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No on AB 890!

No on AB 890!
 

AB 890 is intended to ensure the new category of licensed nurse practitioners have the least restrictive amount of education, training, and testing necessary to ensure competent practice. The purpose of education, training and testing should be to ensure high quality care for patients, not the least amount of burden for the licensed health professional. As their scope is undefined by this bill and they are given authority to practice based on their "experience," independent advanced practice registered nurses would be practicing medicine but are regulated by a newly established Board (the composition of which is not delineated).

Under AB 890, a nurse practitioner would only need three years of clinical experience and supervision under any type of physician before they would be allowed to practice independently. The “Transition to Practice” could be as minimal as a loose affiliation with a physician. By allowing the new board contemplated in this bill, to define minimum standards for transition to practice, the bill grants authority to the profession to define it and does not require any standards or guidelines for content and length. At a bare minimum, the bill should delineate parameters for the transition to practice regulations. This definition also suggests that the "clinical experience and mentorship" could be "without the routine presence of a physician and surgeon," in which case, it is unclear what this would entail, which is problematic as written. Oddly, the definition of the new board, standardized procedures, and transition to practice would be automatically repealed in 2026, which would delete these definitions for the entire article – it is not clear why.

AB 890 indicates that an NP can perform specified functions independently in an existing clinic, facility, etc. where there is a physician practicing. This seems to suggest physician oversight, but it is not because the supervision requirement is removed. Just because a physician is nearby does not mean the physician is involved in care. Moreover, if one goal is to expand access, tying independent practice to existing locations where physicians are present would not further that goal. It is unclear why a physician would need to be practicing in the entity where the NP practices independently without standardized procedures. By definition, independent practitioners practice without oversight within a clearly defined scope and there are

no other independent practitioners licensed by the state who can practice only with the presence (but not supervision) of another independent licensed practitioner. In addition, NPs have historically argued that independent practice was necessary to allow them to practice in areas with no or few physicians.

AB 890 is overly broad and gives NPs the ability to perform functions which encompass much of what would be considered to be the independent practice of medicine. This constitutes a significant risk to patients as there are no clear boundaries for when care should be transferred to a physician. NPs are not trained broadly in “assessing and diagnosing” so it is unclear what the limits of their functions would be based on for these provisions. NPs to determine when to refer a patient, which would require NPs to know what they do not know. NPs would be empowered to decide the timing and nature of the referral and carries the risk of significant patient harm. If an NP is not practicing in a setting where there is a clear referral procedure it could result in care delays for conditions that could be handled seamlessly by a physician. This again, indicates that NP scope would vary from NP to NP based on his or her particular education and training. There is no consistency across the profession and no indication to the patient or anyone else whether or not the NP has the education and training or whether the care is "within the limits of their knowledge and experience" at the time the care is being provided. There is also no input into whether the NP has the knowledge and experience from anyone else, including a physician. It is a self-assessment. Medical conditions are not easily divided into “simple” and “complex” and based on comorbidities there are often situations where a “simple” condition may require physician consultation. Not requiring a plan for referring all types of cases as appropriate places patients at risk. In addition, knowledge of when and how to refer a patient is a critical part of clinical training that should be carefully considered.

Nurse practitioner board certification is not equivalent to physician board certification. Physicians are required to take the USMLE licensing exam (which is 4 parts taken at different points in their training including an in-person patient simulation clinical skill exam), most physicians go on to be board certified in a specialty. The USMLE step 1 alone is 280 questions: Step 2 can be as many as 318 questions plus an in-person exam; Step 3 is 500 questions plus additional patient care simulations. The NP board certification is a multiple choice 150 question exam. Section 237.106 of AB 890 indicates that the board will evaluate competencies tested in the national exam and determine whether additional examination is required. For patient safety, it would seem critical to determine that first, before independent practice is given based on that exam, rather than later if it is determined the exam is not adequate. This assessment should be done prior to implementation of independent practice to assess whether the national certification exam accurately assess competency. If there are gaps, then education and training should be adjusted accordingly rather than developing a new assessment tool at the state level. In addition, the cost of developing this assessment should be entirely borne by the NPs and not transferred as a general expense for the Department of Consumer Affairs.

Doctorate of Nursing Practice (DNP) and Master’s degree programs are currently being offered online and are not accredited to meet specified standards for clinical practice. DNPs are not equivalent to medical training and further reducing the clinical practice requirement for DNPs poses the risk of individuals using the “doctor” title but actually having less clinical experience than other NPs.

 

Read all CMA's talking points here

View LACMA's AB 890 letter to Senator Anthony Portantino here