Bill Allows Specialized Nurses to Practice Independently

In October 2014, Aila Accad’s 35-year-old son passed away in a West Virginia intensive care unit.

“It was the advanced practice nurse who was at his side, filled out the paperwork when he passed, and yet the funeral director, it took an extra three weeks for him to get a signature on that death certificate due to the fact that the physician wasn’t available,” Accad said.

The issue was that back in 2014, West Virginia law stated that advanced practice nurses, including nurse practitioners, were not authorized to sign vital records.

“We couldn’t complete the ashes and so on until we could get the death certificate to have the cremation – it was just very painful,” said Accad. “I don’t know how to describe it.”

The Role of Nurse Practitioners

Nurse practitioners like the one treating Accad’s son, have advanced degrees and often serve as primary care providers. Until now, these nurses were also required to maintain written “collaborative agreements” with physicians, which meant the doctors had to review the nurses’ patient records and sign off on prescriptions.

But a new law will take effect June 10 that allows West Virginia advanced practice nurses with three or more years of experience to start caring for patients without physician oversight.  

Laure Marino is a Charleston-based nurse practitioner who has worked under a collaborative agreement for almost 20 years. She says finding a physician to collaborate with can be difficult – especially in rural areas.

“Most states, West Virginia is one of them, with small town pockets where there are no medical providers have nurse practitioners in them,” she said. “It’s super hard to recruit physicians into, say, Welch, West Virginia.”

So the West Virginia Nurses Association has been fighting to remove the collaborative physician requirement – saying that doing so will allow nurse practitioners to provide care for these rural areas.

But Coy Flowers, of the West Virginia State Medical Association, is not so sure.

“The thing that we at state medical want to do is make sure is that when advanced nurse practitioners say that the point of their bill is to go to underserved areas, they actually go to underserved areas,” he said.  “Whenever we actually tried to get that put into the bill they were very resistant and so we are going to make sure that over the course of the months and years that we do quality checks to make sure those individuals go to those areas that need care.”

They will do that by creating a joint advisory council of four doctors, six nurses, a pharmacist and a public health officer to help oversee the growing nurse practitioner industry. Every two years, the committee will review how the system is working.

Compromises and Concerns

Another compromise is that the nurses still won’t be allowed to independently prescribe schedule II narcotics – the drugs most associated with addiction.

The state medical association is concerned that nurses don’t have the training or expertise necessary to practice independently. Laure Marino says there is no evidence for that.

“They promote that as this is an unsafe model except you can’t prove that,” she said. “That across the country it hasn’t been proven that [the] nurse practitioner model is unsafe or that we have worse outcomes.”

In fact, a 2010 report from the Institute of Medicine called for states to remove many restrictions on nurse practitioners. These nurses can currently practice independently in 21 states.

Marino says West Virginia’s new law doesn’t mean nurses will stop working with doctors.

“When I’m at the end of my scope of practice, and I know exactly where that is, I know what I can and can’t do – and say ‘Here, I’m going to ask my physician colleague to see you, because this is at the end of what I can do for you,’” she said.

Under the new law, nurse practitioners will be allowed to prescribe most medications and sign vital records … like the death certificate for Aila Accad’s son.

There are currently about 1,700 nurse practitioners in West Virginia. Advocates hope the change will help keep them in the state and maybe even attract new providers.

Appalachia Health News is a project of West Virginia Public Broadcasting, with support from the Benedum Foundation.