TMA Opposes Nurse Practitioner Plan

Proposed new rules regulating the scope of practice of advanced practice registered nurses (APRNs) would illegally allow APRNs to make medical diagnoses, and the proposed rules ignore key tenets of a new state law, TMA and nine other state medical societies wrote in a formal comment letter to the Texas State Board of Nursing (TBN).

"Throughout the proposed rules APRNs are given the authority to 'diagnose' medical conditions, yet the Texas Occupations Code … expressly defines 'professional nursing' as not including the acts of medical diagnosis," TMA President Austin I. King, MD, and representatives from the Texas Academy of Family Physicians (TAFP), the Federation of Texas Psychiatry, the Texas Ophthalmological Association, the Texas Orthopaedic Association, the Texas Osteopathic Medical Association, the Texas Pain Society, the Texas Pediatric Society, the Texas Society of Anesthesiologists, and the Texas Society for Gastroenterology and Endoscopy wrote in the letter to TBN. "Medical diagnosis is not among the acts that may be delegated by a physician to a nurse under any circumstances."

The 2013 Texas Legislature — with the strong support of TMA, TAFP, the Texas Academy of Physician Assistants, and the various organizations representing APRNs — passed a law that changed the regulatory structure related to physician delegation of duties for APRNs and physician assistants (PAs). It affected physician delegation and supervision of prescribing privileges and increased the number of PAs and APRNs to whom a physician could delegate. Senate Bill 406 also gave physicians a great deal of leeway in managing their teams of midlevel practitioners according to their style of practice and the needs of their patients.

"When performing those delegated acts, the standards that should be adopted are those of medicine, not nursing," the organizations wrote in their letter. The proposed rules "require APRNs to adhere to standards of nursing practice set forth in the rules and to standards of nursing practice as stated by national professional nursing associations recognized by the TBN. Two medical practice standards or 'schools of medicine,' one for APRNs (when operating under a physician's delegated authority) and one for physicians should not be the result of these proposed rules. Only one school of medicine is supported by the Texas Constitution and the Texas laws authorizing delegation."

The new law gives the physician the authority to decide what acts to delegate to an APRN or PA for a reason. "Due to the limited training and experience required in the abbreviated programs leading to licensure of APRNs (as compared to the required education and training of licensed physicians), it is the delegated physician who must assess the education, training, experience, and competence of each APRN to determine the appropriate amount and type of delegation of medical services," the groups wrote.

TMA routinely fights actions of state agencies that would illegally expand the scope of practice of nonphysician practitioners. 

"This is just one more example of nurse practitioners trying to obtain through rulemaking what they were unable to get from the Texas Legislature, and it goes well beyond the bill they agreed to," said TMA General Counsel Donald P. "Rocky" Wilcox. "We remain vigilant to protect the safety of Texas patients."

Action, July 1, 2014