s APC Toolkit: How Individual APCs Can Participate in Scope of Practice Determinations

F. HOW INDIVIDUAL APCS CAN PARTICIPATE IN SCOPE OF PRACTICE DETERMINATIONS

Participation in our professional organizations is a responsibility for all health professionals. If the professions fail to provide leadership in developing, maintaining, and advancing professional standards and responsibilities, then licensing boards and legislatures will take the lead.

What Professional Organizations Do for Individual NPs, CNMs, and PAs

Although the essential practice documents of each professional role are developed at the national level, each of the professional organizations representing APCs has regional or state chapters.

State nursing organizations are professional organizations which can be organized as labor unions and are often affiliatedwith the American Nurses Association. They provide a variety of services to their members, including lobbying at the state legislature,representing the profession before government agencies, providing continuing education for nurses, and disseminating information and updates about national and state professional issues. State nursing organizations also review and implement standards of practice and education, and in many states they provide collective bargaining services. State nursing organizations also encompass an active community of peers that can effect change and respond to challenges in politics, practice, and labor as well as advocate for nursing and quality health care. State nursing organizations affiliated with the American Nurses Association (ANA) represent advanced practice nursing, which includes CNMs and NPs. States may also have free-standing NP organizations or NP organizations that function as subsidiaries within the state nursing organization.

Similarly, state and regional chapters of the American Academy of Physician Assistants (AAPA), the American College of Nurse-Midwives (ACNM), and the American Academy of Nurse Practitioners (AANP) provide support and leadership for their members in the area of practice essentials.

Getting Involved with Your Professional Organization

Participation in your professional organization can take many forms. A passive (but certainly important) form of participation is to pay membership dues to keep your membership in good standing and support your colleagues in bringing a professional voice to scope of practice conversations at the state and national levels. See Figure III.2

Much of what all the APC organizations accomplish is due to the volunteer efforts of their members: NPs, PAs, and CNMs across the country who contribute their expertise, energy, time, and perspective to the work of these groups. Raising the profile of APCs and their critical role in the future of health care delivery is one of the important activities of these organizations. The more members who are involved in and support their professional organization, the greater the organization’s professional voice and impact.

Most state nursing organizations and chapters of national CNM and PA organizations have professional practice committees that provide leadership in that area. How various state APC organizations structure their professional practice–related activities varies, but all provide guidance and support for developing and maintaining the scope, standards, and competencies of professional APC practice. Join your organization’s professional practice committee if you are interested, or form a subcommittee with other APCs working in reproductive health and/or abortion care. Such a subcommittee can

Working with State-Based Professional Associations: Benefits and Challenges

Most state associations are powerful forces in influencing scope of practice and political decisions affecting APCs. Because the relationship between professional associations and regulatory boards differs from state to state, understanding your state’s unique circumstances will prepare you to develop strategies and messages that will be most effective in meeting your goals.

Case studies throughout the United States lead us to recommend that all APCs belong to their state professional associations, but individuals may resist this recommendation for many reasons. Sue Davidson, Assistant Executive Director of Nursing Practice, Education, and Research at the Oregon Nurses Association (ONA), cites the collective bargaining aspect of her organization as the largest barrier to membership (S. Davidson, personal communication, September 2008). Davidson explains that although ONA (and its sister organization, Nurse Practitioners of Oregon) puts practice issues front and center, many potential members are uncomfortable with or are prohibited from participating in the bargaining aspects and therefore do not see a role for themselves in the association. Davidson believes that even when collective bargaining is not a barrier to membership, the perception of “union politics” and historical antipathy toward bargaining units create divisions within the profession and may prevent clinicians from joining their state association. In Oregon, only 29% of all licensed nurses belong to the ONA, a statistic that may undermine the association’s ability to influence scope of practice conversations and decisions as effectively as it might otherwise. This low membership reflects the national trend to decreasing membership in health professional organizations.

Davidson explains that there has traditionally been a professional expectation (as codified in professional ethics codes for nursing, midwifery and PAs) that licensed professionals would belong to their state and national professional associations. She believes that while collective bargaining is the largest barrier to membership (for nurses), the decrease in membership nationwide is also largely a result of the training received during nursing education. She notes that clinician training programs focus almost entirely on clinical care, yet the majority of challenges to advanced practice nurses such as NPs and CNMs have to do with issues of professional ethics. Clinicians are often not prepared for these types of challenges and are unaware of the support that their professional associations can offer, both in proactively educating about ethical practice and in offering assistance when members are challenged.

Many APCs practicing in the field of reproductive health feel that it is the controversial nature of the specialty that makes them vulnerable. Professionals such as Davidson, however, cite the additional responsibilities, including self-regulation, that bring additional vulnerabilities and point out that beyond issues like abortion, anyone practicing in today’s health care climate is operating in a politically charged environment. We’ve noted that protecting the interests of the public is the primary job of the regulatory boards; these politically appointed boards are bound by law to regulate professional practice and education and to discipline any licensed professional who violates the statutes and rules. Professional licensing boards are mandated to investigate any complaint made against an individual clinician. Clinicians who do not understand the roles and responsibilities of the licensing boards may misinterpret board action as adversarial or punitive.

Preoccupation with the daily demands of their practice or busy personal lives may keep clinicians from seeking involvement in their statewide professional community. Yet it is precisely this involvement, according to Davidson, that not only protects clinicians by bringing their collective voice to scope of practice determinations but also reinvigorates them for practice and shows them how to operate from a base of power rather than a defensive stance. Building alliances with peers and colleagues, presenting a unified voice within one’s professional association, and then representing the views of that profession to the larger community of regulatory boards and legislative bodies can have tremendous impact on the priorities and strategies of those bodies, impact that cannot be replicated by those working outside a professional association. In this regard, membership and involvement in one’s professional organizations is a key element of protecting and advancing scope of practice into politically charged areas of practice such as abortion care.

Membership in a state professional association can offer a chance to network with colleagues, to exchange ideas, strategies, and lessons learned; it gives APCs local professional support that the national specialty organizations cannot replicate. State professional associations can often recommend attorneys with expertise in administrative procedures that govern investigations into scope of practice issues. They may offer benefits, such as a certain amount of free legal assistance for members who need it, as part of their membership fee. Even more important, however, is that whatever the association’s stance on abortion, clinicians will certainly find colleagues who are committed to protecting scope of practice, and these colleagues will support a clinician whom they believe to be acting within her/his scope regardless of their political feelings about a women’s right to choose abortion. Messages like this can go a long way in gaining allies: “No matter how you feel about abortion, this is an issue about scope of practice. It is dangerous to let politically motivated complaints against nurses drive decisions about the best patient care.”

FIGURE III.2

The Importance of Membership in Professional Organizations

Pulling the Load
By Susan Wysocki, RNC, NP, FAANP; President and CEO, Nurse Practitioners in Women’s Health (NPWH)

The other day a nurse practitioner colleague of mine called to ask for NPWH’s help in alerting our members in a state in which an NP was having her scope of practice (SoP) challenged. This NP had been providing pregnancy termination services for several years. The NP was experienced and skilled. But someone complained to the board of nursing (BoN). Even before the BoN had completed their investigation (required whenever such a complaint is made)—legislation was submitted that would create a “doctor only” law for the services that this NP was providing. The legislation passed the state senate before NPs in the state were even aware of it. Leaving aside the fact that the original issue concerned pregnancy termination services, the SoP issue would have set a precedent for “doctor-only” language for other circumstances and procedures as well.

The NP’s state group rallied in support of her practice. The state chapter of the American Academy of Nurse Practitioners did the same. At NPWH, we sent out an email alert to our members in the state to send letters to state legislators asking that this bill limiting NP SoP not be passed. This particular NP needed support from all of these groups if she were to continue her practice. The problem had mushroomed beyond the BoN investigation of a scope of practice issue. The NP needed deeper and wider help and support.

The irony is that the NP under investigation was not a member of any of the groups that supported her. In fact, she was not a member of any state or national NP organization. But these organizations were there for her. Think about why they supported her. They did so because other NPs had been paying their membership dues and supporting these organizations and their goals. Member dues pay for the phone and fax lines that alerted NPs across the state. Member dues allow NPWH to send out email alerts within minutes of receiving the call.

In this particular NP’s case, NPWH did help because the issue could potentially affect every NP in that state, including members of NPWH. Legislation to decrease any NP’s scope of practice could become a new strategy for limiting procedures that NPs are qualified to perform. Membership is your insurance if your scope of practice is ever threatened. Membership is your insurance that when you call, someone will answer the phone (because their salary and the phone bill have been paid). Membership is your insurance if someone other than you is challenged or you are simply in the line of fire.

Source: Previously published in Women’s Health Care for NPs, 7(2), 6, 33; 2008 by NP Communications.

Despite the strong case for membership in one’s professional association, additional barriers should be noted. For some, finances are the issue. APCs who provide abortion care may feel forced to choose between belonging to their professional association or to associations that specifically serve abortion providers (and they may also have to decide between attendance at professional conferences and clinical training opportunities). For those working in small clinics, this financial barrier, albeit an important professional investment, can feel insurmountable. Still others express reluctance to join their professional association because they feel ostracized for their pro-choice stance or their commitment to providing abortion care. All of these are valid concerns that clinicians should address with their professional associations and colleagues.

Building relationships with members of your state professional association before there is a scope of practice challenge (rather than waiting to act until a crisis presents itself) can increase communication and goodwill. We have been surprised to learn that, in some cases, while the pro-choice groups feel that the professional associations are inaccessible, the professional associations believe they cannot take a pro-choice stance because their membership would not support it. Clinicians working in family planning settings and abortion clinics may be ideal catalysts for bringing these parties together in conversation.