Skip to content

Melissa Patrick

Nurse practitioners want to change law that requires them to make deals with physicians to prescribe strong painkillers

By Melissa Patrick

May 25, 2017

This story by CHMP Media Fellow Melissa Patrick first appeared on the Kentucky Health News website.


Nurse practitioners Julie Gaskins, left, and Beth Partin own Family First Health in Columbia. (Photo by Melissa Patrick)

Since 2006 Kentucky’s nurse practitioners have been able to prescribe Schedule 2 drugs, the highest level of legal painkillers, under the supervision of a physician. Now their lobbying group says it’s time to let them work without that restriction because it creates a barrier to care that is badly needed.


Nurse practitioners are advanced practice registered nurses with up to seven years of education, including post-graduate training. They may prescribe medications, diagnose conditions, order and interpret tests, and deliver general care.


Once a Kentucky nurse practitioner works under the supervision of a physician of the same specialty for four years, he or she may prescribe drugs on their own for medical conditions such as high blood pressure or diabetes. But to prescribe Schedule 2 drugs such as opioids, they must have an ongoing “collaborative agreement” with a physician to do so, regardless of their experience.


“A collaborative agreement is for prescribing only; there is no oversight written into the contract,” said Jessica Estes, a psychiatric mental health nurse practitioner in Lewisport. “The physician doesn’t have to review any of my charts. I don’t have to call the physician every time I write one. I only have to have that collaborative in the event I needed to have a conversation with him,” adding that in her 14 years of practice she has only consulted with her collaborator two or three times.


Estes said nurse practitioners are trained to work independently without any supervision over their prescribing. “In fact, I do tele-psychiatry in Minnesota, where I’m completely independent” under that state’s law, she said. “Our scope of practice is actually limited by having to have that collaborator in Kentucky to be able to write those prescriptions.”


The American Association of Nurse Practitioners says 22 states and the District of Columbia allow nurse practitioners to practice with no restrictions on prescribing; 16, including Kentucky, have reduced prescriptive authority; and 12 are considered restrictive. Kentucky has more than 5,400 nurse practitioners.


Being able to prescribe Schedule 2 drugs is not just about being able to prescribe pain pills, said Elizabeth “Beth” Partin, a 25-year family nurse practitioner.


“It’s not always about pain,” Partin said, adding that the lack of a collaborating doctor leaves a nurse practitioner unable to prescribe medications for anxiety, insomnia, shingles, nerve pain, certain cough medicines or attention-deficit hyperactivity disorder – conditions that are often seen in a primary-care office.


Nurse practitioners often struggle to find a physician willing to sign an agreement for non-scheduled drugs, but it’s even harder to find one that will sign an agreement for controlled substances, especially since some insurance companies are refusing to pay for a nurse practitioner’s services unless their collaborating physician is also a provider for them.


Jessica Estes, psychiatric nurse practitioner in Hancock County, testified at a 2014 Senate Licensing & Occupations Committee meeting about a law that allows prescriptive authority for non- scheduled drugs after four years of supervision. (photo provided)

Estes said the psychiatric nurse practitioners in her group experienced this with WellCare, a managed-care organization for Medicare and Medicaid plans. She said because her collaborating psychiatrist was a private physician who accepted no insurance, the group had to change collaborators and ended up signing with a family practice physician who sees enough psychiatric patients to meet the requirements — and was willing to accept WellCare.


“Last year between the four nurse practitioners, we saw about 2,000 visits that were WellCare clients,” Estes said. “If I had not been able to secure that collaborator that also took WellCare, that’s 2,000 patient visits that we would not be able to see in 2017. They would have had to find a new provider.”


She owns Estes Behavioral Health, LLC, which serves more than 6,000 patients, an equal mix of adults and children, from 11 counties. She said about 40 percent of their patients are on Medicaid.


In “most of the counties that we serve, there really aren’t any other providers,” Estes said. “We’ve not run a single ad in the five years we’ve been open; it’s all word of mouth.”


Partin and her daughter, Julie Gaskins, also a nurse practitioner, are co-owners of Family First Healthcare, a rural health clinic in Columbia. Their practice has over 6,000 patient visits a year, with 72 percent of their patients on Medicare or Medicaid.

Traveling from Partin’s clinic in Columbia to Estes’ behavioral- health clinic in Lewisport takes a while. (Google map adapted)


Partin said it takes about three to four months for new patients to get an appointment in Estes’ practice, about 124 miles from her clinic. Adair and Hancock counties are in two of the 87 Health Provider Shortage Areas in the state.


Psychiatric collaborative agreements are also hard to secure because Kentucky has such a shortage of mental health providers. The Association of American Medical Colleges reports that Kentucky has 362 active psychiatrists, or 1 for every 12,192 Kentuckians, and almost 40 percent of them are 60 or older. Estes said the state has fewer than 150 psychiatric APRNs.


“I just had a conversation this week with one of my former nurse-practitioner students who would like to do some private practice on her own, and she’s called seven psychiatrists and they’ve all turned her down, because they are either employees of large organizations or they want an amount of money that she couldn’t afford to pay,” Estes said.


While some collaborating physicians don’t charge anything, most charge between $500 and $5,000 a month, or take a percentage of the nurse practitioner’s annual earnings, Estes and Partin said.


Estes said psychiatric nurse practitioners in Kentucky who can’t find a collaborator either end up working for a large medical group or hospital, or work in tele-psychiatry in states that don’t require such an agreement.


Lobbying and legislating

Legislation to remove the collaborator requirement for prescribing Schedule 2 drugs was introduced during the 2017 legislative session as Senate Bill 158, but did not make it out of committee. The Kentucky Coalition of Nurse Practitioners & Nurse Midwives is in the “early stages” of the legislative process for the 2018 session, said Partin, who has held a leadership role in all nurse-practitioner legislation in Kentucky since 1992.


Her adversaries are the Kentucky Academy of Family Physicians and the Kentucky Medical Association, which have said they do not support any change to the law, contending that it would add to the prescription-drug abuse that continues to plague the state.


KAFP President William C. Thornbury said in a statement,”Family physicians believe SB 158 conflicts with our governor’s policy to combat opioid abuse.” The KMA said, “With the ongoing issue of prescription drug abuse and the discussions around the country about the issue, we would oppose any changes to the current law.”


Senate President Robert Stivers, R-Manchester, who voted against the 2006 bill that expanded nurse practitioner’s Schedule 2 prescription authority, told members of the Senate Judiciary Committee in March that he would be looking into why “half” of the pain pills written in his hometown of 20,000 were written by nurse practitioners — a town that has 12 pharmacies and around 150 opioids prescribed per person each year.


Nurse practitioners disputed the alleged connection between the prescribing authority of nurse practitioners and the over-prescribing of opioids, citing data from the Kentucky All Schedule Prescription Electronic Reporting system.


“The problem in Kentucky existed prior to our ability to write those controlled substances,” Estes said. “The KASPER data very clearly shows that we are not the providers that are writing the majority of those prescriptions.”


Heather Shlosser, director of the psychiatric-mental health nurse practitioner program at Frontier Nursing University in Hyden, said efforts to decrease the number of opioid prescriptions will depend on making sure providers are trained to prescribe them based on evidence-based guidelines — and changing the culture of patients so that they understand that a pill is not always the answer, rather than simply limiting the disciplines that can prescribe them.


“Restricting practice is not helping to expand access and it’s not helping to educate the NP any further than where you stop them with the restriction,” she said. “All the literature tells us that the outcomes are the same whether the care is provided by the physician or a nurse practitioner.”

Tammy Adamson, a patient of Partin’s: “I’ve never had an experience here as to where they didn’t give me the time that I needed, and explained things to me.”  
(Photo by Melissa Patrick)


Gaskins said nurse practitioners are trained to take a holistic approach to care that focuses on education and prevention along with the use of appropriate medications.


Kentucky law only allows psychiatric nurse practitioners to write 30-day prescriptions for ADHD medications with no refills, and primary-care nurse practitioners are limited to a 72-hour prescription.


“That’s a huge problem, especially in Kentucky,” said Shlosser, who is also a mental health nurse practitioner in New Hampshire. “Kentucky has the highest rate of children being diagnosed with ADHD, according to the Centers for Disease Control [and Prevention].”


The CDC reports that 19 percent of Kentucky children aged 4 to 17 have ever been diagnosed with ADHD, compared to 11 percent of children nationwide.


Shlosser added that likely means “a huge number of children” in Kentucky need care for ADHD, but don’t have access to it or have to wait months or drive great distances to get care.


“That is not helping the 10-year-old kid that is struggling,” she said. “We are as providers constantly telling patients, ‘Get treatment, get help, you need to get it together,’ but where are they supposed to go if there are no providers?”



This article was produced as part of the Health Care Workforce Media Fellowship of the Center for Health, Media & Policy, New York, N.Y. The fellowship is supported by a grant from the Johnson & Johnson Foundation. Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Melissa Patrick

Kentucky nurses and their allies seek a mandate for a nurse in every school

By Melissa Patrick

May 9, 2017

– Advocates say move would improve learning outcomes


Kari Hall, Certified Medical Assistant, with a Madison County student

Putting a full-time nurse in every Kentucky school would not only provide health care, but improve education outcomes, say advocates of the idea.


“We need a nurse in every school because we need to quit thinking about health and education as separate entities, because they are not,” said Eva Stone, an advanced-practice registered nurse and co-chair of the school-nurse initiative being mounted by nurses’ groups and their allies.


One of their strongest allies is retired educator Terry Brooks, executive director of Kentucky Youth Advocates, says he is “absolutely convinced that the non-cognitive issues that kids face, like health, have as much to do with their capacity to learn as a teaching method.”


Brooks added, “There is only so much blood that you can wring out of a turnip when it comes to teaching methods. You always want great teaching methods, but my goodness, we have been working on that for decades with results that are a whole lot more the same than they are different. So if it is not producing significant change, we’ve got to look for something else. . . . You are not hearing me say that this is a silver bullet, that, boy, a school nurse is going to fix everything, but I think the presence of a school nurse not only impacts kids’ health, but it impacts the kids’ capacity to learn.”


Those assertions are supported by research, including a recent study that looked at the association between school nurses and academic outcomes of high-school students. It showed that when there was a nurse in a public high school on a full time, every-day basis, graduation rates were higher, absentee rates were lower and ACT scores were higher,” Teena Darnell, assistant professor of nursing at Bellarmine University, said about her research.


“And traveling nurses showed no significance on any level. So if you had a part-time nurse, there was no significant difference on academic performance,” said Kathy Hager, a Bellarmine nursing professor and president of the Kentucky Nurses Association.


Hager is also a member of the “Every School Needs a Nurse, Every Day” initiative that is advocating mandates for a full-time nurse in every public school, as recommended by the American Academy of Pediatrics.


The National Association of School Nurses supports a ratio of one nurse for every 750 healthy students. This was the recommendation of the pediatrics academy until just last year, when it changed its recommendation to a nurse in every school, saying that “The use of a ratio for workload determination in school nursing is inadequate to fill the increasingly complex health needs of students.”


Kentucky has one nurse for every 1,254 students, according to a 2011 KYA report, the latest data available. The Kentucky Department of Education only records nurses hired by school boards (187 this year) and does not include any hired by different funding streams.


Darnell’s research found that 42 percent of Kentucky’s high schools had a full-time nurse, 37 percent had a part-time nurse and 20 percent of them didn’t have one at all. Among all schools, 44 percent had full-time registered nurses; 48 percent had either RNs or licensed practical nurses.


State law requires schools to “make any necessary arrangement” to provide for the immediate health needs of students. Stone said they “do that for the most part, but . . . there is no system of monitoring in place.”


When a nurse isn’t available, student health services are often provided by school employees who are trained to provide those services. Many students have conditions that need frequent attention.


Out of 655,475 students enrolled in Kentucky’s public schools last year, 20,711 were diagnosed with attention deficit hyperactive disorder, 14,054 with allergies, 55,897 with asthma, 1,142 with Type 1 diabetes and 5,259 with a seizure disorder, according to the KDE.


Vicki Williams, RN, Calloway County

Vicki Williams, school-health coordinator and one of three school nurses in Calloway County, which has about 3,400 students, said the school system has about 150 employees who have completed medication training, and others who know certain medical procedures, like blood-sugar testing, taking blood pressure and using g-tubes to the stomach.


And though she is allowed to delegate administration of insulin to other employees, Williams said she isn’t comfortable doing that. “That is where I will draw the line,” she said. “I will not train anybody to give insulin except myself and any other licensed nurse in my building.”


She said schools have many distractions and “Too much insulin is life threatening, and I don’t feel comfortable putting that on somebody who has not had more training than a quick diabetes training after school one day.”


Hager didn’t question that unlicensed employees can be trained to provide such services, but said what they don’t have are the assessment skills of a school nurse. “It takes years of experience to recognize what a person looks like with a low blood sugar reaction,” which often occurs with young diabetics, she said.


Read More →

Melissa Patrick

Seeking Solutions to Kentucky’s Nursing Shortage: Part II

By Melissa Patrick

April 7, 2017


Ed. note: This is the second of a two-part look by CHMP Media Fellow Melissa Patrick at nursing shortages in Kentucky hospitals. How are they, and nursing schools, coping with demand? In many ways, Kentucky’s situation mirrors the challenges in other states – which hit rural areas especially hard. Read Part I here.


This article was originally published by Kentucky Health News. Reprinted with permission as part of the CHMP Nursing and Healthcare Workforce Media Fellowship.


Staffing solutions and challenges

Both Highlands Regional Medical Center in Prestonsburg, and University of Kentucky HealthCare said shortages and a need for specialty trained nurses have caused them to start using agency nurses again.


Agency nurses, also called travel nurses, take short-term contracts that allow them to easily take time off or move around. Their contracts are usually for three months at a time.


“We have not used travel nurses in probably five to seven years,” said Susan Ellis, vice president of Patient Care Services of Highlands. “Their expense is higher than normal. . . . When you thnk for one nurse, you could potentially be paying double,” adding that this added cost “can actually put a small facility on the edge.”


Colleen Swartz, chief nurse executive at UK HealthCare, said the health system had not used agency nurses for more than a decade, but they now make up almost 2 percent of their nursing workforce, mostly in specialty areas where it takes time to train someone.


“We have a rigorous screening process we go through before we accept anyone in that agency kind of format, but honestly we’ve had some really clinically strong nurses come through who we’ve been able to utilize during this period where we’ve been unable to hire ourselves,” Swartz said.


Highlands Regional Medical Center (website photo)

Highlands also offers a sign-on bonus and an incentive program for employee referrals, but Ellis said traveling-nurse agencies also offer this incentive and have lured several of her nurses away.


“And just like I’m trying to use my staff to recruit nurses, the travel companies actually use their staff to recruit staff to travel. And we have lost individuals in our organization who wanted to go travel because they hear about this bright, shiny money travel adventure and they sign on,” she said.


In addition, Highlands is planning to hire four internationally trained nurses, who would commit to working there for two years. Ellis said they would be paid the same as the current staff, but the hospital would be responsible for their recruiting costs, including immigration fees upward of $15,000 per RN.


“I think it is another way to help the problem, and let’s say I’m cautiously optimistic,” she said.


But Fran Feltner said, “I’m not sure it is the answer.” Feltner is director of UK’s Center of Excellence in Rural Health, which focuses on improving health-care provider shortages in Appalachia.


Feltner said she understood why hospitals use internationally trained nurses, but also said they can create a language barrier to care for patients and families who already may struggle with health literacy.


Highlands has also revived its nurse-intern program as a recruiting tool. This paid “shadowing” program, which includes 14 student interns from the local nursing school, pairs an intern with a registered nurse in a department of the student’s interest, in hopes they will join Highlands upon graduation.


The program seems to be working, at least for Samantha Thomas, who will graduate in May with an associate degree in nursing from Big Sandy Community and Technical College in Prestonsburg. Thomas said she joined the internship program to explore working in the intensive care unit and plans to continue working there after graduation.


“I think it’s a really great way for Highlands to recruit nurses because once we work there, then we will want to stay,” she said. “I think I’ll stay there for at least two years until I’m really comfortable with my skills — and I may stay there forever.”


Highlands may be on to something.


UK’s Swartz, who was chief nursing officer at Clark Regional Hospital in Winchester, said that while it is often hard to recruit nurses to rural areas, once they hire on, they are often “so committed to that facility and to the people there, it was very much a service orientation to that community.”


Swartz said UK HealthCare doesn’t offer signing bonuses or incentives for employee referrals, but does have an aggressive recruiting program that touts their “amazing benefits package.”


Appalachian Regional Healthcare, an 11-hospital system that serves Eastern Kentucky and West Virginia, is reported to have severe nursing shortages, with around 177 RN job openings listed on its website, as well as many for licensed practical nurses. ARH also offers a $5,000 signing bonus for qualified full-time RNs and a $2,000 incentive to employees for referring an RN who is hired. To further meet the “dire need for nurses in Eastern Kentucky,” ARH has formed a partnership with Galen College of Nursinga private nursing college, at ARH Hazard, which opened for its first class of associate-degree students in March.


ARH opted to not answer questions on the subject.


Partners in education

Through a strategic partnership, Swartz said UK’s College of Nursing has increased its number of graduates from 80 to 200 over the past five or six years to help the hospital meet its staffing needs.


“But honestly right now, we can probably take another doubling of class size,” she said. “The last several years we hired almost 600 nurses every year because of the growth phases that we’ve been in.”


Swartz said the hospital has had to become more “intentional and deliberate” in planning for recruitment, strategically timing the openings of floors in its new pavilion with graduation dates.


Many nursing-education programs find it hard to expand because they have aging faculty, who must be doctoral-prepared, and non-competitive pay, not to mention limited clinical access for training and student/faculty ratios that are mandated by the state. UK’s College of Nursing just posted five open faculty positions.


Another staffing challenge is that many nurses come immediately out of nursing school with their sights already set on the next job, such as nurse-midwife or nurse practitioner. Swartz said it is not unusual for UK HealthCare to turn over 12 to 15 nurses each year who leave to become certified registered nurse anesthetists.


The American Association of Colleges of Nursing says that in 2014, entry-level Bachelor of Science in Nursing programs turned away 50,681 qualified applicants. This has been common in Kentucky.


There is also a push for nurses with associate degrees, who make up 60 percent of Kentucky’s registered nurses, to get baccalaureate degrees. The state has 15 BSN programs and 40 associate-degree programs.


UK College of Nursing graduates (photo provided)

UK Nursing Dean Janie Heath said the Institute of Medicine recommends that 80 percent of the nursing workforce should be educated at the baccalaureate level by 2020, because there is growing evidence that links nurses with higher education levels to better health outcomes for patients.


“Kentucky, as well as the rest of the country, is moving the needle, but we are not going to make that 2020 mark,” Heath said.


Technology may help. The UK nursing college moved its RN-BSN program fully online in the fall of 2015, after research found that most RNs in Kentucky have easy access to computers and the internet.


And as many hospitals in the state do, both Highlands and UK HealthCare offer tuition reimbursement for employees who further their education.


Patricia “Pat” Burkhart, professor and associate dean of undergraduate faculty affairs at UK’s nursing college, said faculty are working on innovative ways to further develop the nursing workforce, with a focus on second-degree students and second-career military medics.


“What they have wanted is more fast pace,” Burkhart said. “Where our traditional students want their summers off, second degree, which we are calling second-career medics or second-degree students, want to get it done as quick as they can and want to go through the summer, so we are looking at a different model now for them.”


Looking to the future, Health said nursing schools must make sure they are educating students to have primary-care competencies, so they can manage individuals, families and communities.


Resiliency and Retention

Heath said UK’s College of Nursing is working hard to make sure its graduates have the skill sets they need to work in today’s complex environments, whether urban or rural, putting top priority on helping them learn to be resilient.


“Science is there,” Heath said, “that if we are not taking good care of ourselves, we can’t take good care of our patients, our families, our communities.”


Burkhart said, “We are seeing students coming in who are graduates that are looking for work-life balance, so much more than our generation.” She said the industry isn’t adjusting “fast enough” to this changing attitude.


Heath said it’s important for health-care facilities to create healthy environments as a way to retain nurses, suggesting the need for policies and practices that let nurses know they are supported, including things like building inter-professional relationships, or even as simple as providing pet therapy for the staff. Studies show that healthy work environments create better health outcomes for patients, she said.


“It’s the simple things,” she said. “Things like abusive behavior, bullying, screaming, yelling is not tolerated in this environment. You know, when you’ve got that coming out from the top — of zero tolerance of inappropriate behavior — that didn’t cost a thing.”


Burkhart added, “I think we all knew that we needed a caring environment for our patients, but I think [what] we are now being responsive to is that caring environment needs to translate to the staff as well, whether it is respectful discourse, or confidentiality, or the little things that show that you care about your staff, just the way we are asking staff to care about patients. Every patient, every time.”


An example of this philosophy in action is St. Joseph Martin, a critical-access hospital with 25 beds that employs about 45 RNs and is part of KentuckyOne Health. It has been selected as one of the best places to work among small employers in the annual Best Places to Work in Kentucky list for the past three years.


Billie Turner, the hospital’s chief nursing officer and vice president of patient-care services, said it doesn’t have a nursing shortage because it has a great place for nurses to work: “I strongly feel that it is a good work environment, more so than anything else, that helps us with retention.”


This article was produced as part of the Health Care Workforce Media Fellowship, run by the Center for Health, Media & Policy, New York, N.Y. The fellowship is supported by a grant from the Johnson & Johnson Foundation. Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.


Melissa Patrick