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Environment friendlier for bills to give nurses more autuomony

In this file photo from 2017, Sen. Jason Smalley is shown speaking on the Oklahoma Senate floor. [Photo by Steve Sisney, The Oklahoman Archives]

In this file photo from 2017, Sen. Jason Smalley is shown speaking on the Oklahoma Senate floor. [Photo by Steve Sisney, The Oklahoman Archives]

Oklahoma City — After several years of hitting a wall, legislation allowing nurses with advanced degrees to practice without a doctor's supervision could have a chance under a new committee leader.

Sen. Jason Smalley, chair of the Senate health and human services committee, introduced a bill that would end physician supervision of nurse anesthetists and said he plans to hear bills related to scope of practice issues if leadership assigns them to his committee. Former Sen. Ervin Yen, a physician, wouldn't hear the bills when he was chairman of the panel.

“If it's going to advance health care in any way or form, we're going to hear it,” Smalley, R-Stroud, said. “I think our health committee is going to entertain a really robust discussion.”

The new legislative session begins Monday.

While the language in bills could still be amended to add other groups, two types of nurses are pushing for independence so far: nurse practitioners, who provide primary care; and certified registered nurse anesthetists, who sedate patients for surgery and other procedures.

So far, the debate is breaking down along familiar lines: Nurses are pointing to rural access issues, while doctors worry about compromised quality.

Toni Pratt-Reid, legislative chair for the Association of Oklahoma Nurse Practitioners, said the group still is working with Smalley on refining language in Senate Bill 839 to allow nurse practitioners to prescribe independently after seven years of physician supervision. The requirement can force nurse practitioners to suspend their practices when the physicians supervising them retire or die, she said.

Under the current system, nurse practitioners must have a formal agreement with a physician to oversee their prescribing, which can cost as much as $5,000 per month, though most do little day-to-day oversight, Pratt-Reid said.

“They don't review our prescribing. They don't review our diagnoses,” she said. “If it was a cost mechanism that increased patient safety, that would be one thing, but it doesn't.”

Dr. Art Rousseau, a psychiatrist and chair of the Oklahoma State Medical Association's council on state legislation and regulation, disagrees. He said nurse practitioners are valuable in a “treatment team,” but shouldn't be prescribing without supervision.

“We recognize that nurse practitioners are well-educated, but not to the extent that they need to be to be independent practitioners,” he said.

Common ground

The medical association and nursing groups are meeting to see if they can find common ground, Rousseau said, but he doubts expanding nurses' scope of practice will solve problems with health care access in rural areas.

“That's not where the nurse practitioners are,” he said.

The issue of rural access also is a significant point in the debate over how nurse anesthetists should practice.

Jenny Schmitt, president of the Oklahoma Association of Nurse Anesthetists, said it is difficult to convince nurses to practice in Oklahoma because most other states allow them to administer anesthesia without a doctor's formal supervision.

It also makes it difficult for those already here to practice in rural areas, because those areas have relatively few doctors willing to take on the liability that comes with supervision, she said.

If changes aren't made, she said, people will be "feeling the consequences," she said.

Out of 77 Oklahoma counties, 32 don't have any anesthesia providers, which makes it impossible for any hospitals located there to offer surgeries or maternity care, Schmitt said. Most nurse anesthetists are supervised by the surgeon or obstetrician they work alongside, though they have no expertise in sedation, she said.

“We work in more of a collaborative nature,” she said. “They're just serving as someone who meets the requirements of the Board of Nursing.”

Dr. Major Cunningham, president of the Oklahoma Society of Anesthesiologists, said he provides extensive oversight to the nurse anesthetists in his practice and meets with them to discuss how to put each patient under. Doctors have more clinical and basic science training, and the best hospitals in the country use anesthesiologists to lead care, he said.

“It comes down to the fundamental management of their health care,” he said. “I wouldn't want my fellow Oklahomans to have less of an opportunity than people in St. Louis or Cleveland or Boston.”

Balancing concerns about access and quality is the “crux” of the issue, said Rep. Chad Caldwell, chair of the House health services and long-term care committee.

Caldwell, R-Enid, said he isn't sure any of the bills will advance as they are, but they will serve as “conversation starters.” Ideally, the various professional groups will come to a compromise, he said.

“I think everybody would benefit from that,” he said.

Meg Wingerter

Meg Wingerter has covered health at The Oklahoman since July 2017. Previously, she lived in Topeka, Kansas, and worked at Kansas News Service and The Topeka Capital-Journal, where she earned awards for business coverage. She graduated from... Read more ›