Missouri faces a shortage of primary care physicians, particularly in rural and underserved communities, making it challenging for residents in some parts of the state to access health care services.
Advanced Practice Registered Nurses (APRNs) can provide an alternative because they are trained to assess, diagnose, treat and prescribe for medical conditions in much the same way optometrists are trained to assess, diagnose, treat and prescribe for eye-related conditions.
But rules in Missouri restrict APRNs to practicing within 75 miles of their collaborating physician and require an initial one-month direct observation of practice between an APRN and an MD or DO and regular medical record reviews of the APRN from the MD or DO. What’s more, MDs and DOs cannot have collaborative practice with more than six full-time APRNs or physician’s assistants, and APRNs cannot conduct video visits or write for home health orders.
“I think it is very important to hear from nurses on the frontline,” said Pamela Talley, an MSN-DNP student in the College of Nursing who practices at CHIPs Health and Wellness Center on North Grand Ave. in the city of St. Louis. “We see the issues daily. We became nurses to take care of people, in response to seeing people suffer. Nurses have an ethical responsibility to advocate on behalf of those underserved populations. I believe it is a social justice issue and we must advocate for access to health care for all people.”
The students and faculty spent Tuesday morning talking to legislatures such as Sen. Steven Roberts and Sen. Brian Williams about access to health care, including for Talley’s clientele at CHIPS, a nurse-founded, free medical care clinic where most providers are volunteers in what is considered a medical-provider shortage area.
“I’ve been practicing as a pediatric nurse practitioner for over 30 years, mostly in the emergency department,” Kuensting said. “Children are a vulnerable population, often without health insurance, leaving the emergency department as their only source of health care. Organizations such as CHIPs and other nurse-led clinics in medical provider shortage areas can facilitate health maintenance and avoid episodic care visits for individuals and their healthcare needs, but the barriers APRNs face in Missouri make providing care extremely difficult.”
Talley had the opportunity to describe how restrictions impact her ability to care for patients in her community.
“It was great meeting with state legislators to discuss the need to reduce practice restrictions,” Talley said. “These restrictions are a barrier to vulnerable populations in both rural and urban areas. The current collaborative agreement creates restrictions to fundamental access to health care for people to manage their health and to live a quality life.”
She added: “If nurse practitioners could have greater independence and a less restrictive practice they would be able to provide much needed care in those areas where there are the greatest needs.”
There is precedent. Missouri temporarily lifted these restrictions for nearly two years during the COVID-19 pandemic with no adverse events, though that temporary lift expired on Dec. 31.
More and more states have also taken to permanently grants APRNs full-practice authority. On April 10, New York became the 25th state to take such action, and the Veterans Administration issue full practice authority to APRNs, regardless of the state they practice in, about two years ago.
“This course, and particularly this experience, is important for our APRN students to understand why being aware of the issues affecting our practice matter,” Kuensting said, “and more importantly, how to advocate for change.”
Photo at top includes U Missouri St Louis College of Nursing faculty members and students (from left): Laura Kuensting, Pam Talley, Marina Fischer, Marie Turner, Brooke Shahriary, Louise Miller, Kate Skrade, Carla Beckerle, Taylor Nealy, Ann Mwangi-Amann, Paige Bernau, Lucy Kokoi and Tammy Vandermolen at the Missouri Capitol last Tuesday to take part in the Association of Missouri Nurse Practitioners Advocacy Day. (Photo courtesy of Laura Kuensting)
When New York Gov. Kathy Hochul signed the state budget into law, it secured improved health care access for residents in the state. New York joins 24 other states, the District of Columbia and two U.S. territories in adopting Full Practice Authority (FPA) legislation. The legislative action enables nurse practitioners (NPs) to provide the full scope of services they are educated and clinically trained to provide. The American Association of Nurse Practitioners® (AANP) commends Gov. Hochul and the New York Legislature for modernizing nursing licensure law and positioning New York for a healthier future.
“New York has taken a critical step forward in our country, increasing access to vital health care services. New Yorkers will now have full and direct access to the comprehensive care NPs provide,” said April N. Kapu, DNP, APRN, ACNP- BC, FAANP, FCCM, FAAN, president of AANP. “Over the past two years, New York has waived unnecessary and outdated laws limiting access to health care. AANP applauds the state legislature and Gov. Hochul for recognizing that these provisions need to continue. These changes will help New York attract and retain nurse practitioners and provide New Yorkers better access to quality care,” said Kapu.
FPA is the authorization of NPs to evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments; and prescribe medications, all under the exclusive licensure authority of the state board of nursing. This framework eliminates unnecessary, outdated regulatory barriers that prevent patients from accessing these vital care services directly from NPs. Leading health policy experts like the National Academy of Medicine have long recommended that states adopt such legislation to improve health care access and outcomes.
“As the 25th state with Full Practice Authority, New York joins an expanding list of states acting to retire outdated laws that have needlessly constrained their health care workforce and limited patient access to care,” said Jon Fanning, MS, CAE, CNED, chief executive officer of AANP. “This is a no-cost, no-delay solution to strengthening health care for the nation. Decades of research show that states with Full Practice Authority are better positioned to improve access to care, grow their workforce and address health care disparities, while delivering quality health outcomes for patients. We look forward to more states following suit.”
NPs deliver high-quality health care in more than 1 billion patient visits each year. As of April 2022, there are more than 355,000 licensed NPs in the U.S. providing care in communities of all sizes across the nation. Recently, U.S. News and World Report ranked the NP role first on its 2022 Best Health Care Jobs list.
After years of opposition from the Florida Medical Association and seven years of passing in the state House but not in the Senate, the bill to allow Floridian Nurse Practitioners full practice authority has finally been passed. Starting in July 2020, advanced NPs who have accumulated at least 3,000 hours of experience under physician supervision will have the right to independently operate primary care practices in Florida without an attending doctor. To qualify, they will also have to complete minimum graduate level course work in differential diagnosis and pharmacology.
Under the new law, signed on March 11 by Florida Governor Ron
DeSantis, qualified NPs will be able to independently practice family medicine,
general pediatrics and general internal medicine. House Speaker Jose Oliva, who
made the bill a priority, praised the bill’s passage, saying, “Freeing
(advanced practice registered nurses) of the red tape that has historically
stopped them from working to the full extent of their education and training
will immediately improve access to quality care for all.”
In a compromise between the Florida House and Senate, while the bill grants full practice authority to advanced NPs, it does not cover physician assistants or certified registered nurse anesthetists. Calling the bill “a good first step,” the Florida Association of Nurse Anesthetists commented, “Although we are disappointed that the legislation did not include certified registered nurse anesthetists … we are pleased that some of Florida’s (advanced practice nurses) will be able to practice autonomously.” The group added, “Passage of this bill demonstrates Florida’s commitment to modernizing the way health care is being delivered in our state by ensuring that Floridians have full access to health care, particularly in rural areas that are often underserved.”
Florida Republican Representative Cary Pigman, a physician who has filed the bill multiple times in the state House, noted, “Beyond the classroom, the data from statewide experiments across the nation demonstrate without a doubt that nurse practitioners are highly skilled, highly trained, and highly eager to care for patients independently.” Pigman added, “Advance practice professionals achieve higher marks in patient outcomes, patient satisfaction, and they spend more time actually talking to patients.” For more details, visit here.
The state’s legislature are considering granting full practice authority to nurse practitioners who receive additional training and certification to work independently of doctors in an effort to offset the shortage of primary care physicians. With the additional authority, nurse practitioners would be able to treat patients without a “practice agreement” from a supervising physician.
Concerned Californians are supporting the passing of legislature to allow nurse practitioners full practice authority. More than a third of California residents believe there aren’t enough primary care providers and specialists in their communities according to a poll by the California Health Care Foundation. However, California’s doctors’ lobbies have fought the idea for legislature allowing full practice authority, arguing that it would dilute the quality of medical care that patients receive.
Nurse practitioners hold a master’s degree or doctorate in nursing practice, and the majority of nurse practitioners work in primary care. Full practice authority allows nurse practitioners to evaluate patients independently, order diagnostic tests, manage treatments, and prescribe medication.
If California passes new legislature to allow full practice authority for nurse practitioners, it would join 22 other states and the Veterans Administration in doing so. Researchers from the Bay Area Council Economic Institute also believe that it would save the state millions of dollars a year.
To learn more about California’s
efforts to pass legislation granting full practice authority to nurse
practitioners in an effort to offset doctor shortages, visit here.
2017 was an important year for the healthcare industry nationwide, with multiple states enacting new laws to equip advanced practice registered nurses (APRNs) with full practice authority, allowing them to practice to the top of their education scope. APRNs — including nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives — are a critical part of efforts to ensure and expand access to high-quality, cost-effective healthcare across the country.
As we move in 2018, APRNs now have full, autonomous practice and prescribing authority in 25 states and the District and Columbia. In remaining states, APRNs continue to practice under supervision or collaboration with physicians. According to HealthcareFinanceNews.com:
“In 2017, over 20 states reported passage of legislation positively impacting access to and delivery of healthcare nationwide.”
In an effort to respond to the ongoing opioid crisis, several states have also enacted new laws and regulations on the prescribing of controlled substances. California and Oregon passed legislation in 2017 bringing nurses practitioners’ role into line with the federal Comprehensive Addiction and Recovery Act. These new laws clarify the role of nurse practitioners in prescribing buprenorphine, an important part of treatment for opioid use disorders.
To learn more about the national move to grant full practice authority to advanced practice registered nurses, visit here.
