This is the second article in a two-part series on nursing in New Jersey.
Shortages in primary care are already being felt, with a common complaint being the length of time patients wait before being seen by a doctor. But when nearly 1 million New Jersey residents become insured under the new health laws, those delays are expected to stretch markedly.
“Where will they go?” Susan Hassmiller, senior adviser for nursing at the Robert Wood Johnson Foundation, asked rhetorically. “There’s not enough doctors, they’re not going into primary care.”
The answer, experts say, is allowing advanced practice nurses to provide more care.
Patricia A. Barnett, chief executive officer of the New Jersey State Nurses Association & Institute for Nursing, believes there will be enough primary care providers, if the more than 3,000 advanced practice nurses (APNs) in New Jersey are allowed to make use of the full extent of their education and licensure.
APNs are nurses with advanced degrees (masters, post-masters, or doctoral) who are trained to take health histories and provide complete physical exams. They diagnose and treat acute and chronic illnesses. They provide immunizations. They prescribe and manage medications and other therapies. They order and interpret lab tests and x-rays. They provide health teaching and supportive counseling. And they’re regulated by the Board of Nursing.
In primary care, APNs are quickly growing — alongside physician assistants (PAs). Both professions have extensive training. PAs are licensed, have passed the national certificated exam, and are regulated by the Board of Medicine.
But unlike an APN, a PA may not work as an independent practitioner. PAs may only be employed by a physician, practice, hospital, Department of Corrections, or Department of Human Services. Regardless of the employer, the PA must have a supervising physician and may only treat that supervising physician’s patients.
“An APN can function autonomously,” explained Mary Krug, one of the masters-prepared APNs practicing in the state. “We are totally responsible for the care of our patients and document it independently. The only thing that we do that requires a physician in the state of New Jersey is prescribing medications and devices.”
APNs follow a nursing model, which is more holistic in its approach, with a focus on health promotion and prevention of illness, Krug said.
The APN Advantage
Speaking about APNs, Barnett said, “There is strong evidence that this care is cost effective, of high quality, and of great service in increasing access to care for vulnerable populations.”
And it’s a need, added Robert Brenner, chief medical officer at Summit Medical Group, that “has expanded very rapidly.”
The use of APNs at Summit Medical Group, the largest physician-owned multispecialty practice in New Jersey, “is widespread, and in fact, increasing,” Brenner said. The APNs can be found in various offices throughout the group, based in Berkeley Heights, everything from cardiology, where they assist physicians with consultations and stress tests; to primary care, where they are working in the after-hours clinic, to urgent care and pediatrics.
Brenner said. “I don’t want to inhibit that. [Nurses] should be part of the team to the extent that they’ve been trained.”
Research by the Robert Wood Johnson Foundation predicts that there will be a far larger role for primary care nurses under the Affordable Care Act, with expanded duties for routine medical and preventive care.
Even before health reform, doctors were expanding their practices by hiring APNs. “They realize they need help and can’t possibly see all the people they need to see in the time they have,” Krug said.
With a varied nursing career in private practice, a college setting, and a jail, Krug currently works as an APN for a dermatologist in Toms River and Wall, where she routinely performs skin biopsies and freezes small precancerous growths.
She also prescribes medication — but only with the use of a joint protocol, basically a contract with her collaborating doctor that establishes what her duties include, such as prescribing medications or syringes for diabetics.
“It’s really a piece of paper that’s been legislated into our [APN] practice,” Krug said. “I’d be happy to get rid of it.”
The degree to which a physician supervises an APN varies by state. In New Jersey, APNs do not require supervision, but the joint protocol must be in place. Other states require an agreement spelling out what the APN will do and when the physician will determine the care to be given.
In New Jersey, a physician must review at least one patient chart during the course of the year and sign the joint protocol.
“Even though it is called a collaborative agreement, in New Jersey the control is completely one sided,” Barnett said. “The physician can practice without an agreement but an APN cannot write prescriptions without an agreement. If the physician is afraid that the APN may be a competitor, he or she can refuse to write an agreement unless that APN works for him or her. Some physicians make the APNs pay a fee for the agreement.”
Scrapping the Joint Protocol
Efforts are underway in the state Legislature to scrap the protocol entirely. Assemblywoman Nancy F. Muñoz, a Republican in the 21st legislative district, is the lead sponsor of a bill under review that would allow APNs to write prescriptions without the joint protocol. She expects to introduce the measure eliminating the joint protocol in the upcoming Legislative session.
“I strongly believe nurses should be able to practice to the full extent of their education and training,” said Muñoz, a nurse with advanced degrees and experience in surgical ICU and the recovery room.
She’s also the widow of the late Assemblyman Eric Muñoz, a trauma surgeon, and mother of a doctor, possessing a unique perspective. “It shouldn’t be a fight between doctors and nurses. There are enough patients to go around. It’s about having enough healthcare providers who are trained and educated to provide this care.”