AAPPN would like to thank Connie Huffine and Claire Foote for their tremendous work in recording AAPPN’s history.
Early Political Activism
Since its establishment, NWACSPSN (a forerunner of AAPPN) members have been involved in the political process. In 1986, the Washington State mental health reform bill, SB 6400, threatened budgetary cuts for mental health services. Founded by members who had lobbied the legislature to save the UW Department of Psychosocial Nursing, now as an organization, psychiatric clinical specialists found their political voice. NWACSPSN officers met with policymakers to articulate the Association’s support for continued funding for mental health services. In embracing the political process, the organization helped mitigate a potentially devastating reduction of mental health services.
The development of political activism among psychiatric nurse practitioners and clinical specialists allowed them to become part of the collective of advanced practice nurses of all specialties. NWACSPSN became involved in the political activities led by the Washington State Nurses Association. For the first time, WSNA sought psychiatric nurse practitioners’ representation in the developing Nurse Practitioner Special Interest Group (NP-SIG). Until then, there had been a sense that NPs of other specialties had not considered psychiatric nurse practitioners as legitimate nurse practitioners.
Most of the organization’s early leaders were graduates of the UW Department of Psychosocial Nursing. Many had received grants and stipends to support their education. While in graduate school, they developed professional independence and leadership skills. NWACSPSN leaders used those skills to take on such issues as clinicians’ ethical, boundary and clinical guidelines stemming from the development of managed care systems. In the end, one of the most significant outcomes of the work of these nurse practitioners was a seat at the health care policy table. Psychiatric nurse practitioners became legitimized as players in the health care policy system of Washington State.
The Changing Mental Health Environment: Policy and Legislative Achievements of the 1990s
When one considers that less than two decades earlier the prevailing image of the nurse was a woman at the hospital bedside, dressed entirely in white and wearing a white cap, the struggle that Washington State advanced practice nurses waged beginning in the late 1980s and successfully continued throughout the 1990s was remarkable. In late 1988 and early 1989, WSNA formed the Nurse Practitioner Special Interest Group (WSNA NP-SIG), comprising Certified Registered Nurse Anesthetists (CRNAs) and Advanced Registered Nurse Practitioners (ARNPs) across various specialties. NP-SIG was formed to bring to the Washington State legislature the need for completion of prescriptive authority for ARNPs and CRNAs, to include drugs in Schedules II through IV. January, 1989 saw the beginning of a 16-year legislative process to complete prescriptive authority, with Claire Foote and Susan Caverly representing NWACSPSN and psychiatric nurse practitioners.
Within a couple of years of its formation, WSNA NP-SIG evolved into ARNPs United of Washington State, with Susan Caverly and Bob Smithing, a family nurse practitioner, serving as the first co-chairs. NWACSPSN, other Washington advanced practice nursing organizations, and ARNPs United worked to ensure that advanced practice nursing had a voice in writing health care policy and providing clinical services in Washington State.
As the prescriptive authority battle continued, NWACSPSN members worked on other important legislative topics. For example, the 1993 – 1995 Mental Health Stakeholders Group was formed to develop the Washington State Basic Health Plan (BHP). The participation of Martha Herriott and Susan Caverly gave AAPPN an influential voice in determining how mental health services in Washington State would be rationed under the BHP.
In 1996, a year-long ARNP Roundtable was established by the Washington State Nursing Care Quality Assurance Commission to explore possible ways to simplify regulations that would increase flexibility for ARNPs wishing to add specialty areas or to move into other practice arenas. Several AAPPN members served on the roundtable, including Mary Kay Tomko, Reba McGear, Patty Hayes, and Martha Herriott.
The Next Developmental Step: NWACSPSN becomes AAPPN
In 1992, the expansion of managed care in Washington State, and its impact on patients and on the community, became a growing concern to Washington’s mental health clinicians. Claire Foote and Nina Ramsey were two of the founding members of an interdisciplinary group of mental health providers who formed The Washington State Consortium for Mental Health (which evolved into the Washington State Coalition for Mental Health Professionals and Consumers). The Consortium was organized to advocate for mental health consumers; this included lobbying the Washington State legislature to ensure ethical mental health care. (See Addendum 2) NWACSPSN’s next developmental milestone was an outgrowth of Ramsey’s and Foote’s work with the Consortium. A group of NWACSPSN leaders comprised of Susan Caverly, Claire Foote, Martha Herriott, Donna Poole, and Nina Ramsey met to discuss restructuring the association into a more comprehensive, more formal, and more proactive organization. The new structure would allow the organization to become more visible and to have its points of view represented in Olympia and among non-nursing mental health colleagues. Although advanced practice psychiatric nurses comprised only 1% of all mental health professionals in Washington State, colleagues from other mental health disciplines had begun to look to NWACSPSN members for leadership. This ad hoc leadership group conceived of and planned NWACSPN’s first summit.
The May 7, 1994 NWACSPSN Nursing Summit, held at Northwest Hospital, was pivotal in the history and function of the organization. Members voted to reorganize into a proactive, politically active organization.
The group voted to realign conceptualization of its interests in the following ways:
- To monitor changes in the health care system as they relate to advanced practice psychosocial nursing.
- To transform the role the organization would take in relation to these changes, becoming much more active in the political and legislative arenas. This included contracting with a lobbyist to represent the organization before the Washington State Legislature.
- To ensure that advanced practice psychiatric nurses continued to be legally defined as independent providers.
- To ensure that regulatory barriers to the independent practice of psychiatric and mental health advanced practice nurses would be removed, and that new barriers limiting advanced practice nurses’ full participation in the new health care system would not be implemented. One immediate problem restricting ARNP practices in all settings was the limit against ARNPs prescribing medications in Schedules II through IV. Another barrier to independent practice was a law that prohibited ARNPs from practicing and shareholding in corporations with other licensed professionals.
- To ensure that comprehensive mental health benefits would be included as part of the Washington State Basic Health Care Plan.
In 1994 the bylaws were changed and the organization became the Association of Advanced Practice Psychiatric Nurses (AAPPN). Patty Hayes, a graduate of the UW Department of Psychosocial Nursing, was hired as AAPPN’s first lobbyist, and the monthly newsletter was initiated, replacing minutes previously sent to members. On January 30, 1995, AAPPN members were part of a contingency of 60 ARNPs who lobbied legislators in Olympia supporting WSNA’s first legislative day. AAPPN became incorporated as a 501 c (6) on July 14, 1995.
The Association’s reorganization provided AAPPN with financial resources to hire a lobbyist, which increased the organization’s activity and political clout in Olympia. Two bills that were priorities for AAPPN in the 1996 legislative session were SSB 6150, which allowed certain licensed health care professionals to form corporations (which had previously been prohibited); and SB 6129, which prohibited health insurance carriers from writing contracts that denied enrollees and mental health practitioners the option of contracting privately at the enrollee’s expense when benefits have ended.
Hiring a lobbyist also allowed AAPPN to become more involved in working not only on legislation directly related to mental health services and professional practice, but also on broader legislative issues. The 1996 legislative session saw the passage of two important pieces of legislation for which AAPPN’s lobbyist testified: (1) SHB 2420, a bill prohibiting anyone convicted of domestic violence gross misdemeanor or felony from firearms possession until restored by the court, and (2) ESHB 2262, a legislative attempt toward the prohibition of same gender marriage.
In 1998, AAPPN provided input regarding the first Washington State Senate bill on mental health parity. It took from 1998 until 2005 for mental health parity to be enacted in Washington State. This act prohibited insurers from imposing treatment limitations on mental health services if they do not impose comparable limitations on treatment for medical and surgical care. It did not take full effect until July 1, 2010.
Prescriptive Authority: The Signature Battle to Protect Independent Practice
As early as 1989, WSNA began legislative work to complete prescriptive authority. The prescriptive authority battle was epic.
Nurse practitioners were first licensed in Washington State in 1973. In the 1979 Washington State legislation that granted independent prescriptive authority to nurse practitioners, prescriptive authority was limited to legend and Schedule V drugs. Washington State nurse practitioners recognized the importance of and need for the inclusion of scheduled drugs within their prescriptive authority. As noted above, beginning in January, 1989, Susan Caverly and Claire Foote represented advanced practice psychiatric nurses on the WSNA committee that formed that month to bring to the Washington State legislature a bill to include Schedules II through IV drugs within ARNPs’ prescriptive authority. When this proposed bill was initially brought to the Washington State legislature in early 1989, the Washington State Medical Association (WSMA) stated on the record that not including scheduled drugs in NPs’ prescriptive authority in the original legislation had been “an oversight” and should be corrected. However, within two weeks, the national organization representing anesthesiologists convinced WSMA to withdraw its support, and completion of NPs’ prescriptive authority rapidly became a political and professional turf issue between physicians and NPs. It took the investment of arduous hours by numerous people, many years, and the hiring of multiple lobbyists to achieve completion of prescriptive authority for ARNPs. This work was not completed until 2005. It took over 16 years.
Legislative session after legislative session, organized advanced practice nursing in Washington State continued to pursue prescriptive authority completion, while organized medicine continued to fight against the efforts of ARNPs and CRNAs. In 1997, the ninth legislative session since beginning this process, WSMA proposed that it would support prescriptive authority completion for ARNPs – with the qualifier that instead of being licensed by the Washington State Nursing Care Quality Assurance Commission, advanced practice nurses would be licensed by the Washington State Medical Quality Assurance Commission, effectively making ARNPs’ practices in Washington State dependent on physicians’ licenses, similar to the practices of physician assistants. Limiting ARNPs’ autonomous practice was not acceptable to the members of the profession. That Washington legislative session ended in yet another standoff.
The AAPPN March, 1997 newsletter included the following article regarding efforts that legislative session toward completion of prescriptive authority:
“SB 5232 was heard and passed with an amendment on February 3, 1997 in the Senate Health and Long-Term Care Committee. The first draft made by the WSMA placed this agreement under the Medical Quality Assurance Commission and the Board of Osteopathic Medicine. This would have left ARNPs with no say in the rule-making of the law. AAPPN rejected this. The final amendment described a ‘collaborative’ agreement to be implemented between an individual ARNP and an individual physician authorizing that ARNP to prescribe medications in Schedules II through IV. Terms of such collaborative agreements would be jointly developed by the Washington State Nursing Commission (NCQAC), the Washington State Medical Commission and the Board of Osteopathic Medicine. NCQAC had ultimate determination regarding terms of the “collaborative agreement.” Because of this, Washington State Medical Association (WSMA) did not support the bill that passed out of committee. AAPPN issued a call for members to contact their legislators.”
During the 1998 legislative session, Senator Deccio introduced his own “compromise” bill, essentially the WSMA proposal from 1997, which was based on the long-rejected idea that ARNPs could be allowed to prescribe drugs in Schedules II through IV under supervision of an MD or DO. Rules for implementation were to be developed jointly by the boards of Medicine, Osteopathy, and Nursing. Deccio’s 1998 “compromise” was that the board of nursing (NCQAC) would be one of the participants in writing the rules for this legislation. AAPPN’s response to this bill differed from that of ARNPs United: AAPPN’s position was that to support the Deccio bill would be dangerous and reckless. Ultimately, SB 3252 died in the Senate Rules Committee.
By 1999, AAPPN had decided to focus its prescriptive authority efforts on psychiatric/ mental health nursing only, and a new bill was drafted solely for this specialty. However, when AAPPN was unable to gain sponsorship for the bill, it was decided that it would continue its efforts toward prescriptive authority completion for all ARNPs (SB5805).
In May, 1999 SB 5805 “Completing Prescriptive Authority for Advanced Registered Nurse Practitioners” passed the Senate. However, when the bill was not given a hearing that session in the House, ARNPs were promised a hearing in the 2000 legislative session.
In December, 1999 the AAPPN Prescriptive Authority Steering Committee (Donna Poole, Susan Caverly, Claire Foote, Martha Herriott, Nina Ramsey) published a position paper stating AAPPN’s position on any bill that would require physician collaboration: “We oppose SB 5805/HB 2057 and will not support any legislation that weakens independent ARNP practice in Washington State.” In that position paper, the Prescriptive Authority Steering Committee recommended that WSNA mediate between AAPPN and ARNPs United in order to determine a mutually acceptable plan “to let SB 5805/HB 2057 die.” (See Appendix 1)
The following session, 2000, saw the passage of SSB 5805, which required a joint practice agreement (JPA) between an individual ARNP and a designated MD or DO in order for ARNPs to prescribe scheduled drugs; it was implemented in 2001.
SSB 5805 included the following language:
“Sec. 3. RCW 18.79.240 and 1994 sp.s. c 9 s 424 are each amended to read as follows:
(1) In the context of the definition of registered nursing practice and advanced registered nursing practice this chapter shall not be construed as: …
(s) Prohibiting advanced registered nurse practitioners from ordering or prescribing controlled substances as defined in Schedules II through IV of the Uniform Controlled Substances Act, chapter 69.50 RCW, if and to the extent: (i) Doing so is permitted by their scope of practice; (ii) it is in response to a combined request from one or more physicians licensed under chapter 18.71 or 18.57 RCW and an advanced registered nurse practitioner licensed under this chapter, proposing a joint practice arrangement under which such prescriptive authority will be exercised with appropriate collaboration between the practitioners. The medical quality assurance commission the board of osteopathic medicine and surgery, and the [nursing care quality assurance] commission are directed to jointly adopt by consensus by rule a process and criteria that implements the joint practice arrangements authorized under this subsection. (SSB 5805, p.4)
A number of AAPPN members declined to seek prescriptive authority under the auspices of a joint practice agreement.
Early in the 2005 legislative session, armed with data documenting ARNPs’ safe prescribing practices for scheduled drugs in the years since the JPA was implemented, ARNP leaders and lobbyists across specialty areas returned to Olympia, seeking legislation to lift the requirement of joint practice agreements with physicians. By early February, hearings were scheduled in both the House (HB 1479) and Senate (SB 5516). The bill passed the House on March 3, 2005, and passed the Senate on April 5.
On April 13, 2005, Governor Christine Gregroire signed into law House Bill 1479, “Regarding independent prescriptive authority for advanced registered nurse practitioners.” This bill removed the previously mandated joint practice agreement (JPA) between ARNPs and physicians for prescribing drugs in Schedules II through IV. Further, it removed MQAC and the Board of Osteopathic Medicine and Surgery from any authority relating to ARNPs’ full prescriptive authority, placing full authority for rule writing and enforcement under NCQAC. At long last, after 16 years of effort, ARNPs could now independently prescribe controlled substances. The law became effective on July 24, 2005. Referring to this accomplishment, Sharon Case, AAPPN’s lobbyist, wrote in the AAPPN June, 2005 newsletter, “The year 2005 will be historic in the annals of nursing and mental health public policy in Washington State.”
Legislative work by Washington State nurse practitioners, including completion of prescriptive authority, continues to serve as a model for state regulations concerning advanced practice nursing throughout the United States.
The Work Continues
AAPPN’s first 25 years marked the end of an era for the organization with completion of prescriptive authority. Advocacy for ethical mental health care and state regulations continues. Through its own activities, as well as in collaboration with other mental health colleagues in Washington State, AAPPN has both fostered the development of advanced practice psychiatric nursing and continues its work to protect quality ethical mental health services.