After years of failed attempts and vociferous opposition, on August 31 California lawmakers adopted a measure to grant nurse practitioners the ability to practice without doctor supervision — but only after making big concessions to the powerful doctors’ lobby, which nonetheless remains opposed.
The bill—now being considered by Gov. Gavin Newsom—is fenced in by amendments that would stringently limit how much independence nurse practitioners — nurses with advanced training and degrees — can have to practice medicine.
Lawmakers credit these compromises, like them or not, for finally allowing them to push the issue over the finish line, capping years of political scrapping and perhaps one day altering the delivery of health care in California.
“This is not an intrusion on a hallowed profession, it’s a relief,” said state Sen. John Moorlach (R-Costa Mesa), one of four Republican senators who voted for the bill. Moorlach said the measure would get more practitioners into underserved areas that don’t have enough doctors.
“It’s like the cavalry coming up over the hill to provide reinforcements to a tired army of wonderful and overworked doctors,” he said.
California is behind most other states in empowering nurse practitioners. If the bill becomes law, the state would join nearly 40 others to grant some level of independence to nurse practitioners; 22 grant full independence, according to the American Association of Nurse Practitioners. California would have among the most restrictive policies on nurse practitioner independence in the country.
“I’m not going to say I regret any of these changes,” said Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee and authored the bill, AB-890.
Wood opposed previous attempts to remove supervision requirements.
“I wish it could be a little less strict, quite frankly,” he said, adding that this was a reasonable compromise informed by his experiences as a dentist and what he learned from other providers.
Today, nurse practitioners must enter into a written agreement with a physician to oversee their work with patients. In exchange, physicians bill them between $5,000 and $15,000 per year, according to a report by the California Health Care Foundation and the University of California-San Francisco. (California Healthline is an editorially independent service of the California Health Care Foundation.)
“Where we are with the pandemic and the craziness of the world today, it highlights why there’s a need for this,” said Andrew Acosta, a spokesperson for the California Association for Nurse Practitioners. “The doctor shortage isn’t going away anytime soon.”
Under Wood’s measure, nurse practitioners would be able to see patients in their own practice, but only after working under physician supervision for at least three years. The bill also contains many other restrictions.
Nurse practitioners argue that the measure, even with its limitations, would ease primary care shortages, especially in rural areas — a problem the pandemic has made more stark.
Opponents, primarily the powerful California Medical Association, which is the doctors’ lobbying group, counter that stripping nurse practitioners of physician oversight would lead to a lower standard of care, and that nurse practitioners wouldn’t necessarily flock to rural areas once they’re free of physician supervision.
These arguments aren’t new in Sacramento, but lawmakers and lobbyists say this version of the bill succeeded because there are new leaders at the helm of influential legislative committees who were willing to make changes, and because the pandemic has changed health care.
“I think the legislature is starting to realize decades of evidence that nurse practitioners are safe, productive providers,” said Ed Hernandez, a former legislator who was termed out in 2018 and authored the last two failed bills. “I think the policy is finally overshadowing the politics” of the California Medical Association.
Still, the biggest difference this year is the bill itself. Hernandez’s bills, introduced in 2013 and 2015, were “clean” bills that granted independence to nurse practitioners without many requirements.
There’s nothing clean about Wood’s bill, which was heavily amended in the state Senate. Instead of simply lifting the supervision requirements on nurse practitioners, the measure imposes several hoops for nurse practitioners to jump through. Before they could practice independently, nurse practitioners would have to be certified by preapproved national nursing boards, and possibly complete additional California-specific testing if accredited out of state.
Once certified, they would have to practice under physician supervision for at least three years — up to six in some cases — before they could strike out on their own. And they would have to disclose to patients that they aren’t doctors.
The bill even prescribes a Spanish phrase for “nurse practitioner”: enfermera especializada. (Technically, this refers to a female nurse. The bill doesn’t provide the equivalent phrase for a male nurse.)
That’s not even all the amendments — and the measure wouldn’t take effect until 2023.
The requirements were inserted in response to criticism from the California Medical Association that nurse practitioners are not qualified to provide patient care without physician oversight, and that patients wouldn’t understand that they’re seeing someone with less training than a doctor, lawmakers said.
Despite the numerous amendments, the association remains opposed, saying the changes don’t address their fundamental concerns.
“We’ve increased the training required for physicians over the last couple years and now all of a sudden we’re allowing unsupervised providers to treat patients who have even less training,” said association spokesperson Anthony York.
Rounds of negotiations, major concessions and hourslong Zoom calls still could not get the doctors’ group on board, Wood said.
He said it was like chasing “goalposts that continue to move.”
“It’s very disappointing when you work with opposition and nothing is ever good enough,” Wood said. “CMA will never support this bill. They’ll never go neutral on it.”
York said that characterization is not accurate. He pointed to a different bill — SB-1237 — that would allow certified nurse midwives to attend to low-risk pregnancies without physician supervision. The association was initially opposed, but after negotiations and amendments to the bill, it changed its position to neutral. That bill is also headed to Newsom.
“You don’t have to look too far to find a case where we were willing to engage on a scope-of-practice issue,” York said.
David McCuan, a political science professor at Sonoma State University, called the association’s inability to kill Wood’s bill a political “watershed moment” for the group.
“Their M.O. for 70 years has been about blocking, stunting and preventing change,” McCuan said. “The deference toward the medical profession has changed. In that sense, it would be a momentous event if this is signed.”
Though the California Association for Nurse Practitioners is celebrating legislative passage of the measure, even in its amended form, it’s a different story at the national level. Sophia Thomas, president of the American Association of Nurse Practitioners, said in a statement that the bill is choked by too much red tape to provide any meaningful change.
“California’s so-called ‘solution,’ the flawed AB-890, would establish a cascading set of new restrictions on NP practice that would maintain California’s position among the most heavily regulated and restrictive in the nation,” Thomas said.
State Sen. Richard Pan (D-Sacramento), a pediatrician who chairs the Senate Health Committee, said he also opposed the bill, but not simply because he is a doctor or a member of the California Medical Association.
Yet many of his objections reflect those of the association, such as concerns about training and access to care in rural areas.
He also believes independence for nurse practitioners could exacerbate inequalities in the health care system, as people with less means see providers with less training.
“People with more resources are going to go with the person they think is more qualified. That’s just the way it tends to happen,” Pan said.
California Healthline’s Angela Hart contributed to this report.
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
As ICU nurse Alex Duron learned, evangelical schools do not welcome gay students with open arms. After Union University accepted Duron into their graduate program for nurse anesthetists, he thought his next three years were mapped out. Unfortunately, his plans were thrown into disarray when the Jackson, Tennessee evangelical school found evidence that their new student was gay. University officials quickly rescinded Durin’s acceptance on the grounds that he was engaged in “sexually impure relationships.”
While there is some debate about whether a Title IX religious exemption allows schools to deny admission to homosexual students, Union University officials maintain that they have the right to deny admission to gay students. Union cited the school’s Community Values Statements on the “worth of an individual,” which asserts that “sexual relationships are designed by God to be expressed solely within a marriage between a man and a woman” (the statements also declare that “identifying oneself as a gender other than the gender assigned by God at birth is in opposition to the University’s community values”). Duron took issue with the decision, noting on Facebook, “Did you know that Union University is not a fully private school and accepts federal funding? Did you know that your taxes are allowing them to discriminate against LGBTQ+ and their allies?”
Duron signed the university Values statement when he applied, but he paid little heed to the fine print. He did not expect his fiancé to accompany him to Jackson, and in his view, being gay and in a committed relationship would have no bearing on his campus life. He had not been questioned about his sexual preference during the admissions process, but apparently school officials discovered Duron’s fiancé in his LinkedIn profile. Although he had not mentioned his fiancé, the school expressed concern about possible cohabitation when they emailed him about their decision: “Your request for graduate housing and your social media profile, including your intent to live with your partner, indicates your unwillingness to abide by the commitment you made in signing this statement.”
Duron’s prospects have improved since he went public. In an interview with Buzzfeed News, he said he had “dodged a bullet” by not attending Union;s grad program, and after hearing about his story, nursing schools around the country have been contacting him to see if they can find a way to grant him admission this fall.
For more on this story, see the article in Buzzfeed News.
If there are any silver linings to the towering black cloud that is the COVID-19 pandemic, one of them is the relaxation of restrictions on advanced practice registered nurses (APRNs) to allow these practitioners to deliver care during this health crisis. This summer, a national study is documenting those changes to APRN practice and may provide evidence to policymakers about relaxing restrictions on APRNs permanently.
Starting June 1, nurse leaders from three nursing schools in Tennessee have been conducting the National APRN Practice and Pandemic Survey to measure the impact of decisions by state leaders to waive physician oversight of APRNs during the pandemic. Ultimately, investigators hope to have data to be able to introduce in those states that still have practice restrictions evidence to “change some of those practice acts to allow APRNS to practice to the full extent of their education and licensure,” says Ruth Kleinpell, PhD, RN, FAAN, FAANP, FCCM, Independence Foundation professor of nursing education, assistant dean for clinical scholarship, professor of nursing at Vanderbilt University School of Nursing. Kleinpell is one of the principal investigators for the study.
Other principal investigators are Wendy Likes, PhD, DNSc, APRN-BC, FANNP, dean and professor of the University of Tennessee Health Science Center College of Nursing; Carole R. Myers, PhD, RN, FAAN, professor at the University of Tennessee, Knoxville; and Mavis Schorn, PhD, CNM, FACNM, FAAN, FNAP, senior associate dean for academics at Vanderbilt University School of Nursing.
The National APRN Practice and Pandemic Survey runs through the end of August.
So far, over 9,000 APRNs have responded from all 50 states, notes Kleinpell. Of those, 60% to 70% of the respondents report that they have provided care to COVID-19 patients. Some 86% of respondents are nurse practitioners; nurse-anesthetists, nurse-midwives and clinical nurse specialists also have responded.
From State to National
Initial discussions for the survey began when the governor of Tennessee issued an executive order that released some practice restrictions on APRNs, such as a collaborating physician not having to conduct an on-site visit, says Kleinpell. This led to interest in conducting a survey in Tennessee. After further discussions with various organizations, including advanced practice nurse societies, the survey expanded to a national scope.
Across the country, you’ll find a patchwork of suspended and waived regulatory restrictions on APRN practice, detailed in a map from the American Association of Nurse Practitioners. In five states, notes Kleinpell, executive orders temporarily suspended practice requirements; in 16 states, select practice agreement requirements were waived. Some 22 states have adopted full practice authority licensure laws for nurse practitioners.
The study will look at the impact of these changes during the COVID-19 pandemic, says Kleinpell. It will compare states that have full practice to states that have restricted or reduced practice to see what practitioners are reporting not only with respect to the impact on the pandemic but also impact on practice in general, she notes.
When the results are available, the investigators plan to publish their findings and provide state-based summaries. Those results could be available in September or October.
Broadening Patient Access
“Ultimately we would like to have data to be able to substantiate some policy changes at the state level, particularly in those states that continue to have restrictive practices or practices that are burdensome to APRNs,” says Kleinpell. In states that don’t have restrictions, “the APRNs are able to practice based on their licensure and education, which is really how it should be in all fifty states. We’re seeing undue burden not only on the practitioner but on the ability for patients to have care access.”
Among this year’s American Psychiatric Nurses Association (APNA) Award winners are psychiatric nurses specializing in maternal depression, suicide prevention, veteran care, elderly care, and policy-making.
In advance of the 34th Annual Conference (to be held virtually from September 30-October 4), APNA officials have announced the following 2020 award recipients:
APNA Psychiatric Nurse of the Year: Linda Beeber, PhD, PMHCNS-BC, FAANA Professor and Associate Dean of Nursing at the University of North Carolina, Chapel Hill, NC, Dr. Beeber has made notable advances in the treatment of women suffering from maternal depression. APNA officials lauded Dr. Beeber’s achievements, describing her as “Not only an effective leader, but also an inspirational role model for a new generation of clinicians, scholars, and students.”
APNA Award for Distinguished Service: Barbara Limandri, PhD, PMHCNS-BC
Professor Emeritus at Linfield College, Portland, OR, Dr. Limandri is being honored for her career as a scholar, clinician, and teacher who has mentored numerous students on their paths to psychiatric nursing degrees. Among her many achievements, Limandri is known for developing a pioneering suicide prevention training program and course for psychiatric-mental health nurses. The APNA remarks that Dr. Limandri’s “Energy to ‘unselfishly give’ to the psychiatric-mental health nursing profession is remarkable.”
APNA Award for Excellence in Practice—APRN: Michelle Giddings, DNP, PMHNP-BC, FNP-BC
Giddings, a private practitioner in Las Vegas., NV, is being honored for “Her strong advocacy, knowledge, and leadership” in the successful campaign to persuade state legislators to permit Nevada’s psychiatric APRNs to perform Competency to Stand Trial evaluations.
APNA Award for Excellence in Practice—RN: Heather McCormick, BSN, RN-BC, PHN
McCormick, a Clinical Nurse Leader specializing in psychiatric intensive care at the Redwood, CA San Francisco Veterans Affairs Health Care System, is being commended as “A key leader in creating structure for a cultural shift in which the physical, emotional, social, spiritual, cultural and age-specific needs, personal dignity, and autonomy of veterans” is supported during their treatment.
APNA Award for Excellence in Leadership—APRN: LTC JoEllen Schimmels, DNP, RN, PMHNP-BC, FAAN
Schimmels, an Assistant Professor at the Uniformed Services University of the Health Sciences, Bethesda, MD, has “written or led the writing and implementation of most policies and standardized processes related to behavioral health nurses…in military medicine.”
APNA Award for Excellence in Leadership—RN: Suzie Marriott, MS, BSN, RN-BC
As Associate Director of Nursing at Stony Brook University Hospital in NY, Marriott played a key role in implementing the “Safe Wards” model and suicide prevention programs in the UK and the US. The APNA also praises her performance at SBUH during the height of the New York pandemic: “Suzie not only worked to contain transmission in her hospital units, but also provided leadership and crisis support to staff on the medical floors impacted by the care of critically ill patients.”
APNA Award for Excellence in Education: Rosalind de Lisser, APRN, FNP-BC, PMHNP-BC
Citing her eminent “leadership as a clinician educator,” the APNA is recognizing de Lisser, an Assistant Clinical Professor at the University of California San Francisco, for her seminal contributions as a designer of Psychiatric-Mental Health Nurse Practitioner programs in California and for her work as an outstanding mentor.
APNA Award for Excellence in Research: Olimpia Paun, PhD, PMHCNS-BC
The award for Paun, a professor and Rush Alumni Nurses Association Chair in Health and Aging at Rush University, Chicago, IL, honors her achievement in building “An innovative program that focuses on the mental health needs of the dementia family caregiver population.”
APNA Award for Innovation – Individual: Georgia L Stevens, PhD, APRN, PMHCNS-BC
The APNA is hailing Dr. Stevens, Director of the DC-based Partners in Aging & Long-term Caregiving, for her outstanding achievement in her region: “Dr. Stevens’ model for discharge planning and continued care coordination for this older adult population across the state of Maryland has resulted in only a 5% re-hospitalization rate over more than 4 decades.”
APNA Award for Innovation – Chapter: APNA Arizona Chapter
The Arizona Chapter is receiving an award nod for their creation of an online book club, The APNA commends their project as “An excellent way to involve and connect chapter members who live many miles apart—and now with safe distancing this online activity is ideal!”
For more details, visit the press release for the APNA 2020 Awards.
When it comes to caring for patients suffering from COVID-19, nurse practitioners (NPs), as you might expect, are making a major contribution.
Some 61% of NPs are treating patients who have been diagnosed with COVID-19, according to a recent survey from the American Association of Nurse Practitioners (AANP). Almost as many (58%) are offering COVID-19 testing at their practices.
“It was somewhat surprising to see how many nurse practitioners are literally on the frontlines of this pandemic,” said Stephen Ferrara, DNP, FNP, of ColumbiaDoctors Nurse Practitioner Group and Associate Dean of Clinical Affairs at Columbia University School of Nursing. He is also Executive Director of the Nurse Practitioner Association of New York State and the Editor-in-Chief of the Journal of Doctoral Nursing Practice.
Barriers to Treatment
Caring for COVID-19 patients does not come without obstacles, however. NPs identified lack of testing (47%) and lack of personal protective equipment (PPE) (24%) as the top barriers to treating patients with COVID-19, according to an executive summary of the survey. The survey was conducted from May 8 to May 17, 2020 and garnered over 4,800 responses from across the country. In many locations, COVID-19 testing is limited to patients who meet a narrow set of criteria (69%).
Of note, over three-quarters of the survey respondents (79%) said they reused PPE. And more than one out of two (53%) were exposed to SARS-CoV-2 in their practice or elsewhere.
At ColumbiaDoctors, Ferrara notes that he has had to reuse PPE. Specifically, he has reused an N95 mask and changed an outer surgical mask.
The use of PPE is “probably forever changed,” said Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of AANP in an interview with DailyNurse. She notes that the CDC has provided guidance on safely reusing PPE, and that a variety of mask shapes and sizes have been approved.
As in many areas of health care, COVID-19 may lead to significant structural changes. For one thing, notes Thomas, “the expansion of the use of telehealth is going to change the landscape in which we provide health care in this country and will definitely improve access to care for all patients.” NPs, she noted, “are big utilizers of telehealth because we feel it’s important to provide access to patients wherever they are.”
Ferrara’s Manhattan-based primary care practice rapidly adopted telehealth/virtual visits for non-COVID patients, he said. The practice restricted in-person visits only to those patients with COVID-19 symptoms.
Another change involves lowering regulatory obstacles. The AANP and the general NP community, Thomas said, “call on the nation’s governors to suspend all legislative and regulatory barriers that prevent NPs from providing patients with full and direct access to all the health care services that NPs are educated and prepared to provide.”
Five governors, she said, have issued executive orders to allow NPs to practice at the top of their education and training. She hopes that these five governors “will make those executive orders permanent to change that regulatory language, and I hope that we modernize health care delivery in all the other states and allow nurse practitioners to practice at the top of their education and training.”
“Beacon of Light”
As the pandemic continues, NPs need to educate patients, said Thomas, on the importance of wearing masks to prevent the spread of COVID-19. In a July 14 statement, the AANP called on the American public to wear masks, socially distance, and wash hands. NPs, said Thomas, need to be the “beacon of light to their patients.”
Expect more nurses to take on leadership and public policy positions, says Dr. Stephen Ferrara, DNP, FNP-BC, FAANP, editor of the Journal of Doctoral Nursing Practice and Associate Dean of Clinical Affairs at Columbia University Medical Center. Speaking to DailyNurse, Dr. Ferrara described his work managing the treatment of non-COVID patients during the New York outbreak and shared his views on the impact of COVID on the nursing profession.
First, can you tell us a bit more about your work both at Columbia and with Jonas Nursing & Veterans Healthcare?
Stephen Ferrara: In my role as Associate Dean, Clinical Affairs at Columbia University Medical Center, my team and I develop systems and practices to ensure world-class patient care within our clinical locations—most recently that has included managing systems for screening and safety for our non-COVID patients. At Columbia, I serve as associate professor and manage the Columbia Doctors Nurse Practitioner Group, one of the country’s best nurse-run primary care services. I also teach health policy to the Doctor of Nursing Practice (DNP) students, and as Interim Executive Director of Jonas Nursing & Veterans Healthcare, I oversee our nursing scholars program, a group of exceptional nurses pursuing higher education in order to serve vulnerable communities in unique ways.
What have been the challenges of treating non-COVID patients during the height of the NYC outbreak?
SF: It is always our first priority to keep patients safe while providing the most comprehensive care possible. During the height of the outbreak in New York, the greatest challenge was supporting non-COVID patients in first assessing the need for in-person care and then managing the risk of infection against the potential consequences of their condition if gone untreated for a period of time. Education for patients and potential patients on telemedicine and other low-risk care options was also priority for us during this time. Since bringing patients into the office was no longer an option, we quickly transitioned to video visits to triage patient concerns, diagnose and treat minor acute issues and provide continuity of care for existing patients of the practice.
What sorts of adjustments have had to be made in caring for non-COVID health issues?
SF: The first step we had to take was ruling out COVID in patients with similar symptoms and ensuring we were keeping non-COVID patients out of the emergency room to begin with. We stood up a cold, cough and fever clinic which allowed streamlined patient flow, testing and procedures. We were able to rule out infections such as influenza and strep throat. While virtual visits had been part of our offering before the pandemic, they became standard procedure during the outbreak. Critically, we had to adjust staffing procedures and evaluate our supply of appropriate protective resources so that enough would be available for fellow healthcare personnel on the front lines.
What are your views on the impact of telemedicine?
SF: Telemedicine is making the way we administer care safer, more efficient, and potentially more accessible to all our patients. By conducting appointments virtually, we cut down the risk of spreading infection between patients in healthcare offices, and allow individuals who are mobility impaired to receive the help they need faster, from the comfort of their own homes. For the first time, we have the ability to assess patients’ home environment for safety which can help guide us in our treatment recommendations. Of course, in certain cases telemedicine cannot replace in-person examination or care, but with a decrease of patients coming into the office, these cases can often be given more focused attention than before. Additionally, not all patients have access to a smartphone or computer thus a significant barrier to care potentially exists.
In what ways do you expect the nursing profession will be changed by the US experience? What changes in healthcare do you think should/will remain in the long term?
SF: I think the critical role nurses play in our healthcare system, not only with hospitals, but in labs, clinics, offices, and from home, will become more apparent. Their insights and perspective on how we prevent, prepare, and treat situations like these will have lasting effects on the future of care. I believe we will see more nurses rise to leadership positions in our country’s healthcare institutions because of the value of their input, and look forward to the innovations and efficiencies that will follow. We will also see more nurses become increasingly involved in health policy based on their experience and recommendations.
Nurses make up the largest component of the healthcare workforce & have been rated as the most trusted profession per Gallup polling for the last 18 years in a row. As a result, we will see more nurses in elected positions throughout our local, state and federal governments. In terms of the changes brought on by this pandemic which should remain, I have seen this crisis open our eyes to the vulnerabilities of underserved communities and hope our attention remains focused on improving outcomes for these groups.