Nebraska LB 107: How Should Employers of APRNs Respond?
The Nebraska Legislature approved, and, on March 5, 2015, the Governor signed Legislative Bill 107, which amends the Nebraska Nurse Practitioner Practice Act, governing advance practice registered nurses (APRNs), to be effective June 5, 2015. The stated purpose of the Bill includes “to eliminate requirements for integrated practice agreements for nurse practitioners.” Employers of APRNs, and collaborating physicians who have entered into integrated practice agreements with APRNs, may appropriately wonder whether they should keep the old integrated practice agreements in place.
The Nebraska Department of Health and Human Services Division of Regulation and Licensure has long recognized APRNs as independent practitioners, despite statutory language referring to the collaborating physician’s supervision of the APRN. The amendments resulting from LB 107 further the independence of APRNs in Nebraska:
- APRNs are now qualified for licensure if they submit to the Department:
a. A “transition-to-practice” agreement OR
b. Evidence of completion of 2000 hours of practice as a nurse practitioner completed under a transition-to-practice agreement, collaborative agreement or integrated practice agreement, through independent practice, or any combination of such agreements and practice, as allowed by Nebraska or another state where the APRN practiced. - The requirement of an ongoing integrated practice agreement with a collaborating physician is eliminated.
- The historic requirement of a collaborating physician in an ongoing relationship has been replaced with the requirement of a supervising provider, for the initial 2000 hours of practice as an APRN.
- The supervising provider may be a licensed physician or a nurse practitioner which allows a relationship with either a physician or a nurse practitioner who has 10,000 hours of practice as a nurse practitioner.
- The supervising provider is responsible for supervision of the nurse practitioner to ensure the quality of health care provided to patients. No such direct responsibility fell upon the collaborating physician under the historic statutes.
- The statute expressly states that the nurse practitioner and the supervising provider will have joint responsibility for the delivery of health care to a patient based on the scope of practice of the nurse practitioner and the supervising provider. However, each supervising provider and the nurse practitioner will be responsible only for their own professional decisions in managing the health care of patients through consultation, collaboration, and referral.
The amended statutes allow APRNs to function without a supervising practitioner after completion of 2000 hours of practice as described above. Note that the statutes establish a supervisory responsibility in the “supervising provider” that creates potential liability for deficient supervision. To the extent that this was not a responsibility imposed on collaborating physicians, it makes sense that any new transition-to-practice agreements between ARPNs and supervising providers be for a term no longer than the required 2000 practice hours required by law. This will have the effect of avoiding any unnecessary extension of potential liability for deficient supervision.
For any APRN who had begun but not completed the 2000 practice hours prior to these amendments, it would make sense to prepare a transition-to-practice agreement clarifying that the supervising relationship terminates upon completion of the 2000 hours.
For APRNs who are currently subject to integrated practice agreements, those can be terminated, amended or left in place depending upon their contents and the employer’s wishes:
- There is no longer a requirement of an integrated practice agreement under the APRN licensure statutes.
- However, it is likely that employers of APRNs will want to state clearly the collaborative relationship that will exist after the “transition-to-practice” during the initial 2000 practice hours.
Employers may insist upon an ongoing collaborative relationship to include required consultations based on patient acuity and/or test results, as well as standards for medical record documentation, medical record review and physician countersignature. As an example, critical access hospitals are required under Medicare Conditions of Participation to comply with specific medical record review standards. If these requirements or other employer-specific standards of performance are not set forth in employer policies or a written employment agreement with the APRN, the employer may wish to amend the existing integrated practice agreement or leave it in place as is, if it remains relevant and consistent with LB 107 as described above.
It is anticipated that professional interaction between employed APRNs and collaborating physicians will continue as in the past. The new requirement of a supervising provider for the transition-to-practice (initial 2000 practice hours) and the elimination of an ongoing integrated practice agreement will not change the desire of employing physicians and physicians groups or employing institutions to have a meaningful and effective collaborative and consulting relationship between APRNs and physicians.
For those employers that have entered into a written agreement with their employed APRNs, these agreements might refer to the requirement of a collaborative agreement as a condition of employment. Depending upon the employer’s approach post-LB 107, any such employment agreement may need amendment: a. to refer to any new or amended collaborative agreement, or b. if the collaborative agreement was terminated, to delete any reference to it.
Employers of APRNs may find it appropriate to draft for newly hired APRNs with less than 2000 practice hours, a transition-to-practice agreement that terminates the supervisory relationship after 2000 hours, but continues with regard to collaboration and imposes standards for that collaborative relationship, such as medical record review.
For institutional providers, it will be important to discuss these issues with the physicians who serve as collaborating physicians for APRNs, so that they understand the changes in legal standards, and can better monitor the ongoing relationship so as to avoid assuming liability for the APRNs supervision unnecessarily.