. Gonzales, 660 S.W.2d 683 (Mo. 1983).
55. Kelly and Joel, supra note 29, at 476-77;
56. C.P. Cournoyer, The Nurse Manager and the Law (Rockville, Maryland: Aspen Publishers, 1989): at 118.
57. Cournoyer, supra note 50, at 109.
58. National Council of State Boards of Nursing, supra note 17, at 230.
59. Id. at 241.
60. Carson, supra note 37.
61. Ala. Code § 34-21-81 (4)(a) (2002). Nurse practitioners in Alabama demonstrate by certification the "advance knowledge and skills" necessary for "consultation, collaborative management, or referral as indicated by the health status of the client" and thereafter practice as certified registered nurse practitioners.
62. Peine, supra note 13, at "Historical Background." In this section, a historical background is given relative to the Controlled Substances Act (1970) and subsequent regulations.
63. "Collaboration and Independent Practice: Ongoing Issues for Nursing," Nursing Trends and Issues (column), Nursing World, 3, no. 5 (May 1998), available at 〈http:// www.nursingworld.org/readroom/nti/9805nti. htm〉.
64. Carson, supra note 37.
65. Id.
66. Ala. Code § 34-21-80 (2002).
67. Ala. Admin. Code r. 610-X-9 (2002).
68. Ala. Code § 34-21-81 (8) (2002).
69. Ala. Admin. Code r. 610-X-9 (2002).
70. Alabama Board of Nursing, Application for Approval to Practice as an Advanced Practice Nurse in Alabama (December 2002), available at 〈http://www.abn.state.al.us/downloads/ applications/apn-1.pdf〉.
71. Id. The list of approved legend drugs for consideration by the Joint Committee for nurse practitioners to prescribe is as follows: antihistamine and decongestant drugs; analgesics and antipyretics; blood derivatives; coagulation agents; central nervous system agents; agents of electrolytic, caloric, and water balance; expectorants and cough preparation; gastrointestinal drugs; prosthetics/orthotics; local anesthetics; pulmonary drugs; spasmolytics; vitamins; antiinfective agents; autonomic drugs; blood formation; cardiovascular drugs; diagnostic agents; enzymes; ophthalmic drugs; antiinflammatory drugs; hormone and synthetic substitutes; birth control drugs and devices; serums, toxoids, and vaccines; antineoplastic agents; heavy metals; radioactive agents; gold compounds; oxytoxics; and an "other" category.
72. Alabama Board of Nursing, supra note 64.
73. Sherwood et al., supra note 32.
74. A.B. Hamric et al., "Outcomes Associated with Advanced Nursing Practice Prescriptive Authority," Journal of American Nurse Practitioners, 10, no. 38 (March 1998): 113-118, at 118.
75. American Academy of Nurse Practitioners, Position Statement on Nurse Practitioner Prescriptive Privilege (revised 2002), available at 〈http://www.aanp.org/NR/rdonlyres/endrj7vquyv foiqes72iehwsp4trvz43ualmwdmkmn6qrnidad62mapicxl 5zcortuqv2pghxohzte/ Position%2bStatement%2bPrescriptive %2bAuthority.pdf〉.
76. Carson, supra note 37.
77. A Westlaw search of the ALLSTATES and ALLFEDS databases was conducted by the Alabama State Supreme Court Library research attorney on January 11, 2002, using the following: Nurse = 2 Practitioner/P Prescript! "Pain Management".
78. Ala. Code § 34-21-86 (a)(1-2) (2002).
79. Personal communication from Alabama Board of Nursing and Alabama Board of Medical Examiners investigative staff regarding a case under investigation (November 2002).
80. "We met with about 15 CRNP educators. They wanted the Board to do something about third party payment. They wanted to talk about barriers to practice but they did not have a core curriculum...." Comment made by N.G. Lee, executive officer of the Alabama Board of Nursing, in her March 21, 2001 report to the board at its March 21-23, 2001 meeting.
81. Sherwood et al., supra note 32.
82. National Advisory Council on Nurse Education and Practice, supra note 46, at 23.
83. C.J. Dickson and J.B. Mann, Nurse Practitioners in Alabama, A Synthesis of Perceptions of Role and Regulatory Accountability, Concurrent Educational/Research Sessions, (Chicago: National Council of State Boards of Nursing, 1995): at 163-203.
84. J.B. Lazarus and N.G. Lee, Alabama Board of Nursing Initial Report Findings of the RN Workforce 2000 (Montgomery: Alabama Board of Nursing, 2000), report presented at the Alabama Board of Nursing Regulatory Invitational Summit, Prattville, Alabama, October 19, 2001.
85. Spratley et al., supra note 14.
86. This information was obtained from an Alabama Board of Nursing survey conducted in October 2001 of those educational programs offering master's degrees with specialties for family nurse practitioners, adult nursing practitioners, and acute care practitioners. While eight educational institutions offer master's degrees with nurse practitioner tracks, only six offer the specialties described. Due to assurances of confidentiality, neither the programs nor their respondents are named.
87. While the curriculum plans stated that there were clinical experiences in prescriptive practice, individual respondents, in their qualitative responses, commented that their clinical experience was conducted under preceptors and not instructors. Some indicated that their courses were taught online rather than in the classroom or a clinic.
88. Several of the nurse practitioners indicated they were not in collaborative practice at the time of the survey. Reasons were not given; however, when nurse practitioners seek a new collaborative practice, application for approval must again be requested from the Board of Nursing. The request must again be processed through the Joint Committee.
89. This is technically correct. The Alabama Administrative Code, r. 610-X-9, specifies collaborative practice parameters for physicians and nurses.
90. Hoffmann, supra note 10.
91. E-mail survey, Alabama Board of Nursing (December 18, 2001).
92. Information provided by Cyndy Haynes, director of education and practice, West Virginia Board of Examiners for Registered Professional Nurses (January 22, 2002).
93. Interview Guide for Investigators (November 2002): What is needed to improve the investigative process of the Alabama Board of Nursing when collaborative practice is required for prescriptive practices relative to pain management? 1. How many incidents or complaints have you investigated that involve any aspect of prescriptive practice of CRNPs? 2. What does the investigative process involve? (steps, methods) 3. What outcome must be produced in the investigative process? 4. What was the nature of the complaints? 5. Do you perceive that the Board of Nursing is adequately monitoring prescriptive practice in pain management? 6. Why or why not? 7. Did any problems arise specific to the investigations as related to collaborative practice? • Non-specific protocols • Practicing beyond the scope of practice • Both physician and nurse were noncompliant • Physician's privileges for prescribing controlled substances, asking CRNP to exceed protocols • Physician is uncooperative on investigation • Not reporting of noncompliance • Patient came to harm, no cooperation from agency, physician or nurse in providing data • Unavailability of records • Inadequate records • Other 8. What barriers have you encountered in conducting investigations involving collaborative practice for prescriptive practice in pain management? 9. Are we as a regulatory agency addressing the magnitude of violations of legally authorized prescriptive practice of controlled substances in collaborative practice? 10. Would, in your opinion, having a quality management system in place help capture violations? 11. How would you, as an investigator, perceive your role in implementing a QM [quality management] system? 12. Is a formal continuous monitoring process needed for case detection? 13. What components and methods are needed to institute such a process? 14. Do you believe that extending prescriptive practice for controlled substances to CRNPs will compound problems of regulation for public safety and welfare? 15. If you could design a plan for effective monitoring of prescriptive practice in collaborative practice, what would you include?
94. "Alternative disciplinary participants" are nurses enrolled in an alternative disciplinary program who have voluntarily acknowledged substance abuse or a physical or mental condition rendering them unable to meet the standards of the nursing profession, and are monitored without their licenses being placed on probation or revoked subsequent to § 34-21-25(j) of the Alabama Code (2002).
95. The interview with the Board of Medical Examiners investigators was conducted on January 16, 2002.
96. The guidelines being referenced are the "Guidelines for the Use of Controlled Substances for the Treatment of Pain," Ala. Admin. Code r. 540-X-4-.08 (2002). The investigator who made this comment specifically monitors for compliance with the protocols and uses a standard questionnaire.