Oregon's board of nursing certainly shows no fear in breaking new ground. Faced with the passage of state legislation, Oregon's board of nursing stepped up to the plate to deal with the nuts and bolts of adopting a model of prescriptive authority for the clinical nurse specialists. Oregon's new legislation, propelled by the APRN Consensus Model's provision for autonomous prescriptive privilege for all four APRN roles-clinical nurse specialist (CNS), nurse practitioner (NP), certified registered nurse anesthetist (CRNA), and nurse midwife (CNM), sets the stage for a new chapter in health care.
BEGIN WITH THE END IN MIND
Nurses, both registered nurses and APRNs, along with physicians, psychologists, pharmacists, and frankly all health care providers, should be able to practice to the full extent of their education and training in order to meet our nation's public health challenges. Without this, we have a huge challenge finding care as our nation's population ages. The public wants providers they can rely on. Oregon is making great strides in achieving this goal through its recent work related to prescriptive authority for the CNS-one of the important APRNs.
The Oregon board wanted a competency-based approach to granting prescriptive authority to CNSs, the same approach already in place for other APRNs. Competency-based means candidates for prescriptive authority meet predetermined clinical competency based on education and experience. Because CNM and CRNA received prescriptive authority in the late 1970s, the NP, the group most recently granted prescriptive authority, provided a contemporary template for creating competency-based assessment of CNS readiness for prescriptive authority.
CREATING COMPETENCY DETERMINANTS
A board-appointed task force included CNSs, NPs with current prescriptive authority, and a pharmacist. To determine necessary competencies, the task force and board staff did their homework. They analyzed NP curricula and consulted with NP faculty and identified the curricular content addressing NP competency for prescriptive authority including supervised clinical experiences. In the end, they determined that, in Oregon, NP programs had 150 prescribing-specific content and clinical hours embedded across the curriculum. Because NP education prepared successful prescribers, the task force concluded that prescribing competencies for CNSs could be achieved with similar educational requirements.
Why not 100 hr or perhaps why not 200 content and clinical hours? Because by using NP education as a template for achieving competency-based prescribing and because 150 hr of content with supervised clinical experiences was adequate for NPs, it likewise would be adequate for CNSs. To date, Oregon's model for granting CNSs prescriptive authority has worked.
MOVING FORWARD
While autonomous prescriptive privilege is not new to APRNs, it is, in many states, new to the CNS role. Following posting of the new regulations in Oregon, a group of CNSs pursued autonomous prescriptive privilege. They completed the new educational requirements including a supervised practicum and have been practicing safely, with no reports of medication errors or problems related to prescribing. This outcome demonstrates the effectiveness of the new regulations.
Opposition against prescriptive authority for health care providers other than physicians often argues that nonphysician providers will injure patients with inappropriate prescribing. This argument has proved to be untrue with the new APRN prescribers in Oregon. Oregon's model created competencies for CNSs and implemented a plan that followed a proven process for NPs and other APRNs. In the end, these changes allowed patients access to a greater scope of health care services. There are savings in the health care system that can be accrued; the prescribing CNS can save time and money by not needing the patient to make another visit to a physician or other prescriber in order to get needed prescriptions.
WHY NOW?
Prescriptive privileges allow the provider to prescribe more than just medications. Nurse prescribers such as CNSs often prescribe nonpharmacological treatments and devices such as durable medical equipment, items such as walkers, elevated toilet seats, therapeutic mattresses, wound care products, and consultations to other providers-physical therapists, for example. Nurse prescribers may also recommend over-the-counter products and solutions for common problems to protect patients from dangerous interactions between prescribed and over-the-counter medications and nutritional supplements. The Oregon model purposefully included pharmacological and nonpharmacological content in the prescribing educational requirements. This expanded focus of education reinforces CNS practice and gives the public greater access to expert health services. Patients in Oregon can feel confident that all nurse prescribers, including CNSs, are adequately prepared for prescriptive authority.
LESSONS LEARNED
What's good about Oregon's approach? Oregon's board of nursing did due diligence to use what was working as a template for expansion of CNS practice. A thoughtful and deliberate task force relied on the experience of NP educators and clinicians to build competency-based prescriptive authority regulations for CNSs.
Oregon is a leader-But will other states follow? The increasing demands of the public for more access to high-quality health care should drive policy makers to ensure that health care providers, including all APRNs, are working to the full extent of their education and practice. Passage of the APRN Consensus Model offers an opportunity for the states to step forward as leaders, such as Oregon. APRNs have been successfully practicing for more than 50 years, many with prescriptive authority. State regulators needing to add prescriptive authority for CNSs should look to those states that have successfully added prescriptive authority as their model. The Oregon board's work to add prescriptive authority for CNSs should be a model for others.
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