Florida Nurse Practitioners Gain Full Practice Authority

Florida Nurse Practitioners Gain Full Practice Authority

After years of opposition from the Florida Medical Association and seven years of passing in the state House but not in the Senate, the bill to allow Floridian Nurse Practitioners full practice authority has finally been passed. Starting in July 2020, advanced NPs who have accumulated at least 3,000 hours of experience under physician supervision will have the right to independently operate primary care practices in Florida without an attending doctor. To qualify, they will also have to complete minimum graduate level course work in differential diagnosis and pharmacology.

Under the new law, signed on March 11 by Florida Governor Ron DeSantis, qualified NPs will be able to independently practice family medicine, general pediatrics and general internal medicine. House Speaker Jose Oliva, who made the bill a priority, praised the bill’s passage, saying, “Freeing (advanced practice registered nurses) of the red tape that has historically stopped them from working to the full extent of their education and training will immediately improve access to quality care for all.”

In a compromise between the Florida House and Senate, while the bill grants full practice authority to advanced NPs, it does not cover physician assistants or certified registered nurse anesthetists. Calling the bill “a good first step,” the Florida Association of Nurse Anesthetists commented, “Although we are disappointed that the legislation did not include certified registered nurse anesthetists … we are pleased that some of Florida’s (advanced practice nurses) will be able to practice autonomously.” The group added, “Passage of this bill demonstrates Florida’s commitment to modernizing the way health care is being delivered in our state by ensuring that Floridians have full access to health care, particularly in rural areas that are often underserved.”

Florida Republican Representative Cary Pigman, a physician who has filed the bill multiple times in the state House, noted, “Beyond the classroom, the data from statewide experiments across the nation demonstrate without a doubt that nurse practitioners are highly skilled, highly trained, and highly eager to care for patients independently.” Pigman added, “Advance practice professionals achieve higher marks in patient outcomes, patient satisfaction, and they spend more time actually talking to patients.” For more details, visit here.

Health Equity: What Does it Mean for Nursing?

Health Equity: What Does it Mean for Nursing?

According to the Robert Wood Johnson Foundation, “Health equity means increasing opportunities for everyone to live the healthiest life possible, no matter who we are, where we live, or how much money we make.”

Health equity is of vital concern to nurses, whose daily work as patient educators and healthcare practitioners is influenced by interrelated factors such as:

  • Health Disparities
  • Social Determinants of Health
  • Cultural Competence
  • Social Justice

With the help of Drs. Janice Phillips (PhD, RN, FAAN) and Margaret Moss (PhD, RN, JN, FAAN), editors of the upcoming book Health Equity and Nursing, DailyNurse is looking at these basic concepts and exploring the role of health equity considerations in the day-to-day work of nursing.

Health Disparities

“Health disparities” refers to the inequalities in health and health care between different population groups. There are widespread inequalities that impinge upon public and individual health and well-being. Among the patients most directly affected are members of ethnic minorities, immigrant and low-income families, and people living in areas far from accessible care. According to a 2018 study, the US spends an estimated $93 billion in excess medical costs per year due to racial disparities alone.

DailyNurse: Can nurses help to overcome health disparities that affect their patients?

Janice Phillips: “It’s been over a decade since nurse leader Dr. Gloria Smith wrote a commentary “Health Disparities: What Can Nursing Do?’ In her commentary, Dr. Smith encouraged nurses to promote nurse managed primary care and focus on changing local, state and national policies to help address health disparities.

In recent years however, we have expanded our efforts to reduce health disparities to include an emphasis on achieving health equity. Healthy People 2020 defines health disparities as a type of particular difference in health status that is closely linked with economic, social, or environmental disadvantages. Populations that experience greater social and economic hardships are more likely to experience health disparities.

In contrast, health equity is a principle that underscores a commitment to reducing and ultimately eliminating health disparities. Health equity occurs when all populations (especially vulnerable, less advantaged socioeconomic populations) experience their highest level of health. Efforts to achieve health equity are intertwined with our ability to effectively eradicate health disparities. In our daily practice, nurses can be mindful to assess for these and other conditions that may adversely impact health outcomes and make appropriate referrals to members of the health care team such as social workers and case managers who are skillful in addressing identified social needs and can make appropriate referrals for additional services.

On a higher level of intervention, nurses must become skillful in advocating for social policies that can positively impact the myriad of social and economic conditions (inadequate housing, lack of employment and education opportunities) that adversely impact the health and well-being of those we serve.”

Health Equity and Social Determinants of Health (SDOH)

Social determinants of health (SDOHs) are factors apart from medical care and genetics that account for roughly 80 percent of overall individual health outcomes, according to the National Academy of Medicine. SDOHs are factors such as socio-economic status, availability of nutritious food, air and water quality, housing, education, transportation, racial segregation, and exposure to racism and violence. SDOHs can include a patient’s neighborhood and environment, access to health care (including insurance); social, cultural, and community context; level of education; and economic stability—all of which play a role in a nurse’s assessment of a patient’s wellbeing and risks to the same.

DN: In what ways can a nurse incorporate SDOH considerations into treatment?

Janice Phillips: “As they are working on the frontlines providing direct care to patients, it is important for nurses to be mindful of the many social and economic factors that may impact the health and well-being of patients and communities at large. In recent years hospitals have started screening patients for social needs that may have some bearing on a patient’s health and health outcomes. Factors such as access to stable housing, primary care, nutritious foods and transportation have emerged as significant factors impacting health status and health outcomes. Thus nurses are pivotal to integrating these factors when conducting patient assessments and making referrals that can help address the identified social needs. Other factors such as structural racism, income, education, poverty also impact health status and outcomes.

As patient advocates, nurses are well positioned to relay important information to social workers, case managers and other members of the interprofessional health care team who have the expertise to refer patients to needed resources. Nurses are valued collaborators in this regard and are encouraged to familiarize themselves with how their respective hospitals and health care systems are assessing and addressing the identified needs of patients. According to the American Hospital Association, by 2023, 48% of health care organizations will have a standardized means for collecting data on the social determinants of health, making this an important opportunity for nursing practice. Knowing where one’s organization stands with these efforts is an important first step.

Public policies that address the root causes of poor health status and longevity are central to any effort devoted to addressing the social determinants of health. Nurses are encouraged to get involved with their professional organizations, home institutions or other stakeholders who can work together to advance a policy agenda aimed at addressing the myriad of social and economic factors that impact health.”

Cultural Competence

According to Dr Jasmin Whitfield (RN, MSN, MPH, DNP), “culturally competent care is not just acquiring information on a particular group of people but rather developing a respect for and understanding that the beliefs, attitudes, behaviors, language, and rituals of that group all play a role.” The epidemiology, manifestation of disease, and effects of medications vary among different ethnic and cultural minorities, so nurses need to make themselves aware of matters such as ethnicity and culture, sexual preferences, and other points of identity as part of their patient dialogue, as all of these matters have specific health connotations.

DN: How can a nurse deal with topics such as patients’ ethnicity, language, culture, sexual orientation, and gender identity in a sensitive, yet direct manner?

Margaret Moss: “It may be of help for the practicing nurse to know of other care modalities recognizing a cultural component. There is Cultural Safety, defined by Williams (1999), “as an environment that is spiritually, socially and emotionally safe, as well as physically safe for people”. This includes being safe to tell your nurse how you identify, relay your spiritual and other needs without fear of retribution etc. Especially when there is patient-provider racial, gender or ethnic discordance, there can be a tentativeness on either side to communicate effectively and fully.

There is Cultural Humility and Cultural Respect as well. So, a big tip is just ask…very simple. With humility, state you are unaware of any special needs or care they may have and ask. Ask, how do you identify? Instead of guessing and then go from there. Whereas Cultural Competency can be seen as useful for the dominant culture caring for the ‘other’. As an Indigenous nurse, no one offered me a Cultural Competency course or workshop as I cared for dominant culture patients. However, safety, humility and respect always serve to increase a patient’s comfort and optimize results.”

Health Equity and Social Justice in Nursing

Social justice is a key aspect of health equity and is a core concept of nursing ethics. The American Nurses Association (ANA) states that nursing has a “professional responsibility to address unjust systems and structures.” Adhering to this ethic can lead to involvement in some divisive issues, but nurses have been advocates for social justice and human rights since the days of Florence Nightingale.

DN: In your view, what role do today’s nurses have in working towards social justice?

Margaret Moss: “Social Justice (from the Oxford Dictionary at Lexico) is justice in terms of the distribution of wealth, opportunities, and privileges within a society. It is well known, published, proved, that minorities in the US suffer, daily and out of proportion to non-minority peoples, at the lower end of these distributions.  Other groups such as the poor, working poor, chronically ill and disabled, and LGBTQQ2+ suffer as well. To help even out these disparities in the health realm, nurses must advocate. At times, they are the only thing standing between a patient and health or death. 

Similarly, nurses are and must be advocates beyond the individual. Nursing programs at the bachelor’s level and above incorporate Community Health, Population Health, Leadership and often Health Policy into the curriculum. I sought a law degree after my PhD in nursing, as both have at their base-advocacy. I have worked my career in advocating for more just American Indian Health. Social Justice Issues face every nurse every day and they are deep and wide. They hit ethics; policy and procedures that may be seen as detrimental but are, “always done that way”; unpotable water such as in Flint, MI; or Uranium on American Indian reservations; lack of available medicines; unfunded programing, and the massive leading edge of aging care; autism; and a host of other issues.”

DN: Finally, what actions can nurses take to further social justice and health equity in healthcare?

Margaret Moss: “Nurses at 3 million strong have the collective and individual power to help change these imbalances, by showing up (legislatures); speaking up (comment on proposed rules); and participating (in practice and advocacy associations).”

House Hearing: More Research Needed on Health Effects of Cannabis

House Hearing: More Research Needed on Health Effects of Cannabis

WASHINGTON — Healthcare providers don’t know enough about cannabis to talk with patients about the potential risks and benefits, witnesses said at a mid-January House Energy and Commerce Health Subcommittee hearing.

“We need to have much more education with respect to how the use of marijuana products can negatively impact or help someone,” said Nora Volkow, MD, director of the National Institute on Drug Abuse (NIDA). “The problem is we do not have sufficient evidence that could help us mount those programs in a way that’s actually required. At this point, I don’t feel the evidence is sufficient to say, ‘We’re going to recommend that this product should be used by this patient.'” For example, elderly patients who take marijuana-containing products may be on a lot of other medications, and little is known about potential interactions between marijuana and prescription drugs. “So I do believe in the importance of expanding our knowledge so we can develop educational training programs that are based on knowledge, not on anecdote.”

Making it Easier to Research Cannabis

Rep. John Sarbanes (D-Md.) noted that a 2015 survey of healthcare providers concluded that the providers “perceive a knowledge gap related to cannabis dosing, treatment plans, and different areas related to cannabis products, so providers themselves realize the need for research and expertise to be developed in this area.”

The hearing was held to discuss six bills on cannabis, several of which were aimed at making it easier for researchers to obtain cannabis for research purposes. Currently, the only cannabis legally available for research comes from a single farm housed at the University of Mississippi, and researchers who want to use it must get permission from three agencies: the FDA, the Drug Enforcement Administration (DEA), and the NIH. “We need to figure out a way to take advantage of different producers of cannabis plants to evaluate the diversity of products out there, as opposed to limiting us to the Mississippi farm,” said Volkow.

Rep. Kurt Schrader (D-Ore.) agreed. “The sad part is we’re not testing the right stuff,” he said. “I fail to understand why we have one bloody facility that is the sole nexus for research and analysis of CBD [cannabidiol] products. It seems to me we ought to be testing products on the marketplace.” Subcommittee chairman Anna Eshoo (D-Calif.) agreed. “I don’t understand why the three agencies before us can’t get this done,” she said, referring to NIDA, the FDA, and the DEA, which all had officials testifying at the hearing.

The Cannabis Research “Catch-22”

Several subcommittee members expressed frustration over what they called the “Catch 22” problem that cannabis researchers face. “They can’t conduct cannabis research until they can show cannabis has a medical use, but they can’t demonstrate cannabis has a medical use until they conduct research. It doesn’t make sense,” said Eshoo.

“You’ve got to help us figure out how we’re going to get out of this Catch 22,” Rep. Debbie Dingell (D-Mich.) said to the witnesses at the hearing. “This lack of knowledge poses a public health risk.”

One issue with conducting research on marijuana is its classification as a Schedule 1 drug; these are substances deemed to have no medical value and have a high potential for abuse, and their availability is highly restricted. Several bills the subcommittee is considering, including the Legitimate Use of Medicinal Marijuana Act, the Marijuana Freedom and Opportunity Act, and the Marijuana Opportunity Reinvestment and Expungement (MORE) Act, would either downgrade marijuana from a Schedule 1 drug to a Schedule 2 drug, which has fewer restrictions, or remove it from the drug schedule altogether.

Rep. Michael Burgess, MD (R-Texas), the subcommittee’s ranking member, said the latter “is going too far,” adding that “using our congressional authority to override this may be a dangerous move, especially given the lack of research.”

So far, only one marijuana-related drug has been approved by the FDA: Epidiolex, which contains cannabidiol, was approved in June 2018 for treating a rare seizure disorder in patients ages 2 and over.

Diverse Testimony from Both Sides of the Aisle

Both the witnesses and the subcommittee members seemed divided on marijuana’s potential harms and benefits for patients. Volkow mentioned research showing that cannabis exposure during pregnancy was associated with low birthweight and preterm delivery, and added that it was also linked with episodes of psychosis. She also said that there was some evidence that cannabis may be useful in treating spasticity, multiple sclerosis, and pain, “but otherwise there is little benefit for other indications for which patients are using it.”

Rep. Morgan Griffith (R-Va.) said that his support of medical marijuana began some years ago when he learned that people were smuggling marijuana into a Virginia hospital to help a terminally ill father who wanted to be feeling well enough to spend time with his 2-year-old son. Years later, when he told that story at a high school town hall, one student raised his hand and said, “They did that for my daddy too.”

“These communities were 20 years apart, 30 years apart, yet doctors were turning a blind eye to allow marijuana to be brought into the hospital because they recognized that for those patients who are dying, that was the only way they would get relief and get the nutrients they needed to spend a little more time with their children,” Griffith said.

Rep. Greg Gianforte (R-Mont.) said he was opposed to efforts to “make any Schedule 1 drug legal without adequate research.” Instead, “we should focus on combating addiction,” he said.

by Joyce Frieden, News Editor, MedPage Today

Originally published in MedPage Today

In the Midst of an OUD Crisis, Are Health Practitioners Biased Against Addicted Patients?

In the Midst of an OUD Crisis, Are Health Practitioners Biased Against Addicted Patients?

It is well-known that people with Substance Use Disorder (SUD) and Opioid Use Disorder (OUD) face a heavy stigma in society at large. For instance, in Victoria, BC, while exceptional caregivers such as Corey Ranger, the roving Narcan-toting nurse are saving addicts’ lives, hostile bystanders often offer disdainful suggestions such as “Oh, why bother? Just let them die!”

Indeed, it is not uncommon for the general public to regard SUD and OUD as examples of societal weakness and personal failure, rather than viewing the condition as a medical condition that is frequently combined with other chronic disorders. In many cases, those suffering from addiction are also subjected to negative attitudes from nurses, doctors, and other healthcare practitioners. As a nurse in one study says of SUD patients, “[they create] a cycle of problems,” where “the staff perceives them to be annoying or obnoxious…” Another nurse in the same study notes, “staff attitudes are obvious, you can’t really hide them that well.” It is acknowledged that “Stigmatizing attitudes among health professionals have been shown to be widespread, which has detrimental consequences for connecting persons with OUD to treatment.”

Nurses, Doctors and SUD; Nurses and Doctors with SUD

There is an irony when healthcare practitioners display this attitude toward patients with SUD and OUD. According to the American Journal of Psychiatry and the National Council of State Boards of Nursing [NCSBN] publication “Substance Use Disorder in Nursing,” the prevalence of substance use disorders among doctors and nurses is similar to that of the general population—and is higher than the general public in the case of prescription drugs.

However, doctors’ tendency to protect colleagues with SUD, and the policy of the NCSBN that promotes a nonjudgmental, stigma-free approach to treatment of nurses with SUD (approximately 70% of nurses who seek treatment successfully return to practice) coexists with strong evidence that a substantial number of doctors and nurses have a negative attitude toward addicted patients. The consequences are as grave as they are incongruous; as a study in Canadian Nurse.com remarked, “perceived discrimination on the part of health-care staff was a major barrier to [patients’] seeking medical help, both for their substance abuse and for treatment of general and chronic conditions.”

Doctors and OUD: A Static System

“Fresh out of medical school, you can prescribe for pain relief any of the opioid medications that can lead to addiction, but you have to get a special waiver to treat addiction, a disease process. That just doesn’t make sense…”

–Dr. Sandeep Kapoor, director of the Screening, Brief Intervention and Referral to Treatment (SBIRT) program at Northwell Health

The situation of doctors is particularly unfortunate with regard to patients with OUD. The reaction of one doctor, when asked about the sparse availability of buprenorphine treatment, was a flat comment that “Most doctors don’t want to treat OUD or SUD patients.” A Statnews editorial on this topic concludes that a pervasive problem is that a) many doctors do not see addiction “as a brain disorder requiring treatment, but as a personal failing,” and b) “some physicians believe that medication-assisted therapy is little more than switching one addiction for another.”+

Even among those doctors who are willing to treat OUD patients, the problem is compounded by the fact that even now—in the midst of an opiate crisis—treating addicted patients with medications such as buprenorphine is highly regulated, requiring strict state and federal registration. To be permitted to prescribe, regulations require that doctors take eight hours of training (for NPs and PAs the requirement is 24 hours of training), after which they are required to register for a DEA waiver.

A further deterrent to the propagation of buprenorphine treatment is the inspection of office records by DEA agents (see within link, “What to Expect When the DEA Comes to Your Office”). An independent-minded physician—who may already be unenthusiastic about treating “addicts”—is unlikely to readily tolerate this sort of heavy-handed government interference in his or her practice. As it is, at present, despite the generally acknowledged opiate crisis, fewer than 7% of US physicians currently have DEA waivers for the prescription of one of the safest and most effective methods of treatment for opiate addiction.

Ties that Bind

This means that while the opiate crisis is raging, the hands of the practitioners who ought to be on the front lines of the fight are bound—both self-bound and bound by regulations. Doctors Kevin Fiscella and Sarah Wakeman ask in another StatNews editorial, “Would deregulation work?” They go on to note that “after France instituted this approach in 1995, deaths from opioid overdoses dropped nearly 80 percent.” Until attitudes among caregivers become more advanced, and until a proper deregulation movement for the prescription of buprenorphine gains national attention, attempts to stem the crisis are little more than a grand display of running in place.

Bipartisan House Cannabis Decriminalization Bill Passes Initial Committee Vote

Bipartisan House Cannabis Decriminalization Bill Passes Initial Committee Vote

Cannabis and politics are at an intriguing crossroads as we creep ever closer to the next election year. Politicians must decide how to position themselves on the hot-button issue of cannabis legalization. Many potential legalization bills have been proposed in the House of Representatives but very few have ever made it out of committee. National legalization bills have a history of facing intense scrutiny in the houses of Congress. There are a number of reasons for this but the vast differences in political opinions of members of Congress makes compromise on any bill, let alone one about a hot button issue like cannabis legalization, very difficult.

However, on Wednesday, November 20th, a new bill that would decriminalize cannabis nationally, allow states to make their own laws on full-scale legalization, and create the potential for expunging criminal records related to cannabis arrests passed in the House Judiciary Committee.

Chances of the Bill Passing

Though it is tough to envision a cannabis bill actually seeing the light of day, there is hope for this most recent iteration. The bill already has 50 co-sponsors, bipartisan support from notable pro-cannabis legalization Republicans like Matt Gaetz of Florida, and passed the House Judiciary Committee with a vote of 24-10. It is always encouraging when Republicans and Democrats can agree on legislation, especially when it comes to a potential cannabis legalization bill. Recently, the House of Representatives passed the SAFE Banking Act with bipartisan support. The bill allows for cannabis businesses to bank safely and discreetly. Its passage shows the willingness of Congressional Republicans and Democrats to work together to pass a cannabis bill.

The House cannabis bill is undoubtedly an exciting moment for those in the legalization movement. As promising as the bill seems, it is unlikely that it will be passed without major changes. It may pass the Democrat-controlled House of Representatives, but will face an intense battle in the Republican-controlled Senate. As unlikely as the bill’s passage is, those investing in the cannabis industry seem to believe the bill has a chance to become a part of American law soon.

Impact On The Cannabis Industry

As news of the forwarding of the house cannabis bill was announced, cannabis company stocks soared. The three biggest cannabis stocks, Canopy Growth, Tilray Inc., and Aurora Cannabis all saw prices rise between 8% and 15% on Wednesday, according to Reuters. Investor excitement is palpable, but some experts warn about the long term future for the House cannabis bill. Alan Brochstein, managing partner at New Cannabis Ventures, cautioned that the bill is, “such an early step in a long process that there are no near-term implications for cannabis stocks.”

The merits of the House cannabis bill will likely debated for the next few months. Changes will be made and votes will be cast before anything is set in stone. Whether or not this iteration of a legalization bill becomes law is unknown, but the fact that some politicians continue to fight for cannabis legalization is tremendously promising.

Border Flu Shot Protest: 4 Docs arrested

Border Flu Shot Protest: 4 Docs arrested

Four physicians and two others protesting their inability to vaccinate migrant detainees at the U.S. Customs and Border Protection (CBP) headquarters here were arrested last Tuesday for failing to comply with federal orders to disperse.

They were held for about an hour, according to some of those who were arrested.

The two groups of protesters — about 60 people in total — had gathered in two driveways leading to CBP headquarters for about an hour when one of the groups received a warning from federal officials that if they stayed in the driveway, they would be arrested, said Marie DeLuca, MD, an emergency room physician from New York who was one of those arrested. Some of the members had blocked the driveway by laying down across the road while others chanted, “No more death.”

“We stayed peacefully in the driveway entrances of their building and said that if they weren’t going to let us in to vaccinate against the flu, we were going to remain. They didn’t let us. Instead they chose to arrest members in one of the two groups,” DeLuca said.

She said her hands were secured behind her back with zip ties by officials from the Department of Homeland Security (DHS) as she and the other protesters were led into a conference room and told to wait. After about an hour following the protest, they were issued tickets with a court date for “failure to comply with the lawful direction of federal police officers or other authorized individuals,” and then released, she said.

A San Diego Union-Tribune reporter posted a video of some of those doctors being arrested.

At about 2 p.m. Tuesday, DHS’s press secretary tweeted a picture of the protesters and said, “Of course Border Patrol isn’t going to let a random group of radical political activists show up and start injecting people with drugs.”

Sen. Elizabeth Warren (D-Mass.) also tweeted a link to a video of the protesters, saying that “Children are dying in CBP custody due to the flu. Refusing to administer flu vaccines is neglectful and cruel.”

Other doctors arrested, who were part of the group Doctors For Camp Closure, included Mario Mendoza, MD, a former anesthesiologist who now lives in New York City and runs the organization Lifeundocumented.org; Hannah Janeway, MD, an emergency room physician in Los Angeles who helps run the Refugee Health Alliance; and Mathieu De Schutter, a pediatric hospitalist from San Luis Obispo, California. The non-physicians arrested were Rebecca Wollner of Jewish Action San Diego and Matthew Hom, a graduate student from Cerritos, California, who works with the group Never Again Action.

On Monday, the physicians began their three-day vigil and protest of federal immunization policies at the gate of the detention center in San Ysidro at about 11:30 a.m. They stayed until about 4:30 p.m. with no response despite repeated requests. Tuesday’s action took place nearby at the Chula Vista CBP headquarters.

DeLuca said the doctors and their supporters planned to return Wednesday to try one more time to administer the 120 influenza vaccines they brought with them for the detainees. They say it’s important for public health, not just to protect these detainees, but also everyone else they come in contact with.

Members of the groups chanted slogans and carried banners and signs calling on federal officials to let them administer the vaccinations to those inside. The vaccines were purchased with financial donations.

Originally published in MedPage Today.

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