Reader's Voice: Time For Action On The APRN Prescribing Law

Connecticut Nursing News, Mar-May 2005

Lisabeth Johnston, PhD, APRN

Most advanced practice registered nurse are familiar with the wording of Connecticut's nursing statute, revised in 1999, as it applies to advanced practice registered nurse (APRN) practice. In it is a requirement for a collaborative relationship between an APRN and a physician licensed in Connecticut, in order for the APRN to prescribe medications. The requirements for that collaboration are clearly spelled out in the statute.

Intent of the law different than the practice environment

Approximately one year after the implementation of that revision in law, the Connecticut Society of Nurse Psychotherapists (CSNP) conducted a poll of its members to ascertain the reality of the law in practice. The outcome of that poll was reported in the Clinical Nurse Specialist journal1. Members reported that the intent of the law and reality of the practice environment were very different. The intent had been to remove physician supervision and direction of APRN practice and allow the consumer more direct access to APRN care. The members indicated in the poll that severe constraints continued to be placed on psychiatric mental health APRN practice a year later.

They reported that there were many difficulties associated with establishing a collaborative practice relationship and then with establishing mutually agreeable terms for the relationship. For example, finding a physician knowledgeable in the APRNs area and style of practice was not always easy, many physicians were reluctant to engage in a relationship, and many who were willing regarded collaboration as supervision and required terms that went beyond the letter and the spirit of the law. Some physicians required that the APRN work in their practices, pay rent, pay for support services and/or provide a percentage of their income to the physician. All required some payment and some fees were exorbitant.

Changes in the law not satisfactory

Members found the new law highly unsatisfactory, reporting that they were dependent on finding a willing physician and complying with the terms offered in order to be able to proceed with a prescribing practice that would allow consumers direct access to them. Many reported that too much depended on the goodwill and willingness of a physician in order to negotiate and maintain a collaborative agreement and that mutually acceptable collaborative agreements were really at the discretion of the physician. The risks associated with depending on that goodwill for one's livelihood were too great for many APRNs to assume which has limited consumer access to psychiatric APRNs.

This feedback was analyzed and reported within the profession and to some legislators who had asked for the feedback. It was agreed to proceed and let time and practice results determine progress for the immediate future. Five years later in 2004, I was *shocked and dismayed to discover the state of the implementation of the law for one APRN and am compelled to report this nurse's experience as it is only the most extreme example of many examples that have come to light over the last five years.

One advanced practice nurse's experience

In the course of teaching a masters' preparatory class in psychiatric mental health nursing, one of my students, an APRN already certified and practicing as a nurse practitioner in adult medical practice, reported discouragement and indignation resulting from her efforts to establish a collaborative relationship with a psychiatrist in her area preparatory to graduating from the psych/ mental health program, obtaining her certification, and moving into that area of practice. She had taken with her to the introductory meeting with the psychiatrist the names and contact information of other nurse practitioners in collaborative practices; names of well-informed attorneys to contact for more information; samples of collaborative agreements that met the requirements of law; her resume, complete with the name of a psychologist she had worked with for 13 years; and a physician whom she had consulted with for five years, both of whom were known to this psychiatrist. She took her APRN license, NP certification, DEA number, current malpractice insurance certificate, and a copy of the Connecticut nurse practice act.

The psychiatrist did not contact her for two months after this initial meeting. When he did, he wanted her to read the American Psychiatric Association publication on guidelines for physician supervision of nurse practitioners before he met with her again. When they did meet, he had spoken to his attorney and was told that because he could be named in a law suit, he would have to meet with her at least once a month whether or not there was a need to discuss a patient case. He set his fee for these meetings at $150.00/hour. He stated that he would need to review all records on patients on medications and all changes would have to be reported to him. The APRN suggested that this could increase his liability concerns as he would be involving himself in a supervisory way rather than a collaborative way and he replied that that was a matter of semantics. He insisted that he must see her grade in the psychopharmacology course she was currently taking, a course that was already beyond what was required for her to maintain her current license to prescribe. He told her that he saw NPs in general at the level of a third year medical student, implying that they needed careful and constant supervision. She reminded him that she was already a licensed and certified professional with the legal right to prescribe in Connecticut with a collaborative agreement. This made no impression.