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Nurse practitioners advocating through boards and commissions

Kaplan, Louise, PhD, ARNP, FNP-BC, FAANP, FAAN

doi: 10.1097/01.NPR.0000546448.88388.e9
Department: Advocacy in Practice

Louise Kaplan is an associate professor at Washington State University Vancouver, Vancouver, Wash., and family NP at Tumwater Family Practice Clinic, Tumwater, Wash.

The author has disclosed no financial relationships related to this article.

The Nurses on Boards Coalition launched an initiative in 2014 to place 10,000 nurses on corporate, health-related, and other panels, boards, and commissions. The coalition was responding to the 2010 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, which included a recommendation to increase the number of nurses in decision-making leadership positions.1

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Why should nurses serve on boards?

A recent study of nurses who serve on boards identified four key reasons why a nursing presence is so important: nurses are knowledgeable about a wide range of healthcare issues; possess a multitude of skills, including leadership, advocacy, and problem solving; offer a unique patient-centered, holistic perspective; and are afforded opportunities to influence policy, capitalize on consumer trust, and leverage nursing's perspective as the largest health workforce profession.2

The opportunity for NPs to influence boards and commissions can be far reaching. The author interviewed Tracy Klein, PhD, FNP, FAANP, FRE, FAAN, an assistant professor at Washington State University Vancouver College of Nursing. She is an exemplar of an NP who has made sustained, meaningful, and significant contributions to a statewide board. Currently, Dr. Klein is the only NP known to chair a state's drug use review/pharmacy and therapeutics committee.

Dr. Klein initially served on committees advising the state's Medicaid program beginning in 2002. This included terms on the Oregon Health Resources Commission subcommittees, which merged to become the Drug Use Review/Pharmacy and Therapeutics (P&T) oversight committee in 2011. Dr. Klein's appointments to these committees were all made by the governor of Oregon; her current appointment is through the Oregon Health Authority. Dr. Klein was elected vice chair by the P&T committee in 2011 and was elected chair of the committee in January 2018.

Dr. Klein is the only NP who has served on the P&T committee. Oregon law is similar to that of many other states and provides only for pharmacist and physician representation. The law stipulates “two other people who are not physicians or pharmacists” are to be public members.3 With a committee comprised of physicians and pharmacists (even the other public member is a retired pharmacist), Dr. Klein reports that ensuring provider-neutral language is adopted in policies, educational materials, or prior authorization guidelines has been a challenge.

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Giving NPs a voice

“Physician” is often in the initial draft as a de facto term for “prescriber.” While the committee staff has been receptive to feedback, periodic monitoring of language needs to occur. The greatest challenge Dr. Klein has experienced has been in assuring the committee provides evidence-based review of medications and guidelines for prescribers.

Changes in both drug development and the public's expectation of access to new treatments have changed the FDA process to expedite access to drugs under the 21st Century Cures Act, which was passed in 2016.4 While proponents see this as advancing public health, the unintended consequence is that more drugs are being approved without testing on populations who may use them, such as the ill, older adult, or pediatric patient populations.5

Dr. Klein has been well regarded and well respected, which is evidenced by her election to lead the committee. She believes her successes influencing the committee are grounded in her longevity and presence, which provide a voice for the NP role and practice. This ensures NPs are recognized as prescribers and primary care providers (PCPs).

The committee is currently underrepresented by primary care and family practice providers. Dr. Klein and Dr. William Origer, her primary care physician committee colleague who is faculty for a family medicine residency program, have collaborated to ensure family practice providers have access to a wide range of medications for the Medicaid population; they have advocated for policies to minimize having to send a patient to a specialist to receive a medication unless it is necessary for safe use.

Dr. Klein and Dr. Origer have also encouraged consultation with a specialist (which may be by telephone or in writing) to allow prescribing via a PCP for medications that patients may need for ongoing chronic care but who may have barriers to physically visiting a specialist for every prescription. Oregon has a phone consultation line available with specialists at Oregon Health and Science University. The P&T committee policy recognizes phone consultation and telehealth as methods of providing access to expertise across the state.

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Greater NP influence and engagement

NPs can influence their state's P&T committees without being appointed as members. These committees are under great pressure to facilitate access to medications, some of which may not be safe and/or evidence-based. Meetings are public in most states but are rarely attended by individuals other than pharmaceutical representatives. NPs rarely send letters or comment on proposed regulations, and few testify as experts.

Dr. Klein urges a higher profile of NP engagement in the P&T process, even if it involves writing a letter or sending an email. NPs who teach should also encourage students to attend these meetings and learn more about the policy process. Faculty can integrate directly into courses general knowledge gained from committee meetings about the pharmaceutical industry and how and why drugs may be limited by the P&T committee.

What does the future hold for P&T committees, NPs, and the public? Dr. Klein is concerned about the incredible pressure P&T committees face to diminish the role of evidence in decision-making; she believes the public would be surprised they can be prescribed a medication that is FDA-indicated. However, it has never been tested on someone in their age group or with their condition and comorbidities.

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Strong evidence produced by P&T committee reviews is accessible to prescribers from any state. Dr. Klein encourages prescribers to educate themselves and communicate with their patients about the implications of expanded drug access, such as that facilitated by the 21st Century Cures Act and the Right to Try Act of 2017.4,6

Dr. Klein has made major contributions to the health of Oregon citizens through her work on the P&T committee. She also is involved with professional NP organizations, serving on the Board of Directors of ARNPs United of Washington State and the Board of Directors of the American Association of Nurse Practitioners. Dr. Klein is a role model for NPs who exemplifies advocacy in practice that extends beyond the exam room.

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1. Nurses on Boards Coalition. 2018.
2. Sundean LJ, Polifroni EC, Libal K, McGrath JM. The rationale for nurses on boards in the voices of nurses who serve. Nurs Outlook. 2018;66(3):222–232.
3. Oregon Revised Statutes. Committee established, membership. 2017.
5. Herink M. A review of implications of FDA expedited approval pathways, including the breakthrough therapy designation. The Oregon State Drug Review. 2018.
6. Right to Try Act of 2017. 2018.
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