The health care workforce: In critical condition?
To ease shortages, states consider roles of nurses, midwives
by Kate Tormey ~ December 2010 ~ PDF of Firstline Midwest article »
Nearly 11 percent of the Midwest’s population is medically underserved, according to data provided by the U.S. Health Resources and Services Administration. In other words, about 6.4 million people in this region live in an area designated as having a shortage of health professionals.
In order to bring the region to the desired patient-to-provider ratio of 2,000-to-1, about 2,800 additional primary-care workers are needed in the Midwest. In response to this workforce shortage, federal and state policymakers have been working on ways to better train current workers and to encourage more people to choose professions in the health care field.
This region is not the only part of the country that is being affected by a lack of available medical professionals. The problem is on the rise, health experts say, because fewer students are choosing medical careers — and even fewer are opting to serve in a critical part of our nation’s health system: primary care. The shortage is exacerbated by a U.S. population that is aging and that is racked by increasing rates of obesity, diabetes and other chronic conditions.
This fall, the Association of American Medical Colleges issued a report projecting that there will be a nationwide shortage of nearly 63,000 doctors by 2015.
About 32 million more people are expected to have health insurance coverage under federal health care legislation that takes effect in 2014. As this population becomes insured, the demand for primary care is expected to increase.
A federal program called the National Health Service Corps has been successful in filling about 17 percent of the nearly 20,000 medical positions needed to fill the nation’s workforce shortage. (The program provides loan repayment in exchange for service in designated health professional shortage areas.) At the state level, too, policymakers are working to find ways to strengthen their health care workforces.
States offer financial incentives, such as scholarships and loan forgiveness, for physicians who agree to serve in areas experiencing workforce shortages. One of the additional strategies being used by state policymakers is to shore up the workforce that provides care in conjunction with physicians — such as nurses and midwives.
With 3 million professionals practicing nationwide, nurses make up the largest part of the U.S. health care workforce. A recent report released by the Institute of Medicine said that increasing the number of nurses — and strengthening their training and capabilities— should play a major role in expanding access and quality in the health care system.
Meanwhile, states in this region are also considering the licensure of an additional type of provider — the midwife — which often provides care to women and babies in underserved and rural areas. Midwives who don’t have advanced nursing degrees are currently banned from practicing in most Midwestern states, but some policymakers are considering removing these restrictions.
Inside, we look at the policy actions taken by states in this region to give more autonomy to advanced practice nurses and to allow direct-entry midwives to provide care.
The role of advanced practice nurses
Earlier this year, the Institute of Medicine issued a report calling on policymakers to significantly change the role of nurses in our nation’s health care system. The report was the result of a two-year study by a commission charged with issuing recommendations for the future of nursing.
The report concludes that in order to ease the strain on the health care system (too few health professionals trying to serve too many patients), policymakers should strengthen the role of advanced practice nurses — professionals who have advanced degrees in the field. APNs include nurse practitioners, certified nurse midwives, certified registered nurse anesthetists and clinical nurse specialists.
Each state determines the “scope of practice” for nurses, such as whether they can prescribe medications or practice without the oversight of a physician. One of the main recommendations of the commission was for policymakers to allow APNs to “practice to the full extent of their education and training.”
But some groups, such as the American Medical Association, oppose measures to expand scopes of practice for APNs. They cite patient-safety concerns and stress that policymakers should find ways to train more doctors instead of allowing nurses to perform duties currently performed by physicians.
Nationwide, 15 states allow one type of APN — nurse practitioners — to see patients and prescribe medication independently. Iowa is the only Midwestern state in this category.
According to a case study included in the Institute of Medicine report, Iowa’s model has been successful in helping to improve health care access in the state’s rural areas. APNs in the state must be nationally certified in their specialty and complete continuing education requirements. They must also consult a physician on certain tasks, such as admitting patients to the hospital.
As in many other states, Iowa’s scope-of-practice expansions have occurred largely through regulatory, rather than legislative, changes.
Three other Midwestern states give some APNs more leeway to treat patients on their own.
In Indiana, Michigan and North Dakota, nurse practitioners can see patients independently but cannot prescribe medications without a physician’s approval, according to the Robert Wood Johnson Foundation.
In all other Midwestern states, nurse practitioners are required to have physician oversight to practice medicine, known as a “collaborative agreement” with a medical doctor.
But in general, states are giving more autonomy to nurses with advanced degrees. For example, in 2009, 31 states reported expanding scope of practice for nurse practitioners, according to The Pearson Report.
This year, Kansas legislators considered HB 2447, which would have allowed APNs to practice independently of physicians (including prescribing medication as appropriate) and act as patients’ primary-care health providers. The bill would have adopted uniform licensing criteria developed by the National Council of State Boards of Nursing. It also would have required APNs to carry malpractice insurance and to complete continuing education. HB 2447 did not pass out of the House Health and Human Services Committee.
During North Dakota’s most recent legislative session, lawmakers passed legislation allowing APNs to act as primary-care providers in the state’s Medicaid program. SB 2158, signed into law in April 2009, gives APNs the same rights and privileges as physicians, as long as the nurse is providing care allowed under his or her license.
States seek to expand practice of midwifery
Another idea for states is to increase the responsibilities of another type of health care provider: midwives.
During their pregnancy and labor, many women turn to certified nurse midwives — registered nurses with advanced degrees in the field.
Under Wisconsin law, CNMs must enter into a written agreement with a physician with training in obstetrics. If a patient is identified as having a serious medical issue, the CNM must consult with or refer the patient to the collaborating doctor.
AB 675, introduced in 2009, would have given CNMs more autonomy by eliminating the requirement to have a written agreement with a physician. In addition, CNMs would have been granted hospital staff privileges currently given to physicians — such as the right to admit, treat and discharge patients.
This year, South Dakota lawmakers voted to continue a state law that allows a CNM to practice without a collaborative agreement. (The law was due to expire under a sunset provision.)
Nebraska lawmakers considered three laws this session regarding CNMs. LB 457 would have removed the written practice agreement currently required under state law in order to “increase opportunities for CNMs to practice in a variety of settings and locations across the state.” Another bill (LB 406) would have added CNMs to the list of providers who are permitted to provide care in a hospital.
Under Nebraska law, it is illegal for CNMs to attend a home birth. LB 481, which was considered by lawmakers during the last legislative session, would have allowed CNMs to facilitate an out-of-hospital delivery.
In about half the U.S. states, direct-entry midwives also can provide maternal services. A direct-entry midwife is an individual who has studied the practice of midwifery but is not a registered nurse or physician.
Advocates of expanding the practice of midwifery point out that more women are choosing to have babies outside of hospitals, and that having someone present who is experienced with labor and delivery is better than no one at all. (In 2006, the last year for which data are available, nearly 39,000 births occurred outside of hospitals.) They also argue that by licensing midwives, the practice will be better regulated and that women won’t be forced to choose between unassisted delivery and breaking the law.
But groups such as the American Medical Association and the American College of Obstetrics and Gynecology oppose the practice of direct-entry midwifery. They point out that labor and delivery can lead to serious, life-threatening complications, and that the safest place to have a baby is in the presence of highly trained medical specialists.
Currently, direct-entry midwives, referred to as “certified professional midwives,” are permitted to practice in two Midwestern states: Minnesota and Wisconsin.
This year, at least four states (Illinois, Indiana, Iowa and South Dakota) introduced legislation to certify direct-entry midwives. The bills did not pass.
Indiana’s SB 232 would have created a board, appointed by the governor, to oversee the regulation of direct-entry midwives, who would have to be certified by the North American Registry of Midwives. The legislation would have permitted certified direct-entry midwives to prescribe certain medications and would have made it a Class A misdemeanor to practice without a license.
Illinois’ Home Birth Safety Act (HB 226) also called for the licensure of midwives and set out specific medical procedures that they would be permitted to perform. For example, midwives would be able to administer oxygen, apply antibiotic ointment to a newborn and deliver certain medications designed to prevent hemorrhage in the mother.
Iowa’s SF 2070 would have set up a seven-member midwifery board to develop and enforce conditions of licensure, such as training in cardiopulmonary resuscitation and newborn care. People licensed to practice in Iowa would be allowed to use the initials “LM,” for “licensed midwife.”
South Dakota policymakers considered SB 107, which would have provided biennial licenses to midwives who complete certain training and pass a federal criminal background check. Under the bill, the state could not require midwives to receive a nursing degree or work under the supervision of a physician.
Source Guide
- American Academy of Nurse Practitioners »
- American College of Nurse-Midwives »
- American Nurses Association: Scope of Practice »
- Initiative on the Future of Nursing »
- National Association of Certified Professional Midwives »
- National Council of State Boards of Nursing »
- Midwives Alliance of North America »