A report on the future of nursing in the United States that was released by the Institute of Medicine, or IOM, on Oct. 5 has drawn criticism from the AAFP because it does not adequately address the training and certification nurses will need to assume greater responsibilities in the health care system.
The report is woefully inadequate in the area of patient safety, according to AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas.
"I have not read anywhere in the report recommendations about standard training or standard certifications of competencies, which are embedded throughout physician training," he said in an interview with AAFP News Now.
"That is a major drawback of the report," said Goertz. "The report simply says 'Do away with all blocks of full scope of practice. Do away with anything that prohibits an advanced nurse practitioner from having direct patient care or direct licensing.' It doesn't mention anything about how to maintain competencies or ensure patient safety."
The IOM report, "The Future of Nursing: Leading Change, Advancing Health(www.iom.edu)," was sponsored by the Robert Wood Johnson Foundation. It calls for eliminating scope-of-practice barriers and allowing advanced practice nurses to practice to the full extent of their education and training. It also asks Congress to expand the Medicare program to include coverage of advanced practice nursing services "that are within the scope of practice under applicable state law, just as physician services are now covered."
State legislatures, for their part, should reform scope-of-practice regulations to conform to the National Council of State Board of Nursing advanced practice registered nurse model roles and regulations, according to the report. At the same time, CMS should "amend or clarify the requirements for hospital participation in the Medicare program to ensure that advanced practice registered nurses are eligible for clinical privileges, admitting privileges and membership on medical staff."
In response to these recommendations, Goertz said, "Patient care is way too important to decide to do away with various recommendations and certifications and allow it to be done without some sort of standardization and competency measurements."
The AAFP agrees that nurses should practice to the fullest extent of their nurse training, said Goertz. However, he added, the basic educational preparation for the largest proportion of registered nurses is an associate's degree. Forty percent of nurses received their basic nursing education in an associate's degree program, he noted. About 30 percent attended diploma programs and 30 percent attended baccalaureate programs.
Among registered nurses who obtained their initial nursing education during the past five years, 55.4 percent graduated from an associate's degree program and 38 percent graduated from a baccalaureate program; 6 percent graduated from diploma programs.
"By comparison, primary care physicians have four years of postgraduate education in medical school and an additional three to four years of residency training," Goertz said.
He also criticized the report for focusing too much on advanced nursing practice.
"Nursing, as a whole, is not just about advanced practice nursing," said Goertz. "In my community, the largest need from a nurse staffing standpoint is not advanced nursing degree people but bedside nursing -- nursing that works side-by-side with teams of practices in the area."
"The report is an obvious promotion of advanced nurse practitioners," he added.
According to Goertz, the AAFP has always maintained that nurse practitioners should not function as independent health care professionals -- that they should, in fact, only function in an integrated practice arrangement under the direction and responsible supervision of a practicing, licensed physician.
The AAFP also points out that state nurse practitioner laws provide physicians with the authority to delegate the performance of certain medical acts to nurse practitioners who meet specified criteria and who function under certain legal requirements for supervision. However, it is the responsibility of the physician to ensure that appropriate directions are given, understood and executed.