Nurse practitioner Naomi Warren provides primary care for hundreds of devoted patients in McLennan County, one of 220 counties in Texas designated as medically underserved.

While Congress proved incompetent to improve health care, Texas legislators have a golden opportunity right now to dramatically increase access to care. How? By substantially increasing the number of primary care providers. And … it wouldn’t cost a dime.

We’ve got a real problem here. According to The Commonwealth Fund, in 2015 Texas ranked dead last regarding access to and affordability of health care, a shortage of providers being a leading cause. Thirty-five counties have no physician and of Texas’ 254 counties, 220 are considered medically underserved, according to federal data. That leaves 20 percent of Texans — 4.6 million people — without access to a primary care provider.

Bills introduced this session by Sen. Kelly Hancock (R-North Richland Hills) and Rep. Stephanie Klick (R-Fort Worth) could very well pull us out of the ditch. Senate Bill 681 and House Bill 1415 would deploy thousands more advanced practice registered nurses by removing the physician supervision requirement.

First, some context. Advanced practice registered nurses have been around since the 1960s — nurse practitioners (who provide primary care), certified registered nurse anesthetists, certified nurse midwives and clinical nurse specialists. In the 20th century, when doctors were usually men and nurses usually women, doctors staked out ownership of providing primary care, and legislatures inexplicably enabled them.

But nurse practitioners are exquisitely educated, trained and prepared to provide primary care. Dozens of studies throughout the decades demonstrate nurse practitioners provide primary care on par with physicians, having as good or better patient outcomes. They also score higher in communication.

While almost all states have evolved past physicians’ irrational oppression of nurses, Texas remains among a handful of states that restrict their practice.

As part of a legislative compromise for independent practice in 2013, advanced practice nurses were required to obtain a doctor to sign a document agreeing to supervise their work. Under these agreements, physicians don’t see nurses’ patients, audit 10 percent of their charts and don’t even have to live in the same city. The contract agreements are extremely costly, from $20,000 to more than $100,000 per year according to a Dallas Morning News editorial, effectively pricing the practitioners out of Texas.

Four years out from the pay-to-play requirement, we see advanced practice nurses — who are educated in Texas at taxpayer expense and want to stay in Texas — flocking to 21 other states that don’t restrict practice, including all that border Texas. Heck, the New Mexico Legislature recently appropriated money for an advertising campaign to recruit them!

SB 681 and HB 1415 would end the brain drain. We’ve got around 15,500 nurse practitioners practicing here, but we could have thousands more. The bills would also end the Texas Board of Medicine having any regulatory authority over nurses.

The notion of physicians supervising and regulating advanced practice nurses in any way is, in a word, outrageous. Advanced practice nurses are educated and trained by nurses, regulated by nursing, licensed by nursing and governed by nursing. Nursing and medicine are separate professions, and no other health profession is partially regulated by medicine.

Who opposes the bills? Despite the appearance of conflict of interest, the Texas Medical Association cites patient safety as the concern. Yet not a scintilla of evidence exists from states where nurses practice independently that patients are at risk. This is the same organization that produced a workforce report saying that by the year 2025, Texas would be short 10,000 doctors. You’d think they would want the help.

A broad coalition of 20 organizations has formed to support the legislation including AARP, the Texas Association of Business and think tanks that normally oppose each other — the Center for Public Policy Priorities and the Texas Public Policy Foundation.

If every single nurse practitioner and family doctor were deployed, Texas still could not meet the need for primary care, as the growing demand far outstrips the supply. If SB 681 and HB 1415 become law, Texas could keep the advanced practice nurses it educates and could recruit advanced practice nurses from other states.

I looked down and as I saw the bruises, I closed my eyes. Birds were singing, harps were playing. “Ian, dear, would you mind terribly driving me to the neighborhood drive-thru X-ray store?” We arrive and get in the short line. Ian presses the button, and a pleasant voice comes through the intercom to take our order.

“My wife here will have two views, right forearm,” Ian says. We drive through. I roll down my window, stick out my arm and X-rays are shot. We’re told that in about an hour I’ll receive a text message telling me if it’s fine or if I need to drop back by for a quick casting.

The music screeched into minor key as I opened my eyes to reality. The only way to get my arm checked out would be to brave an emergency room. Only a bone sticking through the skin could have compelled me to do that.

The disincentives for going to an ER for any reason are solidly built in. You will likely wait for hours and hours. No one there wants to be there. You’ll be with folks who are hurting, sick and possibly contagious. Many are afraid of what they’ll hear from the doctor. An annoying television will be blaring some god-awful channel. Children and babies will be crying. (Every parent knows that no self-respecting infant or toddler would spike a fever or get sick during normal working hours.)

On Jan. 2, the day I fell, the journal Science published a study showing that the newly insured in Oregon made 40 percent more visits to the emergency room than their uninsured counterparts in the 18-month study period. That same day, a New York Times article suggested that the Oregon study casts doubt on the hope that expanded insurance coverage under the Affordable Care Act will help rein in ER costs. Really?

The Oregon study does not prove that the law insuring more people will not decrease ER costs. Rather, the study shows that alternatives to the use of hospital emergency rooms were not yet in place; an adequate primary care infrastructure was not yet established.

It’s helpful to look at world experience. The other industrialized nations have had universal health coverage for many decades. Based on their experience, the architects of our law knew that when everyone is insured, you’ve got a single-tier system where care is delivered in the proper settings. Those nations have evolved primary care systems where people can go for fevers, sore throats, routine screenings, blood pressure checks, etc. Their ERs are comparatively empty and used for actual emergencies, like motor vehicle accidents, broken bones and stroke and heart attack.

Seeking medical care in those countries is convenient and doesn’t carry the threat of financial ruin. Illness is treated early and screenings prevent disease. The population of those countries have longevity and other positive health indicators, and they are satisfied with their health care. A much lower percentage of their total economic outputs is spent on health care.

Our country has a long way to go to fully establish its primary care infrastructure. It’ll take all hands on deck, and it will take many years. Primary care needs to be better compensated. Medical schools need to turn out more primary care docs. Nursing schools need to increase the number of nurse practitioner slots. Faculty needs to be better paid.

With the highest rate of uninsured in the country, the Texas Legislature needs to do what other medically underserved states have done: remove all barriers to practice for nurses in advanced practice to increase the number of providers. That’s a no-brainer and won’t cost a dime.

Ideally, primary care would be delivered in models such as those of Austin Regional Clinic where 24/7 telephone nurse consultation steers you to timely appointments. Care is delivered by a collaborative team of physicians, nurse practitioners and physician assistants. The clinics have laboratory and radiology onsite and extended evening and weekend hours.

The incentives to avoid the ER are there. People just need a place to go to meet their needs. When they do, ER costs will be reined in. By the way, my arm is fine.

A patient in an acute psychiatric crisis needs a medical assessment that often requires laboratory or imaging studies to rule out other physical contributing factors. That’s fundamental, and it’s why urban areas have psychiatric emergency services within acute care hospitals. Up to now, Austin has turned a blind eye to that basic standard of care.

Here’s the sequence of events that led to where we are:

1861 The Texas State Lunatic Asylum opened, 152 years ago. In 1925, the name changed to Austin State Hospital, perhaps signaling that it was ours. But the fact is the hospital was established to serve 38 Central Texas counties.

As the Central Texas population grew throughout the 20th century, its hub, Austin, failed to keep pace with needed psych emergency beds, so we “overused” our allotment of state hospital beds.

Early 2000s County Probate Judge Guy Herman, whose court handles mental health cases, started a petition drive to create a hospital taxing district to better fund and organize health care. Community leader Clarke Heidrick came on board to push the business community. Austin Mayor Kirk Watson, whose leadership style is to bring people together to solve problems, mobilized the community at large. Many of us campaigned hard and talked to the electorate like grown-ups, explaining the need.

2004 Travis county voters responded and voted to tax themselves to create the district. (I love this town.)

2005 Texas Department of State Health Services Commissioner Eduardo Sánchez, MD, called community officials and health care players together in a room to suggest there may be better ways to work together to a) care for Hurricane Katrina victims and b) provide needed, organized behavioral health services.

2006 The president and CEO of the health care district (now Central Health), Trish Young Brown, convened a policy group of mental health stakeholders: Austin and Travis County elected officials, the county probate judge, law enforcement that provides patient transport and health care provider representatives from Seton, St. David’s HealthCare and Austin Travis County Integral Care (formerly Austin Travis County Mental Health Mental Retardation). The group met monthly and still meets today. A separate operations group was formed to smooth out day-to-day transitions in care.

2011 In September, Sen. Watson announced his audacious 10 Goals in 10 Years, which included initiatives such as providing needed psychiatric care and facilities, building a medical school and a modern teaching hospital and establishing modern health clinics.

Later in 2011, the state’s Medicaid 1115 waiver to transform care was approved by the Centers for Medicare and Medicaid Services, thus bringing down significant federal dollars. Central Health administers the waiver and together with Seton developed 30 ambitious projects to improve care, eight of which involve behavioral health, for example, the use of telepsychiatry in emergency departments.

2012 With goals set, health care improvements planned and federal dollars contingent on local contributions, Travis County voters again voted to increase their taxes to support health care, this time for a medical school. (I love this town.)

The new 17-room psych ER at University Medical Center Brackenridge will be staffed by people who are comfortable and competent to care for those in a psychiatric crisis including social workers, case managers, 35 nurses and 10 who can prescribe medication — seven psychiatrists and three advanced practice nurses. It will be a quiet place with an enclosed patio and common room. By 2016, it should serve 10,500 patients per year.

Champagne corks didn’t pop at the press conference, though, as every single speaker — Seton board Vice Chair Sr. Helen Brewer, Sen. Watson, Mayor Lee Leffingwell, Young Brown, Judge Herman and Seton President/CEO Jesús Garza — humbly acknowledged that while this is an incredibly important step forward, Austin still lags far behind other Texas urban areas of our size and that we are nowhere near where we need to be in mental health care.

But hey, let’s not look back. It’s a new day in Austin. We’ve got good leadership, smart voters and lots of talent. On the horizon we’ve got a new psych ER, a medical school, new teaching hospital, new clinics and a federal government that wants to help pay for it. One day, together, we’ll reach the holy grail of health care: people getting the right care in the right setting in the right amount.

Jim Willmann, JD, Texas Nurses Association director of governmental affairs, listens while Elizabeth Sjoberg, RN, JD, associate general counsel of the Texas Hospital Association, speaks at a legislative hearing. Kathy Thomas, MN, RN, FAAN, executive director of the Texas Board of Nursing, sits at Jim's right. Photo courtesy of the Texas Nurses Association.

Something happened last week, though, that offers a glimmer of hope to pull us a little further up from the bottom of the heap. Sen. Jane Nelson, R-Flower Mound (chair of the Senate Health and Human Services Committee) and Rep. Lois Kolkhorst, R-Brenham (chair of the House Public Health Committee) filed legislation to loosen the tight restrictions on the scope of practice and prescriptive power of advanced practice registered nurses and physician assistants.

For these providers to order drugs or devices, the requirement for on-site physician supervision will be replaced with periodic face-to-face meetings; the number of advanced practice nurses or PAs to whom a physician can delegate prescriptive authority will be nearly doubled; and coordination among the boards of nursing, medicine and physician assistants will be improved.

The many years of states’ struggle with APN scope of practice has led to legislation that is unduly restrictive and perpetually contradictory. In 2012, 18 states and the District of Columbia allowed advanced practice registered nurses (nurses with master’s degrees and advanced training) to see patients, make basic diagnoses and write prescriptions without a doctor’s involvement. Other states allow them to practice in loose collaboration with physicians. In Texas, nurse practitioners are allowed to practice in clinics and offices only if they have formally been delegated such duties by a doctor.

It seems strange that on military bases in Texas nurse practitioners and physician assistants practice independently of doctors, but off base, these same practitioners find their powers dramatically restricted. This despite being studied up one side and down the other (unlike physicians) with consistent findings that within their areas of competence the care provided by nurse practitioners was equivalent to that of doctors and their actually scoring higher on communication and patient satisfaction.

Attorney Jim Willmann, general counsel for the Texas Nurses Association since 1977, is a veteran of the drug wars. He’s a patient man. He goes about his work researching, educating, negotiating and writing bill language in his calm, soft-spoken manner and has earned the trust of legislators as well as the medicine and hospital lobbies. Every session (and during the Winkler County nurses imbroglio) he helps me accept the world in Texas as it is, not as I would have it.

Willmann notes that the few gains made by advanced practice nurses have been shaped by the confluence of external events with strong legislative leadership. In 1981, former senators Chet Brooks and Carlos Truán pressed an agreement among medicine, nursing and pharmacy to allow nurses to administer and provide, through standing delegation orders, birth control pills and treatment for sexually transmitted diseases in clinics.

In 1989, a significant funding cutback of the federally qualified health centers resulted in a crisis of cutting services if only physicians could prescribe. Brooks and Truán forged an agreement among medicine, nursing and other parties giving advanced practice nurses the power to prescribe in sites serving medically underserved populations.

In 1995, former Rep. Hugo Berlanga with support from Senator Judith Zaffirini, D-Laredo, shepherded an agreement whereby advanced practice nurses could prescribe in a variety of settings including physician primary practice sites and facility-based practices.

In 2003, nurses were allowed to prescribe controlled substances, and the Medicaid reimbursement rate was increased from 85 to 92 percent of the physician’s fee.

In neonatal intensive care, I’ve worked alongside neonatal nurse practitioners for 20 years. They’re smart. They know their limits. They are good at what they do. They will ask if they don’t know something. They talk to the families and listen. They want to take care of the babies and their families, not just fix the prematurity.

More than 521 advanced practice RNs and PAs are credentialed and practicing at the Seton Healthcare Family. Seton employs 174 and 347 are employed by private physicians. The business case is obvious: They’re natural partners with physicians, but cost far less, and you get high-quality care and patient satisfaction.

This session, facing a serious shortage of primary care physicians and with hopefully millions more Texans becoming insured with the Affordable Care Act, it’s all hands on deck. There’s no doubt Nelson’s and Kolkhorst’s legislation will improve access to health care.

Thank you, Dean Stuifbergen, distinguished faculty, friends and families.

Congratulations, Class of 2012! Here you are. You’ve completed something extremely difficult, been in school, many of you, your whole lives. You’ve probably questioned yourselves again and again. Something incredible is happening to you right now, and I’ve been asked to delay the moment you get your diploma.

After commencement address, UTASON

I remember sitting out there where the families are when my daughter graduated from this nursing school. I know what you’ve been through. I was thinking, “How lucky the profession is to have her.”

I also remember sitting where you guys in the caps and robes are. I remember thinking, “Please, Lord, get that commencement speaker off the stage quick so I can get to that diploma before someone figures out there’s been a screw-up and I can’t graduate after all.”

I got here on a bus. In the 1970s, I had a degree in Spanish that I didn’t know what to do with. I sold sandwiches at the corner of Dean Keeton and Speedway and drove a UT shuttle bus. Those jobs were great fun, and the best part was getting to wear overalls to work!

My bus route went from Littlefield Fountain to the Married Student housing out on Lake Austin Blvd. Every morning around 7 a.m., this shy nurse got on my bus. Claudia was the only passenger on the 40-foot-long bus and gradually she progressed from the back to the front of the bus where I got to hear stories about her shift the night before. They were INCREDIBLE. They’d make me sad or outraged or they’d melt my heart. Humor wove a common thread throughout the stories.

I came of age when John Kennedy was president. I believe everyone is born wanting to make a difference in the world, but President Kennedy made me and my generation believe that we actually could.

It was obvious to me how Claudia — without even knowing it — was making a real difference in people’s lives. She was living the dream.

I began to believe that I could do what Claudia was doing. So, I went into nursing — for the stories and to make a difference. Plus, getting to wear scrubs to work every day had to be almost as great as wearing overalls.

I followed Claudia into neonatal ICU more than three decades ago. She left many years ago, but I remained until last year. We’re still close friends. Health care makes GREAT story, and it’s been a real privilege to be able to write those stories for pay for nearly 20 years alongside my neonatal job.

I am so proud that you are joining us into this noble profession. Don’t take my word for it. The Gallup poll has ranked nursing as America’s Most Trusted Profession every year since it was added to the list in 1999. We did get knocked to second place in 2001 when firefighters ranked first, but it took a terrorist attack to do it.

I know nursing school is a tough road. I’m sure you appreciate your families and friends who helped you get through it. I got an F for an entire clinical rotation. That instructor is not here today. But I really, really wish she were. Being a new nurse for me was a horribly bumpy road, but take heart, it’s not how you start out, it’s what you accomplish during your career.

You’re graduating from a top-tier university and a great nursing school. You’ll always be proud to say you have a degree from this school. You know now, patients are taken care of by health care teams, and nurses coordinate those teams. Many of your team members will have master’s and doctoral degrees, so, you’re wise to get a higher education.

Congratulations to the PhDs for reaching the pinnacle of nursing education. The baccalaureates and the masters — you’re amazing. I’ve met some of you at work and your infectious enthusiasm renews and inspires. And you are so smart and sharp! You could have gone into any profession; some of you already have. Many of you have other degrees.

Now listen. I want to personally thank each and every one of you for answering society’s call for nurturing by going into nursing. None of us did it to get rich, but the rewards are priceless.

A few years into my nursing career, in the mid-1980s, this disease that eventually was named AIDS came out of nowhere. Everyone in health care was terrified of contracting it at work. My brother, who lived in San Francisco, would call me, frustrated that the Food and Drug Administration would not release the AIDS drugs.

Like all the others in the mid-’80s, he died a horrible death young and only months after being diagnosed. That’s when I realized that policy was important and that it can determine if people live or die. I entered graduate school to study health policy at the nursing school and at the LBJ School of Public Affairs. Never again could I separate health care from policy.

You are entering your profession when health policy is on fire and when history is being made. Nursing is playing a critically important role in the transformation going on in health care.

I think that it all began with that frightening 1999 Institute of Medicine report that found upward of 100,000 people die in any given year from medical errors in hospitals. A prestigious study found last year that that number may be 10 times as high. Medicare is spending more than $30 billion a year on patients harmed, so patient safety has become a matter of policy.

Nurses know the answers to patient care issues. I can’t speak from personal experience about other hospital systems, but where I work and in other Magnet® and Pathway to Excellence® hospitals, nurses lead the collaborations that improve patient safety. Seton nurses led an initiative that virtually eliminated bedsores, and now we’re ranked first internationally in preventing them.

Here’s another example. There’s nothing sadder in the neonatal ICU than a full-term infant who was injured at birth. So, nurses and doctors got together and developed a bundle of best practices for obstetricians. Seton’s birth injury rate dropped like a stone from half the national average to zero, and Medicaid billing fell from half a million dollars to zero.

Now, if you asked those nurses if they were making policy, they’d say, “Nah, just working on practice guidelines.” But make no mistake, they ARE making policy and as their practice models spread throughout the country, it’s saving untold numbers of lives and injuries, heartbreak and billions of dollars.

Nurses know the answers. About 200 nurse-run clinics nation-wide, most associated with university schools of nursing and located in underserved areas, are providing primary care, prevention services and managing chronic diseases such as hypertension, diabetes, obesity and asthma. Their outcomes are phenomenal. UT Austin School of Nursing is associated with two nurse-run clinics that are vital to this community: the Family Wellness Center in East Austin and the Children’s Wellness Center in Del Valle. All of that activity is policy-driven.

I know you guys are engaged. After lying dormant for decades, the youth vote reawakened with a vengeance. That tells me you are awake to the world — and to the possibilities.

Just last month, Travis County voters approved your getting a brand new UT medical school right over there. That school will help this prestigious nursing school and the schools of biomedical engineering, pharmacy and others to create world-changing innovation. Policy matters.

If you completed an advanced practice track now or plan to in the future, pay attention to your state legislature. Another session begins next month, and those folks down there at the capitol will determine if you can practice to the full extent of your education. Even though Texas ranks last in access to care and has the worst shortage of primary care providers per population, Texas is one of five states that practically shackle nurse practitioners. That’s not acceptable.

This session, the legislative agenda of the Texas Nurses Association (that’s your professional organization) will continue to work on removing barriers to advanced practice, combatting the nursing shortage by continuing to fund nursing education and protecting you from workplace violence, so you won’t get beaten up at work. Policy matters.

You undoubtedly know the now legendary Winkler County nurses whistleblower story. As a result of that case, last session TNA passed a law, sponsored by nurse legislator Donna Howard, that will protect nurses from criminal prosecution for patient advocacy. Policy matters.

And now to the bomb of health care policy … something all the rest of the industrialized nations have: universal coverage. Finally.

Every U.S. president throughout the 20th century had universal medical care high on his agenda, but President Barack Obama got the job done. He succeeded where others failed by having a fierce determination and by learning from the mistakes of past presidents.

Lyndon Johnson used to say, “Make your move during the honeymoon, before the dead cats stink up the porch.” Obama made his move during the honeymoon; didn’t get drawn down into the mud-wrestling of the technical, nitty-gritty details like Carter and Clinton; and he did not cede to the enemies when defeat was imminent.

Fury and acrimony surrounded the signing of the law on March 23, 2010. That’s a nice way of saying that all hell broke loose. Almost half the state attorneys general filed suit; the U.S. Supreme Court ruled on its constitutionality (favorably); and many governors, including ours, have refused to set up the exchanges or expand Medicaid.

We forget that the same fury and acrimony surrounded the passage of Medicare in 1965, but it’s now an essential and popular program. We’re still in the eye of the storm, but on Oct. 1, 2013, almost all Americans can go to an insurance exchange website and shop for a plan that meets their needs. Demand for advanced practice nurses will skyrocket. So, get ready. It’s a new dawn.

You might be thinking about costs right now. With or without universal coverage, our country’s long-term prosperity depends on controlling health care costs, and the answers are coming from within the industry, not from the outside. Nurses are critical to finding the solutions for cost-effective, high-quality care. Look, if corporations producing commodities like TVs, microwaves and cars can make better products and save money by eliminating waste and increasing efficiency, so can health care.

In conclusion, you’ve chosen a terrific way to make a living and worked really hard to get here. I know you’ll be great nurses because you’re smart and you’ve graduated from this school. Nursing offers SO MANY paths. You may or may not stumble onto the one that’s right for you in the beginning, but have faith that you WILL find it. I promise

But understand … some of the work you do while off the clock can make the biggest difference. Policy is not a spectator sport. Not for nursing, not now. It’s messy and it takes tenacity, but it’s worth it because it’s the only way to make progress. Be a part of it, both where you work and through your professional organization. Now go out there and make a difference. Thank you.

On his watch, Texas has held the disgraceful rank of last in access to health care, as well as last in percentage of residents without health insurance. Of Texas’ 254 counties, 194 (wholly or partially) are designated by the federal government as having acute shortages of primary care physicians. Of that number, 21 counties have one; 27 have zero.

There’s an elephant-in-the-room solution for the problem. It wouldn’t cost a dime but would save millions of dollars every year. Answer: Remove unwarranted constraints that limit advanced nurse professionals from practicing to the full level of their education.

In all 50 states, advanced practice registered nurses are credentialed and licensed by their boards of nursing to diagnose, treat and prescribe. About 80 percent provide primary care; the rest, specialty care. All provide preventive care and health teaching, and they’re great at what they do.

Texas is fortunate to have a large cadre of these qualified nurses, licensed by the Texas Board of Nursing, who are eager to practice to the full extent of their preparation. Their education involves extensive study of pharmaceutics, as the ability to prescribe medications is essential to providing primary care. As part of credentialing, nurses have this authority, but state laws vary on how they are allowed to prescribe.

Texas has the poorest access to care in part because it has the most restrictive laws in the nation on nurses’ ability to prescribe. Eighteen states grant independent prescriptive authority; 17 require a collaborative agreement with physicians; and 15, including Texas, require physician delegation to prescribe. Five states in the past three years switched from collaborative to independent authority.

Given the federal government’s designation of a widespread, acute physician shortage in areas of Texas, you can imagine how collaboration and delegation agreements would be tricky, if not impossible.

Why hasn’t Texas removed barriers to advanced nurses practicing to their full potential? Under the iron grip of deep-pocketed organized medicine, legislators have held back advanced practice nurses for 40 years.

Each legislative session, doctors dress up in white lab coats and explain to the health committees why they should remain the quarterback, the gatekeeper to health care. They say nurse practitioners are dangerous, but that they hire them and keep a close eye on them to ensure safety. They talk about how much longer their education took.

What they’re not talking about are the hundreds of studies showing safety and outcome levels equivalent to physicians and a higher rating for communication.

It’s as if they’re saying, “If you give them an inch, they’ll take a mile.” Legislators swallow their arguments hook, line and sinker, and with the governor’s approval, the phony hierarchy is kept alive. Perry and other governors fail to lead by not challenging the status quo nor placing the issue on their agendas.

Doctors’ arguments are curious, given they can’t come anywhere near producing enough providers. Family doctors are retiring. Medical students graduate with enormous debt and opt for the specialties over less lucrative primary care. If every nurse practitioner and family doctor were deployed, Texas still could not meet its need for accessible primary care.

Last session, Perry could have called for emergency legislation to alleviate the dire need for health care access, which disgraces his state. Instead he chose abortion legislation, despite 2011 data showing a significant and steady decline since 2000 — bucking the national trend. The nefarious law that he signed has landed in federal district court.

People suffer when they don’t have access to primary care; they stay sick longer. When the problem gets unbearable, they face long-distance drives for care and long waits in crowded emergency rooms — the wrong setting. At least in an ER they’re assured of eventually seeing a medical professional. This common and unnecessary Texas scenario is dangerous, causes needless human suffering and burdens health care systems.

By putting these nurses to work to their full potential, a visionary leader would create jobs while increasing access. It’s a shovel-ready project, and with the absence of Perry’s attention for 11 years, legislators continue to miss the boat.

A friend of mine was born, raised and educated in Texas and is heartbroken that she can’t practice as an advanced nurse in her native state. She could if she lived in three bordering states: New Mexico, Louisiana and Arkansas. She chose New Mexico.

Perry, you could be touting your health care record on the campaign trail. Be a real leader. Let the public interest be your guide and free up nurses to elevate us from last in the nation in access to care.

No state needs primary care providers more than Texas, which has a severe shortage. Texas ranks last in access to health care and in the percentage of residents without health insurance. Of Texas’ 254 counties, 188 are designated by the federal government as having acute shortages of primary care physicians. Of that number, 16 counties have one and 23 have zero.

If every nurse practitioner and family doctor were deployed, we still couldn’t meet the need. Texans are desperate for health care.

Doing the math and to help meet the need, the Legislative Budget Board recommended autonomous practice of advanced practice nurses after a preceptorship.

In Texas, our Legislature — session after session — keeps the most restrictive laws in the country. Nurse practitioners don’t want to perform brain surgery. They just want to provide primary care and are quick to refer cases to a doctor when necessary.

Most states with far less need do not legislate practice barriers to nurse practitioners. Given the severity of our problem, shouldn’t we at least bring ourselves in line with those other states?

Texas has a large cadre of licensed, competent and qualified nurse professionals supremely educated, trained and eager to provide primary care. Hundreds of studies have shown their safety records to be equal to those of doctors —with the exception of their communication skills, which rank higher.

Superior communication skills are exemplified by nurse practitioner Naomi Warren from Winkler County in far West Texas, now famous for the whistle-blower/retaliation case. Having practiced in Winkler for more than a decade, she knew her patients well. They trusted her and were devoted to her.

When she quit her job in Winkler County rather than work alongside the doctor she and many others viewed as incompetent and dangerous, she moved her practice to neighboring Monahans Clinic. Even though they had to drive 50 miles round-trip to see her, 600 of her patients followed her.

The main legislative hurdle, or sticking point, is physician delegation. For example, a nurse cannot diagnose and treat the medical conditions of a patient without a physician willing to leave his or her practice, travel to a nurse practitioner’s site and sign charts for care that had already been provided.

Medically underserved areas are lucky to have one provider, much less two, necessitated by the delegation rule. In addition, the number of patients a doctor can see in a day is diminished. This rule significantly exacerbates Texas’ severe access problem. But physician delegation is embodied in Texas law, not federal law, so it’s amenable to legislative reform.

Hungry to have the human resources to meet the health care needs of their constituents, a wide variety of interest groups support nursing’s bills. Stakeholders include the Texas Association of Business; AARP Texas; the Texas Rural Health Association; insurance companies such as United HealthCare Texas, AmeriGroup and WellPoint; and many affected individual physicians and others.

As in years past, the only organized opposition comes from physician groups. Their opposition is vehement, and they make large campaign contributions. But why bother? It’s not as if primary care doctors could even remotely fill the need, and they won’t in the foreseeable future.

Older physicians saw the long, on-call hours of practicing primary care as an honorable profession. In turn, they were greatly respected by the people in the community with whom they developed strong relationships over the years. They were often paid in kind. But their numbers are dwindling; many are retiring.

Seeing poor reimbursement rates, few doctors in training choose primary care, where they will make two to 10 times less than their colleagues.

Organized medicine’s powerful opposition is not in the best interest of Texans with no health care. Is it about control? Is it about money? Perhaps they see autonomous advanced nurse practice as an encroachment on their territory. I don’t know why.

But I do know that given the economy, the state budget deficit, the severity of the access problem and the longevity of medicine’s success in killing nursing bills, that turning the tide will be difficult. But it will be historic, a victory for those desperate for health care.

For that to happen, legislators will need to recognize and resist the inherent conflict of interest of deep-pocketed organized medicine. It will take compassion and courage on their part. But they can be proud of their votes because it’s the right thing to do.

As a 30-year neonatal intensive care unit nurse, I know that America funds and delivers the finest high-technology care in the world.

But when I admit so many babies of working parents with no insurance and work way too hard to find primary care providers for the babies we send home, I know our country has a terrible problem. It’s a senseless paradox to have easy access to the most complex care yet at the same time have such difficulty accessing preventative care and treatment for acute (fevers, sore throats and the like) and chronic illnesses.

As President Barack Obama said Wednesday night in an address to a joint session of Congress, “Our health care problem is our deficit problem.” Reform should ensure that all Americans have coverage as well as easy access to primary care.

How much healthier would we be and how much more efficiently would we spend health care dollars if everyone could get the care they need when they need it? A recent study reported in the American Journal of Medicine found that in an average-size metropolitan area, each 1 percent increase in the number of primary care physicians led to a decrease of 503 hospital visits, 2,968 emergency room visits and 512 surgeries.

An acute shortage of primary care providers is one of this country’s deep-seated problems. In the 1960s, physicians began opting out of general practice for the more lucrative specialties because of lopsided physician reimbursement.

Counterintuitively, primary care — arguably the most complex specialty — is one of the most poorly reimbursed. As a result, only 2 percent of current medical students — who may well begin practice with $140,000 in loans — plan to take up primary care. That’s down from 14.6 percent in 1992.

Obama’s reform plan more fairly reimburses primary care providers. This country must stop looking solely to physicians to meet primary care needs.

A more sensible, rational way to deliver primary care is through large collaborative practices staffed with physicians, nurse practitioners and physician assistants who are salaried. Nurse practitioners and physician assistants begin careers with far less debt than physicians and are eminently qualified and prepared to offer primary care. They do not hesitate to refer to physician specialists as necessary.

Albeit not primary care, the collaboration of salaried neonatologists, neonatal nurse practitioners and pediatricians and electronic health records functions beautifully where I work in neonatal intensive care. That’s the way Pediatrix, a large, national physician management group, operates.

The Cleveland Clinic that the president visited in July has salaried physicians with no bonuses and annual contracts. These collaborative practices provide high-quality and cost-effective care and should be replicated nationally for primary care in a reformed system.

To meet primary care needs, all qualified providers must be able to practice unencumbered and unfettered. Antiquated regulations constraining nurses’ practice date back to the 1930s when nurses, who were mainly women, were seen as assistants to physicians, who were mostly men. Such contraints include limits on scope of practice, direct reimbursement and prescriptive authority.

Many states have made significant progress in removing barriers, but we are not where we need to be to meet the country’s needs. Individual states must continue to legislatively remove barriers to advanced nurse practice.

Other evolved democracies have realized national imperatives to ensure their citizens have coverage and access to primary care. These countries have empty emergency rooms, save for trauma, heart attacks, strokes and people needing those rare procedures not available elsewhere.

Obama said Wednesday that it is our calling, our character to meet big challenges, that “we did not come here just to clean up crises. We came to build a future.”

This article describes current and projected numbers of nurses in the workforce, the demand for registered nurses, the effect nursing shortages have on patient care, and anticipated employment opportunities for RNs in 2004.

NURSING THE NUMBERS

Every four years since the mid 1970s, the Bureau of Health Professions of the U.S. Department of Health and Human Services has provided the most extensive and comprehensive statistics available on registered nurses currently licensed to practice in the United States. The following data are from the most recent survey, conducted in 2000, available online at http://www.bhpr.hrsa.gov/nursing/sampsurvpre.htm.[ii]

How many are we? According to the survey, the estimated number of licensed RNs in the United States is 2,696,540. Although this figure represents a 5.4% increase from 1996, it is the lowest increase reported since the beginning of the quadrennial surveys. (Between 1992 and 1996, the total number of RNs increased by about 14.2%.) Of the total number of licensed RNs, 58.5% work full time, compared with 52.0% in 1980; 23.2% work part time, down from 24.6% in 1980; and 18.3% are not employed as RNs, down from 23.4% in 1980. The total number of RNs employed in nursing is 2,201,813.

How old are we? As a workforce, we are aging. The average age of an RN is 45.2; the average age in 1996 was 44.5 years. In 1980, 52.9% of RNs were under 40. According to the 2000 data, 31.7% are under 40. A recent exhaustive study by Buerhaus and colleagues in the Journal of the American Medical Association predicted that the total number of equivalent RNs per capita working full time would peak around the year 2007 and decline steadily thereafter as the largest cohorts of RNs retire.[iii] By 2020, according to the study, the RN workforce will be roughly the same size as it is now, which will be 20% below projected demand. The study found that the main reason for the older workforce is a decline in the number of young women choosing nursing as a career since 1980.

How have we been prepared? During the past 20 years, entry-level nursing education has shifted away from diploma to associate-degree or bachelor’s degree programs. In 1980, 63% of licensed RNs had received their basic nursing education through diploma programs, compared with 29.6% now. In 1980, 19% of nurses graduated from associate-degree programs, compared with 40.3% now; 17.3% had baccalaureate degrees in 1980, compared with 29.3% now. The net effect of these changes is that nurses are spending less time on their entry-level education. Even though the number of bachelor’s and master’s programs is increasing, a far greater increase is seen in the number of nurses in associate-degree programs than in the number of nurses in hospital programs. Associate-degree programs are two years long; hospital programs are three.

The number of two-year community colleges with RN programs exploded in the 1960s and has steadily increased since then. At the same time, three-year hospital diploma programs have been closing. Not only was the demand greater for the two-year programs, but hospitals were forced through harsh economic forces — brought about by the managed care system — to close unprofitable programs.

One result of these shifting trends in basic nursing education is that, according to Donley and Flaherty, practicing nurses are undereducated when compared with other members of the health care team. This is a real problem, as they view it, because “undereducated members of the health care team rarely sit at policy tables or are invited to participate as members of governing boards. Consequently, there is little opportunity for the majority of practicing nurses to engage in clinical or health care policy.”[iv]

On the bright side, more nurses than ever are pursuing postgraduate education. In 1980, 5% of the 1,662,382 RNs had a master’s or doctoral degree. According to the last survey, 10.2% of nearly 2.7 million RNs have such degrees. These statistics also reflect the dramatic increase in the number of master’s degree programs in nursing available to people who have bachelor’s degrees in areas other than nursing. The influx of baccalaureate-prepared people from other fields into nursing increases our diversity and broadens our perspective.

Where do we work? Of today’s employed RNs, 59.1% work in hospitals, 18.3% in public and community health (including occupational and school health settings), 9.5% in ambulatory care, 6.9% in nursing homes and extended care facilities, 2.1% in nursing education, and 3.6% in other settings (such as prisons, jails, and insurance companies). The settings that saw the largest increase in number of RNs were the public and community health sectors, including state health departments, community health centers, and visiting nursing services.

How much do we make? The Bureau of Health Professions survey measures average RN earnings through two indices: the actual average earnings of RNs employed full time and the “real” average earnings of those RNs, based on the consumer price index for 1982 to 1984. The actual average annual salary of a full-time RN is at an all-time high of $46,782—it was $17,398 in 1980.[v] However, real compensation amounts to only $23,369 when changes in the purchasing power of the dollar are taken into account through the consumer price index. Real salaries have been about the same since 1992.

How many of us work in advanced practice? The number of nurses prepared to be nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists rose to 196,279 by 2000, or 7.3% of RNs—up from 6.3% in 1996. Of nurses working in advanced practice, most are nurse practitioners; the next largest group is clinical nurse specialists. These two together, including people who are trained to do both jobs, make up approximately 80% of all APNs. Nurse midwives account for 4.7% of APNs (up from 1996), and nurse anesthetists comprise 15.2% (up from 1996).

NURSING THE DEMAND

Today there are more than 126,000 unfilled nursing positions—around 7% below the workforce requirement.¹ The nursing shortage is expected to continue at this rate so that the number of nurses is 12% below what’s needed by the year 2010, 20% below by 2015, and a staggering 29% below the workforce need in 2020.³

Advances in medical technology and pharmaceuticals as well as healthy lifestyle choices have resulted in “the graying of America” as life expectancy increases and quality of life improves. The current number of unfilled nursing positions pales when compared with the number of nurses needed when 78 million baby boomers begin placing unprecedented demands on the system when they hit 65 in a few years.

WHY THE SHORTAGE?

Why, if there’s job security and decent pay, is there such a profound shortage of nurses? The reasons are numerous and complex. A 20-year buildup of conditions created the “perfect storm”—our current protracted, calamitous nursing shortage. The economic pressures that started with the introduction of the managed care system in the 1980s and continued with hospital mergers in the 1990s necessitated a rethinking of how care was delivered.

This transformed healthcare system transferred much of inpatient care to the outpatient setting and to the home. This shift is reflected in the dramatic decrease in hospital average lengths of stay in the last two decades. In 1980, the average length of stay was 7.3 days.[vi] In 2000, the average length had fallen to 4.9 days.[vii] What this means for the nearly 60% of RNs who work in hospitals is that today’s patients are sicker than in the past, requiring more intense nursing care.

Another factor that has influenced today’s shortage was a 1995 report by a blue-ribbon commission funded by the Pew Charitable Trusts. The report warned that hospital mergers would close the doors of almost 50% of our nation’s hospitals by 2000, which would mean a loss of 60% of hospital beds and a surplus of 200,000 to 300,000 nurses.[viii] The Pew prediction was wrong, and far fewer hospitals closed than anticipated, but the report left its mark on history by discouraging young people from entering the nursing field.

The reshaping of health care by market forces has meant fewer hospital resources for nursing. Dealing with intense assignments and extra shifts (including mandatory overtime), nurses are overworked and have become stressed, burned out, and left with little job satisfaction; all these contribute to the nursing shortage. Furthermore, as nurses get older and retire, more people are leaving than entering the profession, even with increased enrollments in schools of nursing. Women account for 95% of nurses, and young women are not choosing to become nurses as frequently as they once did. This is leading to a further reduction in the number of nurses. But at the same time that nursing enrollment is down, the number of women entering medicine is up. Medical schools now boast a 50:50 female to male enrollment ratio (see www.aamc.org/data/facts/famg52002a.htm for information.) We don’t have the capacity to educate as many nurses as we used to, as evidenced by a far higher number of applicants than enrollees.

Gail Collins wrote about the shortage in a 2001 New York Times article: “[Nurses are] unhappy, and they’re spreading the word. . . . Management has a right to be efficient and demand results, as long as everybody remembers that the nurses of the future have a right to sign up for dentistry or accounting.”[ix]

NURSING THE EFFECTS

According to a white paper by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the nursing shortage is “a prescription for danger.”¹ The JCAHO report shows that the shortage contributed to a staggering 24% of the unanticipated problems in hospitals that result in patient death or injury, citing insufficient numbers of nurses as a reason for those cases. The JCAHO used its “sentinel event” reporting system (a computer database that includes 1,609 reports of patient deaths and injuries between 1996 and the report date), as well as detailed explanations from hospitals to generate these results.¹

The paucity of nurses affects more than patient injuries and deaths. It contributes to some of the thorniest problems in health care today. It’s a major factor in ED overcrowding and “diversions,” cancellation of elective surgeries, discontinuation of clinical services, and limitations in the health care system’s ability to respond to mass casualties. Ninety percent of nursing homes report that they do not have enough nurses to provide even the most basic level of care, and some home health agencies are being forced to refuse new admissions.¹

WHO CAN FIX THE SHORTAGE?

Reversing the nursing shortage will not be simple, but the shortage is fixable, and it’s up to us. It will take a community—nurse executives, hospital leadership, policymakers, schools of nursing, physicians, accreditors, private industry, and nurses ourselves. The cited 20002 JCAHO report also called for reforms to the nursing education system and for the federal government to tie Medicaid and Medicare payments to a hospital’s improvement in nursing care and nurses’ work environments.

The nursing profession. Perhaps the greatest hope for alleviating the nursing shortage is the Magnet Recognition Program, the brainchild of the American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association. Magnet hospitals are desirable settings for RNs and better patient outcomes than do other hospitals; this gives them an edge in recruiting and retaining nurses in a tough market.

The Magnet program came about in response to the severe nursing shortage of the early 1980s. The American Academy of Nursing, the ANA, and a group of nurse executives were looking to combat that shortage and decided to conduct a national study to identify those hospitals that attracted and retained nurses. That study led to 41 hospitals receiving the designation “Magnet hospital.”[x] There  are now two groups of Magnet hospitals — one from the early 1980s, the other certified since the early 1990s.

In the early 1990s the ANA, through the ANCC, formalized the (Magnet) program to acknowledge excellence in nursing. It’s a form of external peer review available to all hospitals and healthcare organizations. The Magnet designation is awarded according to 14 standards of nursing: high-quality care, strong nursing leadership (including a nursing staff that makes decisions about clinical care and its own practice), dynamic performance improvement, large number of APNs, heavy involvement on the part of nurses with the community, and high degree of interdisciplinary collaboration. Organizations are evaluated in a process that consists of several stages, including documentation of attainment of the 14 standards and on-site review. Currently 85 organizations in the United States and Britain have been awarded this nursing seal of approval. Magnet status is elite: Fewer than 2% of hospitals have achieved this rigorously determined certification.[xi] Magnet recertification is required every four years. Studies by Linda H. Aiken, PhD, RN, FRCN, FAAN, and others have demonstrated the value of the Magnet program in terms of fostering both positive patient outcomes and satisfactory work environments for nurses.^{10, [xii]}

Policymakers. The nursing shortage has certainly gotten the attention of the U.S. media. Policymakers at the state and national levels have watched the news, read their newspapers, listened to their constituents, and begun to pass legislation to alleviate the shortage.

In mid 2002 Congress passed, and President Bush signed, the Nurse Reinvestment Act. This law modified funding for existing nursing programs—including ones for advanced practice nursing, basic nursing (nurse education, practice, and retention), nursing workforce diversity, and loan repayment and scholarship—and created geriatric care training and faculty loan programs. For fiscal year 2003, Congress appropriated a total of $113 million for all nursing programs—an overall increase of $20 million over levels from fiscal year 2002 but still less than the recommended $250 million.{Public Law No. 108-007. Omnibus appropriations bill for FY03, passed February 20, 2003.}

Most states have begun to address the shortage through legislation and funding to expand nursing. Some states have passed laws to improve the workplace. Texas, for example, addressed nurse staffing ratios administratively: The Texas Hospital Association and the Texas Nurses Association worked with the state’s department of health, which has rule-making authority, to change nurse staffing plans in March 2002. Texas hospitals are now also required to form advisory committees with mandated input from front-line nurses. The implementation of California’s safe-staffing law, signed in October 1999, proved difficult; all hospitals in California must comply by January 1, 2004. In 2003, states’ hands were tied when all but a handful of states experienced huge budget shortfalls.

Private industry. It’s in the best interest of private industry for our nation to have a full and sustainable nursing workforce. One example of private industry aggressively addressing the shortage is Johnson & Johnson’s 2002 advertising campaign, featuring the “dare to care” television spots which portrayed nurses very positively and appealingly. In February 2002, the company launched a two-year, $20 million campaign to attract more people to the nursing profession. The campaign includes scholarships for undergraduate nursing students and nurse educators; television ads celebrating nurses and their contributions; national fundraising events to honor excellence in nursing (and to support the student and faculty scholarships); and recruitment brochures, posters, and videos for distribution in 20,000 high schools, 1,500 nursing schools, and nursing organizations. In addition, the company launched a Web site, www.discovernursing.com, that offers information on careers in nursing, profiles of 105 nurses across the nation in different jobs, a database of nursing schools, and more than 300 nursing scholarship programs.

Nurses ourselves. It used to be said that nurses “eat their young,” holding recent graduates to very high standards, sometimes resulting in their departure from the profession. Today, established nurses embrace new nurses and traveling nurses. Nurses everywhere feel the strain of the shortage every day, and they’re happy to get what help they can; they show their appreciation.

When I see new graduates I thank them for going into nursing. When I see promising young people, I ask them if they’re happy with their jobs, and if not, I ask them to think about becoming nurses. Nurses ourselves are surely our profession’s best recruiters.

One of the most basic ways individual nurses can contribute is by joining the ANA, state and national professional nursing organizations, as well as specialty organizations. Organized nursing plays a critical role in informing the public and policymakers about the needs of the profession. The people in these organizations are the voice of nursing in the halls of state houses and in Congress (sometimes with the help of the media). Nurses must prompt elected officials when nursing bills come up for vote.

NURSING THE OPPORTUNITIES

Both the complexity of health care and the shortage have brought about unprecedented opportunities for nurses. The following are only a few areas of nursing that are innovative and promising.

Staff nursing. The need for hospital staff nurses has continued to rise, and the good news in nursing is that nurses can continue to work at the bedside while finding fulfillment. With the move toward Magnet nursing, the bar has been raised for staff-nurse contributions in hospitals. Staff nurses have opportunities that did not exist before.

I am a staff nurse at a Magnet hospital. Staff nurses are encouraged to participate meaningfully in making decisions that affect patient care and the work environment. I participate in a refined shared governance structure and culture consisting of a strong chief nursing officer, a nursing executive council, a nursing congress, and eight specialty councils (acute and postacute care, ambulatory care, behavioral health, critical care, emergency care, pediatrics, perinatal, and surgery). This hospital, like other Magnet hospitals, has a high degree of interdisciplinary collaboration, which I find very rewarding. We have a clinical ladder program that rewards nurses for participating in shared governance and for promoting health on a volunteer basis in the community.

Teaching. There is also a shortage of nurse faculty members.{Hinshaw AS. A continuing challenge: the shortage of educationally prepared nursing faculty. Online Journal of Issues in Nursing. January 31, 2001. http://www.nursingworld.org/ojin/topic14/tpc14_3.htm.} New money from government to increase the supply of nurses will have little effect if there aren’t enough teachers. Furthermore, the faculty shortage is a major factor limiting enrollment in schools of nursing.

The average age of a nursing teacher is 50.2, and with the retirement of this “graying professoriate,” the shortage is expected to escalate.{Hinshaw 2001 (above).} (This phenomenon is unique to nursing because nurses are encouraged to gain clinical experience before earning higher degrees and teaching.) A nurse with five years’ solid experience can teach. With opportunities to guide future nurses as well as chances to do important research, teaching can be very rewarding. Nurses wanting to teach may do well to consider pursuing that goal earlier in their careers than the last generation did.

Genetics nursing. The remarkable work of the U.S. Human Genome Project is a catalyst for growth in the number of opportunities available to nurses. Coordinated by the Department of Energy and the National Institutes of Health, the project, which began in 1990, has mapped the human genome—the collection of about 35,000 genes and the sequences of the 3 billion base pairs that make up human DNA.{Human Genome Project Information found at http://www.ornl.gov/TechResources/Human_Genome/home.html} The implications for health care are profound. Most health conditions are believed to result from a combination of genetics and environmental influences; the new knowledge will improve the prediction, diagnosis, and treatment of many illnesses.

Physicians, nurses, and other health care workers, regardless of specialty, will need to integrate new information on genetics into routine practice, especially when explaining responsiveness to treatment and options for care.{Jenkins JF. An historical perspective on genetic care. Online Journal of Issues in Nursing. Sept. 30, 2002. http://nursingworld.org/ojin/topic13/tpc13_2.htm.} In response, medicine has developed a specialty, offering services, resources, and education in genetics. For example, where I work in the NICU, when a neonatologist suspects a patient has a particular syndrome but is unsure of which one, another medical specialist—a geneticist—is called in to help identify the syndrome. The geneticist identifies the syndrome, gives a prognosis and the probability that the syndrome will occur in other children of the same parents. Staff nurses assist in reducing complex information into practical, understandable terms for families.

As part of genetics teams, nurses provide care in regional genetics networks, private office settings, and specialty genetics clinics, offering assessment, education, counseling, testing, and interpreting of test results. The International Society for Nurses in Genetics (ISONG) (www.globalreferrals.com) is recognized as the main organization in offering annual conferences, developing nursing standards of practice, and promoting communication and research on genetics.

Nurses with a master’s in nursing may qualify for the credential of APN in genetics. Those with a bachelor’s may qualify for the genetics-nurse credential. The Genetic Nursing Credentialing Commission (www.geneticnurse.org), a subsidiary of ISONG, recognizes clinical nursing practice with a genetics component by granting credentials based on a portfolio of evidence indicating professional experience.

Advanced practice nursing. This collective term refers to four specialties: nurse practitioner, clinical nurse specialist, certified nurse midwife, and certified registered nurse anesthetist. The number of APNs has increased with a rise in opportunities for employment: In 2000, there were nearly 200,000 APNs, or 7.3% of the total RN population, up from 6.3 in 1996.{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).}

APNs are trained by nurses, credentialed by nurses, regulated by nurses, and most have their own medical malpractice insurance. These highly qualified providers are legally allowed to practice in all 50 states. Certain requirements, such as that they be supervised by physicians, vary from state to state and are specified through the states’ nursing practice acts and medical practice acts, the rules of their nursing and medical boards, and hospital licensing laws. {Inglis T. Nurse anesthetists: one step forward, one step back: physician supervision requirements for CRNAs jeopardize access to care. AJN 2003;103 (1):91-4.}

I’ve worked in the same NICU for the past 24 years. In the 1990s, our medical coverage evolved from 100% neonatologists to around 50% neonatologists and 50% neonatal nurse practitioners (NNPs), all employed by a national physician management group. Most of the NNPs here are former NICU staff nurses who completed advanced NNP training and stayed at our hospital. Their work involves nursing and medicine: They write orders (cosigned by a neonatologist) and expertly perform most of the procedures neonatologists perform, such as intubation, insertion of arterial lines, and lumbar punctures. The NNPs have improved the scope of medical care because of their holistic approach to practice and by providing relief to overworked physicians burdened by a neonatologist shortage.

In the hospital where I work, APNs work in other positions. Certified registered nurse anesthetists work alongside anesthesiologists to deliver anesthesia care. Certified nurse midwives deliver infants in a highly sought-after method of childbirth. Nurse practitioners and clinical nurse specialists make up roughly 80% of APNs,{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).} and their subspecialties are as varied and numerous as nurses’ interests: community health, gerontology, family practice, medical–surgical, neonatology, pediatrics, perinatal care, psychiatry and mental health, and women’s health, to name just a few.

Infusion nursing. Happily for patients and nurses, medicine is no longer dependent on peripherally inserted short-term catheters for venous access. Implanted, tunneled, and peripherally inserted central catheters (PICCs) are used for long-term venous access, ideal for patients receiving chemotherapy with irritant or vesicant drugs, long-term antibiotic therapy, and total parenteral nutrition. The insertion procedure, which is a sterile technique, with placement confirmed by X-ray, requires a medical order.

Where I work in the NICU, nurse clinicians take an eight-hour class from nurses hired by the makers of the neonatal PICCs. After three successful supervised insertions, participants are deemed by our institution competent to insert them. For the rest of the adult and children patient population in our hospital network, a cadre of “venous-access” nurses are on call to insert them. National certification as an infusion nurse is available through the Infusion Nurses Society (see www.ins1.org for information).

End-of-life nursing. The aging population has increased the demand for gerontology nurses. At the same time, a national movement toward dignifying the death experience has been taking place, giving renewed life to hospice and palliative care.

In the 1990s, numerous studies revealed disturbing data about people dying in U.S. hospitals being subjected to unwanted extraordinary measures. Family members were not happy with how patients were treated at the end of their lives. Then, in 2000, Bill Moyers’s public-television series, On Our Own Terms: Moyers on Dying, opened a dialogue about death and dying. (The show was partially funded by the Robert Wood Johnson Foundation, which exerted more cultural influence on health care by providing grants for programs that improved end-of-life care. )

Nurses comprise and manage end-of-life, palliative, and hospice care teams in many settings—at patients’ houses and in hospitals, and elsewhere in the community. Staff nurses whose patients are dying (in NICUs, EDs, ICUs, and long-term care facilities, for example) are finding more enlightened collaboration possible with physicians and other healthcare workers.

Public health nursing. The largest increase in RN employment from 1996 to 2000 was in the public and community health settings (state health departments, for example).{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).} Because of the events of September 11, 2001, it is likely that more RNs will be employed in this setting. The Centers for Disease Control and Prevention is working with universities, the Department of Homeland Security, and state and local health departments to prepare for and respond to acts of terrorism. Last year, nurses were asked to voluntarily immunize themselves against smallpox — a vaccination not without potentially lethal side effects.

ALWAYS IN DEMAND

The areas discussed here represent only a tiny fraction of the boundless opportunities available to nurses. One thing is clear: Nurses can now choose alternatives, and because of the changes brought about by the Magnet program, they can work in settings where they are valued and can positively affect patient care and their own work environments.

The high demand has increased the number of choices for nurses. Travel nursing is in full bloom to fill seasonal needs at hospitals and elsewhere, and this kind of work is a wonderful opportunity for young nurses looking for the right community. As nurse consultants, meanwhile, nurses can work in offices, home care, health care licensing and regulating agencies, schools, legal practices, jails, and insurance and pharmaceutical companies—the list is long.

Qualified nurses are always in demand, as “the primary source of care and support for patients at the most vulnerable points in their lives,” as the JCAHO recently stated.{from JCAHO report August 7, 2002.} “Nearly every person’s health care experience involves a registered nurse. Birth and death, and all the various forms of care in between, are attended by the knowledge, support, and comfort of nurses.”

[ii][ii] Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000. Rockville, MD: U.S. Department of Health and Human Services; 2002. http://www.bhpr.hrsa.gov/nursing/sampsurvpre.htm.

[iii] Buerhaus PI, Staiger DO, and Auerbach DI. Implications of an aging registered nurse workforce. JAMA 2000;283(22):2948-54.

[iv] Donley R, Flaherty MJ. Revisiting the American Nurses Association’s first position on education for nurses. Online Journal of Issues in Nursing. May 31, 2002. 7:2, manuscript 1. http://www.nursingworld.org/ojin/topic18/tpc18_1.htm.

[v] http://www.bhpr.hrsa.gov/nursing/images/avgsalary.jpg.

[vi] National Center for Health Statistics, Vital and Health Statistics, series 13, as cited by the Statistical Abstract of the United States, 1997, published by the U.S. Department of Commerce.

[vii] National Center for Health Statistics, Fast Stats AtoZ, Hospital Utilization, Advance Data from Vital and Health Statistics, No. 329, June 19, 2002. http://www.cdc.gov/nchs/fastats/hospital.htm.

[viii] Pew Health Professions Commission. Critical challenges: revitalizing the health professions for the 21st century. December 1995. http://www.futurehealth.ucsf.edu/summaries/challenges.html.}

[ix] Collins G. Nursing a shortage. New York Times, August 13, 2001.

[x] Aiken LH, Havens DS, and Sloane DM. The magnet nursing services recognition program: a comparison of two groups of magnet hospitals. AJN 2000;100(3):26-35.

[xi] American Nurses Credentialing Center, Magnet Recognition. http://www.nursingworld.org/ancc/magnet/magnet2.htm.

[xii] Aiken, Havens, and Sloane. 2000 (above). and Aiken LH. Superior outcomes for magnet hospitals: the evidence base. In: McClure ML and Hinshaw AS (eds.), Magnet hospitals revisited: attraction and retention of professional nurses. Washington, DC: American Nurses Publishing, 2002: p. 61-81.

On January 18, 2001, as one of the numerous “midnight” regulations of the Clinton administration, the federal requirement for hospital physician supervision of nurse anesthetists was dropped. But on November 13, 2001, just before the January ruling was to go into effect, it was reversed by the Bush administration.

The November ruling requires physician supervision of CRNAs in hospitals receiving Medicare reimbursement. The ruling compromises by permitting state governors to request a waiver to opt out of the requirement, if deemed in the best interest of the state’s residents. The governor may do so only after consulting the state’s boards of nursing and medicine, and after determining if opting out is consistent with state law. To date, six states have opted out of the requirement — in order, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, and New Mexico.

Although nurse anesthetists are legally allowed to provide anesthesia in all 50 states, some states require that they do so with supervision. However, 31 states don’t require physician supervision of CRNAs. This is specified though the states’ nursing and medical practice acts, the rules of their nursing and medical boards, and their hospital licensing laws: all three must be in accordance in order to secure exemption from the new ruling.

How the Rulings Effect Practice

“In my judgment, the supervision rulings do not affect practice or the quality of anesthesia care,” said Sandi Peters, CRNA, former president of the Texas Association of Nurse Anesthetists. “I practice in three rural hospitals. In one practice site Im employed as a staff anesthetist; in the other two I independently contract. The physician who supervises me is usually a surgeon who likely has hd no advanced anesthesia training. Physician supervised or not, my practice is the same at all three hospitals.”

“Physician supervision of nurse anesthetists has absolutely nothing to do with practice or patient safety,” says Ira Gunn, MLN, CRNA, FAAN, who for nearly 50 years has practiced anesthesia and worked extensively with state legislatures, the Congress and administrative bodies regulating the nurse anesthesia profession. The 30,000-member American Association of Nurse Anesthetists (AANA) established a professional advocacy award in her name. “It has to do with politics, turf, control and income. It’s a holdover from the days of the ‘captain-of-the-ship’ legal doctrine, which became obsolete long ago in most jurisdictions.”

Gunn clarified a common misperception about who exactly “supervises” CRNAs. “People assume that physician supervision rulings are about anesthesiologists supervising nurse anesthetists. That isn’t true. Physician supervision rulings refer to any physician, including those without advanced anesthesia training. In practice it’s likely a surgeon,” said Gunn. “The American Society of Anesthesiologists (ASA) successfully campaigned to convince surgeons that they were liable for CRNAs. Nothing could be further from the truth. CRNAs carry their own medical malpractice insurance. Nurse anesthetists are trained by nurses, credentialed by nurses, and regulated by nurses. The profession is independent of medicine.”

Peters agrees. “ASA’s misleading information made surgeons feel that they would be liable for any mishap if they didn’t supervise CRNAs. The surgeons I work with haven’t had advanced anesthesia training, and many tell me they don’t feel qualified or comfortable supervising my anesthesia care.”

“In another twist on the subject, HCFA (the federal Health Care Financing Administration) never defined ‘supervision,’” Peters continues. “In practice, it could mean anything from a physician being somewhere in the building to one looking over the old ether screen and asking the CRNA if everything’s okay. So, there’s no consistency. Supervision is meaningless in real-life practice.”

“The Bush administration reversal was deeply disappointing to practicing CRNAs,” Peters says, “because it meant an opportunity was lost to lose unnecessary encumbrances to practice. It also places a procedural burden on state governors to opt out.”

Deborah Chambers, CRNA, MHSA, past president of AANA, says, “The AANA believes that CMS (Centers for Medicare & Medicaid Services) got it right the first time with the January 2001 rule on supervision. But since the November 13 ruling is in place, the AANA will work with that rule to ensure safe, high-quality anesthesia care for all Americans. We are confident that governors will make the right decisions for the citizens of their states by choosing to opt out of the requirement.”

Witkowski, too, is disappointed in the latest ruling. “It promotes a phony hierarchy of providers, granting physicians greater status and economic reward. It’s demoralizing to the ‘underlings,’ the dedicated people who do the work. It makes them feel beaten down and leave the profession, contributing to the shortage of anesthesia providers. What’s worse, rulings like these drive up prices and limit access,” she says.

A question of Geography

Access to health care is a challenge in U.S. rural areas, as most healthcare providers prefer to practice in urban areas. Thus, the Clinton administration’s January 2001 ruling was strongly supported by the both the American Hospital Association and the National Rural Health Association. Small wonder, as CRNAs are the sole providers of anesthesia in many inner-city hospitals and in more than 65% of rural hospitals, according to the AANA. [http://www.aana.com/crna/ataglance.asp]

Rodney Lester, PhD, CRNA, president of the AANA, understands the critical role CRNAs play in meeting the healthcare needs of rural communities. “If it weren’t for CRNAs, people living in rural and medically underserved areas simply wouldn’t be able to maintain access to the services they need requiring anesthesia—for example, trauma stabilization, diagnostic procedures, and emergency surgeries related to obstetrics, orthopedics, and a myriad of acute conditions,” Lester says.

Hospital medical bylaws reflect this geographic difference in access to services. In the 29 states where physician supervision of CRNAs is not required by law, the medical bylaws of rural hospitals typically don’t require supervision.  However, urban hospital bylaws, which are far more restrictive, tend to require physician supervision. As Witkowski explains, “Some bylaws in urban hospitals with plenty of physician coverage can be so limiting that [CRNAs] wouldn’t be able to make any independent judgments at all. CRNAs would do well to read their hospital’s bylaws and address those that are too restrictive.”

The Future of Physician Supervision

The future of the physician supervision requirement is anyone’s guess. Publicly, the ASA frames physician supervision of CRNAs in terms of patient safety rather than interprofessional turf, and it hailed the Bush ruling as a major victory. But from Gunn’s perspective, “CRNAs have always worked collaboratively with physicians, so supervision is neither necessary nor appropriate.”

Some believe the new ruling may be a violation of the original Medicare Act. Glen Maxey (D-Austin), a healthcare consultant who represented Travis County in the Texas legislature from 1991 to 2002, believes the January ruling shouldn’t have been rescinded. “When Medicare was passed in 1965,” Maxey says, “a fundamental principle of the program was that it wouldn’t interfere with state law regarding the regulation of healthcare professionals. Since the January 2001 ruling would have deferred to the states on supervision, it should have been allowed to stand.”