Before the Joint Committee on Mental Health and Substance Abuse
The Massachusetts Medical Society wishes to be recorded in opposition to H 1793. This legislation would remove the existing statutory framework underlying the relationship between physicians and psychiatric nurse practitioners. This legislation creates no public protections or standards to replace the legal basis for the functioning team approach to collaborative and supervisory relationships among psychiatric nurses and physicians which has served the Commonwealth so well over the years.
If psychiatric nurse practitioners are to become independent in their practice, it is important for legislators to understand who may become a psychiatric nurse practitioner in Massachusetts. Existing law governing who may be a nurse practitioner is unchanged by this bill. Chapter 112, Section 80B, which is referenced in H 1793 states:
“Nurse authorized to practice in the expanded role means a nurse with:
(a) current licensure as a registered nurse in the Commonwealth;
(b) advanced nursing knowledge and clinical skills acquired through an appropriate nursing education program, as described in 244 CMR 4.13 or, until April 15, 1993, as acquired through appropriate education and clinical experience, or their equivalent, as described in 244 CMR 4.14; and
(c) current certification in a specific practice area as described in 244 CMR 4.13”
Thus the legislature has left it to the nursing board entirely to describe in its regulations what education is required to be a nurse practitioner. The current regulations cited above state:
4.13: Requirements for Authorization
The requirements governing authorization as a nurse practicing in an expanded role consist of active licensure as a registered nurse in the Commonwealth and compliance, as evidenced by documentation filed with and acceptable to the Board, with the following requirements as appropriate: 244 CMR 4.00 4/8/94 (Effective 3/11/94) – corrected Revised 9/2/11 w/corrections 10/14/11
(3) Psychiatric Nurse Mental Health Clinical Specialist. The following requirements apply to persons seeking authorization to practice as a psychiatric nurse mental health clinical specialist on or after January 1, 1984.
(a) Satisfactory completion of a formal educational program (whose attendance and training requirements are the equivalent of one academic year) in addition to generic nursing preparation which has been approved by a national professional nursing accrediting body which the Board recognizes as such. The program must have as its objective the preparation of nurses to practice as psychiatric nurse mental health clinical specialists.
(b) Current certification by a nationally recognized accrediting body approved by the Board.
There is nothing in statute requiring a specific degree for independent practice of nurse practitioners. The Nursing Board approves its own regulations without oversight by the Public Health Council. Thus even these minimal educational requirements could be reduced at any time. Section 4.14 referenced above includes grandfathering provisions and experience in lieu of education for advance practice nurses practicing prior to 1993. Even though this provision ended 20 years ago, many advanced practice nurses may still be licensed under its provisions and not meet the minimal requirements listed above.
The Massachusetts Medical Society urges the legislature not to expose the public, particularly our most vulnerable patients, to the independent practice of individuals with minimal training and no oversight whatsoever. Independent practice is not the model that has helped nurse practitioners in establishing their profession. Integrated teams are the standard of care as well as the model for the future.
Any consideration of independent practice for nurse practitioners must address the lack of public protections required of nursing. Nurse practitioners are not subject to the public protections the legislature has created for the practice of medicine by physicians. Nurse practitioners do not have profiles listing their education, specialties and history of discipline, criminal convictions or malpractice payments. Nurse practitioners are not currently required to use the prescription monitoring program. They are not required to have professional liability coverage. They are not subject to mandatory continuing education requirements in specific areas as are physicians. They do not have requirements regarding electronic medical records and a host of other legislative mandates which apply to physicians.
Finally, the Board of Nursing and the Board of Registration in Medicine have vastly different budgets and staff resources. The Medicine Board has a much larger staff and budget and the capacity and experience to review issues regarding quality of care and safety of practice which are unavailable to the nursing board.
Nationally, organized nursing has been working very hard to expand the scope of practice of nursing. The MMS urges individual legislators to consider the benefits to the public at large in dismantling the Massachusetts system of integrating nurse practitioners into a comprehensive health care team and replacing it with a legal framework for the independent practice of medicine by nurses.
H 1793 presents an unbalanced approach which works to the interest of a few individual nurses seeking to independently practice psychiatry while presenting no protections to patients. The MMS urges opposition to this bill.
