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Advanced practicing nursing: Collaboration versus Supervision
Advanced practice nursing is a profession which has existed since the primary care physician shortage of the 1960s (Buppert, 2008). At that time it was envisioned that APNs would make nursing and medical diagnoses and treat patients with medical therapeutics, ordering pharmacotherapeutics and other treatments (Buppert, 2008). In fact, since the 1960s physicians and APNs have worked together in an effort to manage patients and facilitate quality health outcomes (Clarin, 2007). Although the various nursing specialties situated under this umbrella term have grown to include certified nurse midwives (CNMs), certified nurse anesthetists (CNAs), certified nurse specialists (CNSs) now referred to as psychiatric CNSs or psychiatric nurse practitioners (PsychNPs) and nurse practitioners (NPs) (Massachusetts Health And Human Services, 2013) in Massachusetts, those primary aforementioned responsibilities have not changed, but expanded and collaboration continues to be an integral, yet heavily debated aspect of this profession. Today there is still misinterpretation and debate over the role of physician-advanced practice nurse collaboration and physician supervision in the ability of the advanced practice nurse to carry out his/her responsibilities as quality health care providers.

Collaboration
Collaboration, simply defined, means “to work jointly with others or together especially in an intellectual endeavor” (Meriram-Webster, 2013). K. Palmer  Simple as it sounds, it is increasingly confusing interpreting APN-physician collaboration as defined at the federal and state level. Collaboration is defined at the Federal level as a “ process in which a nurse practitioner works with a physician to deliver health care services within the scope of the practitioner's professional expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanism as defined by the law of the State in which the services are performed. Citation:42U.S.C.S.Ş1395x(aa)(6) (Bupert, 2008). K. Palmer

There are currently 19 states that require collaboration: Alabama, California, Connecticut, Delaware, Georgia, Indiana, Kansas, Louisiana, Massachusetts, Missouri, Mississippi, Nevada, New York, Ohio, Pennsylvania, Texas and Wisconsin (Phillips, 2012). K. Palmer The board of nursing in each state regulates the process by which the APN-physician collaboration should be conducted and administered. The specifics of the collaboration vary widely among the states. APNs are mandated to have collaboration with at least one physician; however, many healthcare care professionals (e.g., chiropractors, optometrist, podiatrist, psychologists, physical therapists, acupuncturist, audiologists, and registered nurses) are not required to have a physician collaboration. The mandate for professional collaboration for APNs limits their scope of practice relative to other healthcare professionals within the healthcare system.ros

In Massachusetts the role of collaboration between APNs and physicians extends from top down. The board of nursing, in collaboration (or in conjunction with) the board of medicine, determine the regulations governing the APN scope of practice (Citation: MASS. ANN. LAWS CH. 112, 80B in Buppert, 2008). At the Massachusetts state level collaboration is a process and a relationship allowing the APN to work with various health care professionals in an effort “to deliver health care within the scope of various professionals’ expertise and lawful practice, and with medical direction and appropriate supervision as provided for in the guidelines required by 2.44 CMR 4.22, 4.23 and 4.25. However, s/he are limited by 2.44 CMR 4.00.” (Secretary of the Commonwealth’s State Publications and Regulations Division, 2011).

In collaboration with supervising physicians, APRNs develop written guidelines under which they are required to practice. These guidelines designate a specific physician who is available to the nurse to provide medical direction. Within an institution, nursing and medical administrative staff, or the BON if there are no administrative staff, must review and approve guidelines (Phillips, 2012). S. Loy

Supervision
Collaboration differs from supervision. The terms are, however, often used interchangeably to indicate some degree of involvement is required. Inherent within the federal definition of collaboration is a mandate for each state to stipulate and define the requirement of physician supervision of a nurse practitioner. Supervision specifies how physicians will delegate responsibilities to the APN direct medical care, and determine the scope of practice of the APN. Depending on the state, collaboration may or may not include a requirement of APN supervision by a physician. Supervision which is productive should, however, include collaborative interaction between the APN and the supervising physician.

The definition of supervision varies from state to state. For example Massachusetts defines supervision according to the requirements of the supervising physician who holds an “unrestricted full license in Massachusetts who has completed accredited medical education or is board certified in the nurse’s area of speciality, or has hospital admitting privileges in his/her specialty area; is licensed by the U.S. Drug Enforcement Administration and the Massachusetts Department of Public Health to prescribe (written or orally); develops and signs mutually agreed-upon guidelines with the nurse engaged in prescriptive practice; and reviews and provides direction for the nurse’s prescriptive practice at least every three months or passes the buck to another qualified physician” (Secretary of the Commonwealth’s State Publications and Regulations Division, 2011). Supervision in this manner limits the knowledge and experience of the APN.

Significant strides have been made by many states in regard to APNs gaining sole authority for scope of practice with no requirements for direct physician supervision. As of 2010, 24 states reported that an APN scope of practice is regulated solely by the board of nursing with no statutory or regulatory requirements for physician direction, supervision, or collaboration. In 20 states, the board of nursing has sole authority for the scope of practice of APNs, but there is a requirement for physician collaboration. APRNs can prescribe, including controlled substances, independent of physician involvement in 14 states; in 35 states APNs can prescribe, including controlled substances, with some degree of physician involvement (Phillips, 2010). All states now allow some form of prescriptive authority (Pearson, 2002). (Denisco and Barker, 2013, p. 235) ros

Massachusetts (MA) requirements for APRNs
In Massachusetts the title of APNs (or advanced practice registered nurses, APRNs) covers the following roles:  Nurse Practitioner, Nurse Midwives, Nurse Anesthesiologists, and Psychiatric CNS (Massachusetts Health And Human Services, 2013). S. Loy  Advanced practice nurses work jointly with physicians and other healthcare providers, such as physical therapists, registered nurses, psychologists, etc. to provide comprehensive, safe, and quality care to patients. When multiple disciplines are involved in delivering care, the nature of the collaboration is facilitated through three types of relationships: 1) multi-disciplinary, i.e., functioning within the boundaries of each discipline or area of expertise to solve problems; 2)  interdisciplinary, i.e., functioning through coordinating the linkages between disciplines to develop reciprocal exchanges such as, sharing of information, developing new methods, perspectives and approaches to common issues and concerns; and 3)  trans-disciplinary (i.e.,  functioning across disciplines and beyond responsibilities of roles, to include scientists, non-scientists in efforts to develop (Newhouse. And Spring, 2007, p. 309).,  Collaborative practice, should not be a requirement solely for APNs, but interdisciplinary (or ideally trans-disciplinary) collaborative practice should be a standard goal for all healthcare professionals in order to promote high quality and cost-effective care (Newhouse. and Spring, 2007, p. 314). ros

1. Nurse Practitioners
The Massachusetts Department of Health and Human Services considers Nurse Practitioners as nurses engaged in prescriptive practices and practicing in the expanded role. The “expanded role,” as outlined by the DHHS is an important concept for the scope of practice of advanced nursing professions. It is defined as the activities of a Registered Nurse with the additional employment of advanced skills in evaluation, diagnostics and treatment, and management of therapeutic regimens for chronic conditions. Nurse Practitioners, Nurse Midwives, Psychiatric Nurse Mental Health Clinical Specialists, and Nurse Anesthetists all practice within this definition (DHHS, 2013).

Contrary to popular belief, Nurse Practitioners are authorized to practice across specialities. This is to say that the Massachusetts DHHS mandates that nurses practice within their specific role (NP, Midwife, Anesthetist, Psychiatric), but  are not limited to practicing within their specialty area (Family, Women’s Health, Adult/Gero). The aforementioned specialty certifications are meant to demonstrate a level of competency with a specific population. If a Nurse Practitioner decides to practice outside of his or her certified specialty, he or she should consider whether he or she is competent to provide services to the population and has a collaborative relationship with a supervising physician with the credentials to care for the population (DHHS, 2013). -AJC

3. Certified Nurse Midwives
In Massachusetts, certified nurse-midwives (CNMs) are required to “practice within a healthcare system and have clinical relationships with obstetrician-gynecologists that provide for consultation, collaborative management or referral” but there is no requirement for supervision by a physician (An Act Relative to Enhancing the Practice of Nurse-Midwives, 2012). In this way, the regulation of CNM practice differs from that of other APNs/APRNs in Massachusetts.

This state of affairs represents a fairly recent change. “An Act Relative to Enhancing the Practice of Nurse-Midwives” was signed into law in February of 2012. It replaces language requiring CNMs to practice “as a member of a health care team which includes a qualified physician… [who has] admitting privileges in a hospital licensed … for the operation of maternity and newborn services” and allows CNMs prescriptive power and the authority to order and interpret tests. These latter responsibilities are crucial to allowing CNMs to practice without supervision in their entire scope of practice.

Physician groups in Massachusetts opposed the change in law, criticizing the expanded authority to order and interpret tests (Zimmerman, 2012); removing this authority would effectively require physician supervision and thus prevent independent practice by CNMs. Another criticism was that by requiring clinical relationships with obstetrician-gynecologists, the law would somehow prevented CNMs from collaborating with family practice doctors who provide care obstetric and gynecology care (Zimmerman, 2012). This is a specious argument; the law places no limits on collaboration between healthcare professionals (An Act Relative to Enhancing the Practice of Nurse-Midwives, 2012). Of course, not all physicians opposed the change in regulations, and the support of a key physician advocate was recognized by the Massachussetts Affliate of the American College of Nurse-Midwives (MA ACNM) (“Partnership proves successful,” 2012).

According to Joanna King, director of government relations at ACNM, 45 states, including Massachusetts, allow CNMs to practice without physician supervision (Barr, 2012). It should be noted that midwives who are not APRNs, such as certified professional midwives and lay midwives, are not covered by this legislation.

4. Certified Nurse Anesthesiologists
In Massachusetts, similar to other APRNs. nurse anesthesiologists are required to work in collaboration with a physician who meets the The Board of Registration in Medicine’s regulation 243 CMR 2:10. Nurse Anesthesiologists must work with alongside a physician or in collaboration with another anesthesiologist, to provide care for patients. Because anesthesiology is such a specific field and there are limited numbers of direct providers, the board expanded supervision to provide more opportunities for Nurse Anesthesiologists to practice. In 2011 the Board approved physicians practicing in a speciality other than anesthesiology to act as supervising physicians for Nurse Anesthesiologists in Massachusetts. Typically when a Nurse Anesthetist is working with physicians other than anesthesiologists, they work with the surgeon, dentist, or other clinicians performing the procedure requiring the patient to be sedated. (Commonwealth Of Massachusetts 2013). s loy

The future of APRNs: Collaborating or Supervised
Collaboration began with the inception of the NPs role in the 1960s, however barriers continue to exists, which is problematic, as “the main goal of NP-physician collaborative team are positive patient care outcomes” (Clarin, 2007, p.2). Today Massachusetts is one of nineteen states where the board of nursing is the only organization authorized to define the scope of practice, which has a requirement of physician collaboration, not supervision, for nurses in the expanded role (Phillips, 2012). K. Palmer  Research shows that collaboration, not supervision, results in greater patient satisfaction, improved patient outcomes and lower hospital costs (Jones and Fitzpatrick, 2009).

The “Consensus Model for APRN Regulation” was developed during 2004-2008 by a collaborative group that included nursing accreditation, certification, and membership organizations and has been endorsed by 47 national nursing and nursing-related organizations (ACNM, 2013). It is aimed at promoting common definitions and regulation for APRNs throughout the United States. It strongly recommends that APRNs be licensed as “independent practitioners with no regulatory requirements for collaboration, direction or supervision (APRN Joint Dialogue Group, 2008, p. 13).” Theoretically speaking a collaborative mandate for ANPs is a reasonable requirement, but it is one-sided and may create a barrier to nursing practice. Although all healthcare professionals share a common goal of quality patient care, the disciplines are based on different training models, and therefore, have different perspectives. This is evident when considering the ANP-physician collaboration. The differences in training, as well as “the lack of understanding of the ANP’s scope of practice, prescribing and reimbursement … creates an obstacle to any other profession attempting to understand the NP role” (Clarin, 2007, p. 540). Clarin (2007) identifies the barriers to effective ANP- physician collaborative care as: 1) lack of knowledge of NP scope of practice; 2)  lack of knowledge of NP role; 3) poor physician attitude; 4) lack of respect; 5) poor communication;  and 5) patient and family reluctance to accept NP care (pp,539-546). Similarly, these barriers could limit the effective development of a productive supervisory relationship between and ANP and physician. The environmental and organizational context may determine whether an ANP can determine with whom they collaborate or by whom they are supervised. It is the state, however, that ultimately determines whether collaboration and/or supervision is required for an ANP to legally practice.