While the dialysis treatment hasn’t changed significantly in the last few years, how the treatment is provided is undergoing transformation. Medicare, the primary payer, is demanding adherence to quality measures. Integrated care is becoming a new model. And the roles of the dialysis team are changing as a result.

This month, in recognition of the National Kidney Foundation Spring Clinicals and American Nephrology Nurses Association annual conferences, we take a look at the expanding roles for nurses and social workers. This ongoing series will also look at how the roles for renal dietitians and patient care technicians are undergoing change.

––Mark E. Neumann

Nursing: rules on authority vary by state

Nursing’s role has always been influenced by state regulation. Recently, two states––New York and Minnesota––looked at the authority that nurses have in the health care setting and made changes.

Minnesota:  new regulations took effect Jan. 1 which grant advanced practice registered nurses with one year’s experience more authority for prescribing and independent practice. The state, however, is adding a more stringent credentialing process. The law’s supporters, such as the Minnesota Association of Nurse Anesthetists, praised it for removing barriers and increasing access to care.

New York: Nurse practitioners with over 3,600 hours of clinical practice no longer are required to have a written collaborative agreement with a physician, nor will they be required to submit patient charts to a physician for review, according to the new state law. Instead, experienced practitioners will only be required to have an established relationship with a physician or hospital for referral or consultation.

The new rules are a part of the Nurse Practitioner Modernization Act, signed into law with the state’s budget in April 2014.

New York will join 19 other states and the District of Columbia that have passed similar legislation, creating what the American Association of Nurse Practitioners calls “full practice” environments in which regulations do not reduce or restrict nurse practitioners’ practices. But the law was opposed by the Medical Society of the State of New York, which said in hearings that use of nurse practitioners does not lower costs and that patients of nurse practitioners tend to have higher utilization rates. “We can fathom no instance where the quality of patient care can reasonably require the elimination of the written practice agreement and protocols,” the Association said.

NN&I asked Debra Castner, RN, APRN, CNN, the facilitator for the Advanced Practice Nurses Special Practice Network of the American Nephrology Nurses Association, and a nurse practitioner in Forked River, N.J., on how this tug-of-authority still remains between nurses and nephrologists.

Castner: Why are we having the same conversation and disagreements over and over again regarding scope of practice for the advanced practice registered nurse (APRN) role? Scopes of Practice (SoP) regulations were intended to assure the public that professionals are providing safe care. Yet some physician groups are trying to use limits on SoP as a way to prevent access to competent, cost-effective care. In this situation, it is being used to control APRNs and the public’s access to care.

“It is unfortunate that we continue to hear the same unfounded dialogue from some physicians. There are so many patients who cannot access providers due to geography, reimbursement, or lack of choice. Some specialties, such as nephrology, clearly do not have enough physicians to provide care.

“Research shows that APRNs provide comparable––and often times superior — care to our patients. The Institute of Medicine report, “The future of nursing: Leading change, advancing health,” presents opinions from experts in many fields who support that federal and state barriers be removed to allow APRNs full practice authority (Newhouse et al, 2011; August, 2011, FTC, 2014).

Twenty-two states and Washington, D.C., allow nurse practitioners to diagnose and treat without physician involvement. Twenty-four states require, in writing, a description of the APRN/MD relationship, and four states ask for an informal relationship that doesn’t need to be documented. These ‘relationships’ form no purpose for improvement in patient care other than setting up restriction of trade. Patients are doing well in the states with no restriction.

Though I work in New Jersey, what happens in other areas affects me as well. I work with six nephrologists and, as a team, we often brainstorm on how to best approach a patient problem and collaborate in a natural way that makes sense to our practice and patients.
Advantages to allowing APRNs to work in full practice authority as they have been educated to do include:

  •     Improved access to care
  •     Addressing the primary care shortage
  •     Streamlining and delivering care efficiently and safely
  •     Decreased cost of care
  •     Protecting patient choice
  •     Removing delay in care
  •     Preventing sudden interruption in care if a physician decides to not maintain an agreement with an APRN due to death, retirement, etc. (ANA, 2014; NGA, 2012)

Let’s use our energies to develop programs that help patients. Patient needs should come first, not the financial or emotional preferences of physicians or any one group of health care professionals.

We all have talents and knowledge to bring to patient care. It’s time for all health care providers to be able to work in an environment overseen by their professional networks as a team.


American Nurses Association, 2012.  Policy Makers on the Effective Utilization of Advanced Practice Registered Nurses. http://www.nursingworld.org/EspeciallyForYou/AdvancedPracticeNurses/Health-Care-Reform-and-the-APRN/Policy-Makers-on-the-Effective-Utilization-of-APRNs.pdf. Accessed 1/11/2015.

Federal Trade Commission March 2014, Policy Paper: Competition and the regulation of advanced practice nurses. www.ftc.gov/policy/reports/policy-reports/commission-and-staff-reports

Institute of Medicine, 2010. Committee on the Robert Wood Johnson Foundation
Initiative on the Future of Nursing, at the Institute of Medicine;

The Future of Nursing: Leading Change, Advancing Health. http://www.nap.edu/catalog/12956.html. Accessed 1/11/2015
National Governors Association, 2012. “The role of the nurse practitioner in meeting increasing demand for primary care. Health Resources and Services Administration (HRSA) Grant # 110-450-4504.

Newhouse R. et al. Advanced Practice Nurse Outcomes. Nursing Economics$ Sept/Oct 26(5) 2011.

New Jersey State Nurses Association, 2014. Full Practice Authority. http://apnnj.wildapricot.org/Resources/Documents/WP%20II%20Final%20corrected%20PDF%20ctt.pdf. Accessed 1/10/2015.