Legislative victories just don’t happen. The victories are a result of nurse practitioners signing up to become members of their professional organizations, either the Iowa Nurse Practitioners Society (INPS), or the Iowa Association of Nurse Practitioners (IANP). In turn, IANP/INPS use some of their resources to hire together a lobbyist who works with legislators on issues important to nurse practitioners, keeps ARNPs updated as to what bills are being introduced, and consults with nurse practitioners as to the best strategies to get our ideas passed into law, and prevent bad ideas from being passed.
HF 83 allowed boards of supervisors, city councils, and school boards to contract with any non-profit nurses’ association for public health nursing services. HF 83 was signed by Governor Harold Hughes on April 4th.
HF 554 dealt with the regulation of the practice of nursing. It set fees for nursing exams. $30 for the exam, and $20 if you had to retake the exam. There was a late fee of $2 instituted if the nurse was late in renewal of the license. HF 554 changed the chief staff person from “Secretary” to “Executive Director’ for the Board of Nursing. The Board of Nurse Examiners was changed to the Iowa Board of Nursing in HF 554. HF 554 was signed on May 27th.
SF 231 appropriated $17,600 for salaries, support, maintenance, equipment and miscellaneous expenses for employees of a Governor’s Commission to study nursing in Iowa and for travel and related expenses of the commission’s members.
SF 277 related to the establishment and administration of professional and occupational licensing boards, to abolish all trust funds and special funds of a professional and occupational licensing boards and allowing certain additional fees and providing for penalties. For the nursing examiners’ board:
One registered nurse from a college or university; One registered nurse from a hospital conducted school of nursing; One registered nurse from an area community or vocational tech nursing department; One registered nurse practitioner; One licensed practical nurse practitioner; and two members of the general public.
Each association of a profession is allowed to recommend names of potential board members to the Governor who is not obligated to follow the recommendation.
The board of nurse examiners may appoint a full time executive director who shall not be a member of the board. The salary for the executive director will be set by the legislature.
SF 277 was signed by Governor Robert Ray on May 28th.
SF 123 related to the inclusion of nursing and pharmacy within the definition of professions for purposes of the Iowa Professional Corporations Act (496C.2 . SF 123 was signed on March 18, 1975.
HF 803 was a bill concerning the compensation of persons suffering loss as a result of medical malpractice. The bill authorized the Insurance Commissioner to take steps to make sure that malpractice insurance was available to licensed health care providers. The definition of a licensed health care provider was as follows: licensed health care provider means and includes a physician and surgeon, osteopath, osteopathic physician and surgeon, dentist, podiatrist, pharmacist, chiropractor, or nurse licensed pursuant to chapter 147 and hospitals licensed pursuant to chapter 135B. HF 803 was signed by Governor Ray on June 30, 1975.
HF 1503 related to the practice of nursing and provided for disciplinary procedures. “The practice of nursing” means the practice of a registered nurse or a licensed practical nurse. The bill outlined what nursing does not mean: basically not getting into other medical profession’s duties. HF 1503 limited pharmacy for nursing to drugs which are recognized by the medical and nursing professions and approved by the board as proper to be performed by a registered nurse. HF 1503 defined “practice of the profession of a registered nurse” and defined “the practice of a licensed practical nurse.” HF 1503 stated that the Board of Nursing shall appoint a full time executive director who shall be a registered nurse. HF 1503 was signed by Governor Ray on June 23.
SF 387 related to liability for the performance of or refusal to perform abortions. SF 387 provided that providers can’t be punished for refusing to participate in an abortion procedure. The bill was signed on March 19th.
SF 312 required professional and occupational licensees, as a condition of license renewal, to participate in continuing education, delegate rulemaking authority, professional review and disciplinary action. The Board of Nursing was included in this bill which was signed by Governor Ray on July 12.
In 1980 the legislature passed a law, SF 2070, to allow nurse practitioners and other providers to dispense drugs, irrespective of Attorney General Tom Miller’s opinion to the contrary. Governor Ray signed the bill on May 23, 1980.
The legislature passed HF 2430 which provided that registered nurses under chapter 152 are not required to disclose confidential communication in court proceedings. The bill was signed on May 17th.
On April 6th, 1983, chapter 7 of the administrative rules of the Board of Nursing took effect. This chapter governs nurse practitioners.
HF 613 related to the funding of state agencies for designated service programs. “It is the intent of the General Assembly that a licensed practical nurse may practice in head start programs without the need of supervision of a licensed registered nurse or a licensed physician. To the extent that subrule 590 IAC 6.3(3) conflicts with this provision, the subrule is void.”
HF 613 was signed by Governor Branstad on June 13th.
SF 2262 related to health insurance by requiring that coverage for educational programs for diabetes be offered. Nurses could do covered outpatient self-management educational programs. HF 2262 was signed on 5/16/84 by Governor Branstad.
SF 345 specified professionals to dispense and issue prescription drugs and controlled substances and to delegate dispensing functions. Persons other than pharmacists, dentists, podiatrists, and veterinarians, cannot dispense prescription drugs or controlled substances. PAs and RNs may supply pharmacist services when pharmacist services aren’t available or when it’s in the best interest of the patient, or on order of a physician. PAs and RNs in remote clinics may dispense drugs, but have to regularly consult with a pharmacist.
SF 345 was signed on 2/21/84.
SF 1287 was a bill regulating advanced emergency medical technicians and paramedics. The Advance Emergency Care Council was created. Positions were created for two registered nurses who were active in the delivery of emergency medical care. The bill also provided that when physicians or registered nurses were not available to oversee the care, an EMT may do so. SF 1287 was signed on 5/16/84.
HF 2436 was a bill dealing with the licensure and operation of a hospice program. RNs were listed as part of the “Interdisciplinary Team” of the hospice. HF 2436 was signed by Governor Branstad on 5/15/84.
SF 2334 was an appropriations bill which had the same language about head start programs that HF 613 had in 1983. “It is the intent of the General Assembly that a licensed practical nurse may practice in head start programs without the need of supervision of a licensed registered nurse or a licensed physician. To the extent that subrule 590 IAC 6.3(3) conflicts with this provision, the subrule is void.” SF 2334 was signed on 5/18/84.
HF 451 was a bill related to child protection….hospital and health care facility employees are added to the mandatory reporting requirements if they treat a child exhibiting signs of physical abuse – health care practitioners do direct reporting and don’t have to first report to the hospital if they work there. HF 451 was signed by Governor Branstad on 5/23/85.
HF 168 dealt with the licensure of dieticians….nurses were exempted from needing to obtain a dieticians’ license. HF 168 was signed on 5/22/85.
HF 160 removed the exception which allowed licensed practical nurses to staff an authorized ambulance service or rescue squad service. HF 160 maintained the exception for registered nurses. HF 160 was signed on 5/15/85.
SF 433 was a bill on the certification and regulation of respiratory care practitioners …..the definition of “respiratory care protocols” means policies and procedures developed by an organized health care system through consultation with health care providers including certified registered nurses. SF 433 was signed on 5/20/85.
HF 2493 related to criminal penalties arising from the operation of motor vehicles ….medical personnel, including nurses, who use reasonable care and accepted medical practices in withdrawing blood specimens are immune from liability for their actions in complying with requests made of them pursuant to search warrants or pursuant to 321J.11. Registered nurses are named among medical professionals who can withdraw a blood sample for determining alcoholic concentrations. Governor Branstad signed HF 2493 on 5/27/86.
HF 371 was a bill on emergency medical care providers….the bill added “first response service” to the list of emergency services that registered nurses are allowed to perform. Governor Branstad signed HF 371 on 5/2/89.
HF 774 was an appropriations bill which included a nursing loan program for $200,000. Governor Branstad used his line item veto authority to veto this appropriation explaining that he had already asked the College Aid Commission to investigate such a program; however, he had not received full information back from the College Aid Commission as to the needed investment.
SF 2423 was an appropriations bill on educational and cultural programs. $225,000 was appropriated to the Iowa Department of Public Health for administering a graduate nursing program at accredited private colleges and universities, money for salaries, equipment, student services, and rural recruitment. 80% of the students had to be Iowans – all must be licensed to practice nursing in Iowa.
HF 2518 was a professional licensure bill. All medical professionals, including nurses, were required to keep their licenses displayed in the primary place in which the person practiced. When the nurse changed residence or place of practice, the Board of Nursing shall be notified. HF 2518 also provided that the BON may require a recent photo of a nursing applicant.
SF 2410 was a bill on higher education coordination, administration, standards, and funding study authorized, in coordination with the Board of Nursing. The study included an assessment of the state’s supply of nursing educators who possess the educational qualification identified in the administrative rules, submission of any findings, and a review of the rules, and the completed study by the administrative rules review committee. The Board of Educational Examiners was to submit the findings, along with suggested changes, to the General Assembly by July 1, 1991.
SF 455 was a bill on dependent adult abuse. Health practitioners, including nurses, were required to report cases of dependent adult abuse to the Department of Human Services. The bill as signed by Governor Branstad on June 4, 1991.
HF 655 was a bill on emergency care providers. HF 655 required hospitals to contact health care providers, including nurses, if they had been exposed to a patient with a “contagious or infectious disease.” The bill was signed on May 9th.
SF 363 had to do with the authority of nurse practitioners to prescribe drugs. SF 363 gave nurse practitioners the right to prescribe non controlled substances or devices under certain circumstances. NPs got prescriptive authority if they were registered in a recognized nursing specialty, other than nurse anesthetists, and could prescribe substances and devices, if the substances and devices were recognized by the Board of Medical Examiners and the Board of Nursing. The drugs and devices had to be regulated under rules accepted by the Board of Medical Examiners and adopted by the Board of Nursing in consultation with the Board of Pharmacy Examiners. Governor Branstad signed SF 363 on 6/5/91.
SF 2 was a bill dealing with sexual exploitation by a counselor or therapist. SF 2 provided that sexual abuse by a counselor or mental health provider, including nurses, was not a forcible felony. SF 2 further provided that a victim had to file an action for damages within five years. SF 2 was signed on 5/8/91.
SF 221 dealt with child abuse, dependent adult abuse, child care, and juvenile shelter care. SF 221 stated that mental health professionals must report to the Department of Human Services any mental injury to the child’s intellectual or psychiatric capacity. SF 221 was signed on 5/3/93.
SF 117 was a bill on children exposed to illegal drugs. SF 117 strengthened reporting requirements to DHS by dropping the following qualifier which was in the statute: “unless the natural mother has shown good faith in seeking appropriate care and treatment.” SF 117 further provided that positive test results can’t be used for criminal prosecution of a parent resulting in intrauterine exposure of an illegal drug. SF 117 was signed on 5/4/93.
HF 451 was a bill on reporting to law enforcement. HF 451 required medical professionals, including nurses, to report to law enforcement agencies stab wounds, gunshot wounds, or other serious bodily injuries to victims. The report had to be made within a twelve hours period. HF 451 was signed on 5/4/93.
HJR 17 was a joint resolution to nullify an administrative rule of the Board of Nursing defining the term nurse and providing an effective date. The resolution was signed by Governor Branstad on 4/23/93.
HF 561 related to the practices of nursing and dentistry. The BON may appoint investigators, not members of the BON, to assist in the provisions of the law related to those licensed to practice nursing. The investigators shall have the powers and status of peace officers when enforcing violations of chapters 147, 152, and 272C. HF 561 was signed on 4/26/93.
SF 2053, signed by Governor Terry Branstad on May 2, 1994, gave prescriptive authority to advanced registered nurse practitioners.
HF 2144, signed by Governor Terry Branstad on April 25, 1996, stated that a policy or contract providing for third party payment or prepayment of health or medical expenses shall include a provision for the payment of necessary medical or surgical care and treatment provided by an advanced registered nurse practitioner.
SF 277, signed by Governor Tom Vilsack on April 21, 1999, gave hospital clinical privileges to advanced registered nurse practitioners.
HF 2105 established chapter 152E which is the nurse and advanced practice registered nurse compact law. Iowa was one of the early states to join the compact whose purpose is to seek uniformity in practice for nurse around the United States and to foster reciprocity of state licenses for nurses and advanced practice nurses. Governor Tom Vilsack signed HF 2105 into law on March 16, 2000.
Governor Tom Vilsack became the first Governor to send a letter to CMS opting out of the rule requiring physician supervision of CRNAs in performing anesthesia. In his December 12, 2001 letter, Governor Vilsack cited the fact that 91 of Iowa’s 118 hospitals relied solely on CRNAs to provide anesthesia care.
SF 277, school nurses, signed by Governor Culver on 4/26/2007…. each school district shall have a school nurse to provide health services to its students. Each school district shall work toward the goal of having one school nurse for every seven hundred fifty students enrolled in the school district.
HF 2539 passed the legislature in 2008. It related to health care reform including health care coverage intended for children and adults, health information technology, end-of-life care decision making, preexisting conditions and dependent children coverage, medical homes, prevention and chronic care management, a buy-in provision for certain individuals under the medical assistance program, disease prevention and wellness initiatives, and health care transparency.
HF 2151 was the bill to repeal the sunset from the ARNP compact in the code. Without the passage of HF 2151, Iowa’s participation in the compact would have ended on July 1, 2008. HF 2151 contains no future repeal dates. Governor Culver signed the bill into law on March 5. It went into effect on that date.
HF 2603 authorized psychiatric advanced registered nurse practitioners to file certain court reports on chronic substance abusers and persons with mental illness who do not require full time placement in a treatment facility. The law requires a psychiatrist to personally evaluate the patient at least on an annual basis as part of the authorization. Governor Culver signed the bill on April 11.
HF 2212 was the bill outlawing smoking in most public places. Governor Culver signed the bill into law on April 15, 2008.
HF 2679 contained $100,000 in funding for the registered nurse and nurse educator loan forgiveness program.
IANP/INPS appeared at a public hearing, conducted by the Board of Nursing, on June 3, 2009, in support of the BON’s proposed rule which would make it clear that ARNPs and CRNAs have the right, after taking the requisite courses, to supervise the use of fluoroscopic x-ray equipment. The Iowa Medical Society appeared in opposition to this proposed rule.
HJR 2206, introduced in 2010, would have nullified the Board of Nursing’s administrative rule allowing ANRPs to provide direct supervision in the use of fluoroscopic X-ray equipment. HJR 2006 was referred to the House Judiciary Committee where Chairman Kurt Swaim refused to consider the resolution.
SSB 3085/HF 2136 would have completely disallowed CRNAs and all nurse practitioners from doing any kind of interventional pain management. Nurse practitioners and CRNAs were able to convince the legislature not to consider these bills in 2010.
The Iowa Hospital Association, with support of the NP Committee, successfully amended SF 2201(section 16) so that ARNPs and PAs could be paid while credentialing was being processed and before it was completed. SF 2201 was signed by Governor Culver on April 9th, 2010.
HF 674 dealt with treatment of serious wounds. Medical personnel, in addition to reporting gun shot and stab wounds to law enforcement, have to report those coming in for treatment as a result of vehicle accidents, if there is something criminal to report, such as excessive alcohol.
SF 2384 established an Iowa needs nurses now initiative.
SF 143, signed into law on March 30th, allowed ARNPs and PAs to report on persons incapable of driving and to send in physicals indicating when the person can resume driving.
HF 393, signed into law on April 6th, allowed ARNPs to sign death certificates. HF 393 was strongly opposed by the Iowa Medical Society.
HF 2165 was a law relating to physician orders for scope of treatment. ARNPs were listed as part of this system of keeping clear advanced directives that accompany the patient as the patient moves from one place to another for treatments. HF 2165 passed the legislature and was signed by Governor Branstad on March 7, 2012.
SF 2248 was a law relating to the licensed professionals authorized to prescribe respiratory care services. This law was important because of changes by CMS on what gets paid for by Medicare and Medicaid. If a state’s scope of practice act did not give clear authority for a function, nurse practitioners won’t get paid for their work.
SF 2247, a bill relating to terminology changes in Iowa Code, made references to mental retardation. Mental retardation references in the code were changed to intellectual disability. “Intellectual disability” means a disability of children and adults who as a result of inadequately developed intelligence have a significant impairment in ability to learn or to adapt to the demands of society. Governor Branstad signed the bill on March 22, 2012.
SF 2312 was the second bill passed out of the three dealing with mental health redesign. The important part of SF 2312 for ARNPs is the definition of mental health professional.
It is the intent of the legislature that all future references in legislation to mental health professional will be cross referenced to this definition. Nurse practitioners had to do some strong lobbying to assist in getting a definition that reflected the independence of our practice. The definition of mental health professional is as follows:
"Mental health professional” means an individual who has either (a or b) of the following qualifications:
a. The individual meets all of the following requirements: (1) The individual holds at least a master’s degree in a mental health field, including but not limited to psychology, counseling and guidance, nursing, and social work, or is an advanced registered nurse practitioner, a physician assistant, or a physician and surgeon or an osteopathic physician and surgeon. (2) The individual holds a current Iowa license if practicing in a field covered by an Iowa licensure law. (3) The individual has at least two years of post-degree clinical experience, supervised by another mental health professional, in assessing mental health needs and problems and in providing appropriate mental health services.
b. The individual holds a current Iowa license if practicing in a field covered by an Iowa licensure law and is a psychiatrist, an advanced registered nurse practitioner who holds a national certification in psychiatric mental health care registered by the board of nursing, a physician assistant practicing under the supervision of a psychiatrist, or an individual who holds a doctorate degree in psychology and is licensed by the Board of Psychology. SF 2312 was signed by Governor Branstad on April 12, 2012.
SF 2315 was the centerpiece of mental health redesign. The most difficult part of this bill was the funding involved between the state and local governments. For ARNPs, the most difficult part was making sure that all the definitions reflected the independent practice of ARNPs. Here is the definition of mental health services in the bill. Prior to an amendment ARNPs instigated, the section was called “psychiatric services.”
"Mental health services” means services provided by a mental health professional operating within the scope of the professional’s practice which address mental, emotional, medical, or behavioral problems.
In one section of the bill, we convinced legislators to change language which had psychiatrists delegating duties to ARNPs. The changed language read as follows: After the respondent’s admission, the observation, medical treatment, and hospital care of the respondent may be provided by a mental health professional, as defined in section 228.1, who is licensed as a physician, advanced registered nurse practitioner or physician assistant. SF 2315 contained useful language on how to treat patients with co-occurring conditions:
“A mental health professional, as defined in section 228.1, who is employed by a treatment provider under the program, may provide treatment to a person with co-occurring substance-related and mental health disorder. Such treatment may also be provided by a person employed by such a treatment provider who is receiving the supervision required to meet the definition of mental health professional but has not completed the supervision component.”
The Iowa Supreme Court delivered a resounding victory for nursing and nurse practitioners on May 31. The issue was supervision of fluoroscopy, an issue which had been stewing since 2007. The high court reversed the Polk County District Court and upheld the BON and IDPH administrative rules regarding the supervision by ARNPS of radiation techs conducting fluoroscopy. As an added benefit of the Iowa Supreme Court ruling, the decision makes clear that the Board of Nursing is in total control of the scope of practice for nurses. Since the 1970’s, interpretation over part of the BON statute implied that the BON had to consult with other health and medical groups when dealing with scope of practice matters. Some have implied that the other groups held some kind of veto power over the BON, if they disagreed with a proposal.
The Iowa DOT promulgated an administrative rule completing the journey of allowing nurse practitioners to both report drivers who shouldn’t be on the road for health reasons and to have physical exams accepted by DOT to allow those drivers to return to driving. The rule went into effect on May 8th, 2013.
HF 486 dropped language from the code which required nurse practitioners to confer with physicians before making referrals to orthotic, prosthetic, and pedorthic professionals. The law was signed on April 5th.
SF 203 was important because we had to be watchful so that ARNPs, working in sub-acute facilities, could maintain their autonomy of practice, to the extent of their scope of practice. The original drafting of this bill would have allowed only psychiatrists to supervise the treatment care plans for those being treated in the facility. We were able to convince the legislature to change the bill from psychiatrists to mental health professionals, which includes ARNPs. SF 203 was signed into law on April 5th.
SF 115 was a change in the intermediate drivers’ license law, a concept that ARNPs had supported for a number of years. The intermediate license has been expanded from six months to twelve months. SF 115 also requires, for the first six months of the intermediate license, that the driver can have only one other underage and unrelated passenger, unless such provision is waived by the parents. This law, signed by the Governor on May 1, takes effect on January 1 of 2014.
HF 604 created a new rural loan funding program for nurse practitioners to be administered by the College Student Aid Commission. The legislature appropriated $400,000 for the program for the 2014 fiscal year beginning in July. For nurse practitioners the program will work only at the University of Iowa for those students seeking a doctorate of nursing practices degree. For PAs, the eligible program is a master’s degree from Des Moines University.
SF 452, which was passed into law, contained a section on death certificates. When an electronic system for filing death certificates is developed, each professional allowed to sign death certificates shall use the electronic system. Advanced registered nurse practitioners are listed among those professionals. This is due to the passage into law of HF 393 in 2011, allowing nurse practitioners to sign death certificates of their patients. SF 452 also incorporated HF 9 and SF 393, requiring pulse oximetry screening for newborns. Each newborn is be tested for congenital heart disease by means of pulse oximetry or other means as developed by administrative rule. The attending health care professional is responsible for seeing that the test is administered. If the parent objects to the test, it will not be done, and the objection shall be noted in the newborn’s medical records.
SF 2120 was a bill which amended chapter 147.74 of the code. This code section outlines medical professionals and the acronyms which professionals may use. SF 2120 legalized the use of “ARNP.” It was discovered that nurse practitioners were never included in this subsection of chapter 147. Because the bill was written using the term “licensed” in conjunction with nurse practitioners, it is the Attorney General’s opinion that the Board of Nursing can institute a licensing program for nurse practitioners instead of the current “registration” program. Therefore, this seemingly minor law, signed on March 26th, inadvertently became a much more meaningful law.
SF 203 was a bill introduced by the Board of Nursing, having to do with persons and activities regulated by the Board of Nursing. SF 203 was basically a bill updating language, such as adding a definition of nurse practitioner to the code for the first time in chapter 152. SF 203 also changed all references of “registered with” to “licensed by” the BON for nurse practitioners throughout the code of Iowa where the language previously occurred. All laws from other code sections, also contained in chapter 152, were changed to reflect the appropriate language for the licensing of nurse practitioners. SF 203 also changed the requirement when the BON wanted a licensee to have a medical examination by a physician to a “medical evaluation” by a health care provider. SF 203 was signed by Governor Branstad on April 24th.