rendered the practice of medicine not only comprehensive but also (in medicine’s own view) exclusive,15 a preemption of the field that was reinforced when physicians obtained statutory authority to control the activities of other health care providers.

Most APRNs are in the opposite situation. Because virtually all states still base their licensure frameworks on the persistent underlying principle that the practice of medicine encompasses both the ability and the legal authority to treat all possible human conditions, the scopes of practice for APRNs (and other health professionals) are exercises in legislative exception making, a “carving out” of small, politically achievable spheres of practice authority from the universal domain of medicine. As a result, APRNs’ scopes of practice are so circumscribed that their competence extends far beyond their authority. At any point in their career, APRNs can do much more than they may legally do. As APRNs acquire new skills, they must seek administrative or statutory revision of their defined scopes of practice (a costly and often difficult enterprise).

As the health care system has grown over the past 40 years, the education and roles of APRNs have continually evolved so that nurses now enter the workplace willing and qualified to provide more services than they previously did. As the services supported by evolving education programs expanded, so did the overlap of practice boundaries of APRNs and physicians. APRNs are more than physician extenders or substitutes. They cover the care continuum from health promotion and disease prevention to early diagnosis to prevent or limit disability. These services are grounded in and shaped by their nursing education, with its particular ideology and professional identity. NPs also learn how to work with teams of providers, which is perhaps one of the most important factors in the successful care of chronically ill patients. Although they use skills traditionally residing in the realm of medicine, APRNs integrate a range of skills from several disciplines, including social work, nutrition, and physical therapy.

Almost 25 years ago, an analysis by the Office of Technology Assessment (OTA) indicated that NPs could safely and effectively provide more than 90 percent of pediatric primary care services and 75 percent of general primary care services, while CRNAs could provide 65 percent of anesthesia services. OTA concluded further that CNMs could be 98 percent as productive as obstetricians in providing maternity services (Office of Technology Assessment, 1986). APRNs also have competencies that include the knowledge to refer patients with complex problems to physicians, just as physicians refer patients who need services they are not trained to provide, such as medication counseling, developmental screening, or case management, to APRNs. As discussed in Chapter 1 and reviewed in Annex 1-1, APRNs provide services, in addition to primary care, in a wide range of areas, including neonatal care, acute care, geriatrics, community health, and


Sociologist Eliot Freidson has aptly characterized this statutory preemption as “the exclusive right to practice” (Freidson, 1970).

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