Practice authority for advanced practitioner nurses took another stride forward on May 10 when Michigan became the 20th state to opt out of federal regulations that require physician supervision of Certified Registered Nurse Anesthetists (CRNAs).
Gov. Gretchen Whitmer’s action in signing the opt-out ensures Michigan’s patients have access to value-based, high-quality care and optimizes healthcare teams across the state, according to Adam Kuz, MS, CRNA, president of the Michigan Association of Nurse Anesthetists (MANA).
In March 2020, to maximize healthcare resources during the outbreak of the COVID-19 pandemic, Gov. Whitmer enacted an executive order removing physician supervision for CRNAs. In July 2021, she signed HB4359 to remove supervision requirements for CRNAs in the state nurse practice act, and HB4359 is now permanent.
Highlights of the law include:
All of the following apply to a registered professional nurse who holds a specialty certification as a nurse anesthetist:
(a) In addition to performing duties within the scope of the practice of nursing, his or her scope of practice includes any of the following anesthesia and analgesia services:
(i) Development of a plan of care.
(ii) Performance of all patient assessments, procedures, and monitoring to implement the plan of care or to address patient emergencies that arise during implementation of the plan of care.
(iii) Selection, ordering, or prescribing and the administration of anesthesia and analgesic agents, including pharmacological agents that are prescription drugs as defined in section 17708 or controlled substances. For purposes of this subparagraph, the authority of a registered professional nurse who holds a specialty certification as a nurse anesthetist to prescribe pharmacological agents is limited to pharmacological agents for administration to patients as described in subdivision (b), (c), or (d), and his or her authority does not include any activity that would permit a patient to self-administer, obtain, or receive pharmacological agents, including prescription drugs or controlled substances, outside of the facility in which the anesthetic or analgesic service is performed or beyond the perioperative, periobstetrical, or periprocedural period.
(b) He or she may provide the anesthesia and analgesia services described in subdivision (a) without supervision and as the sole and independent anesthesia provider while he or she is collaboratively participating in a patient-centered care team.
“Removing barriers to CRNA practice allows Michigan hospitals to select the anesthesia delivery model that maximizes their workforce and increases access to safe, affordable care for all patients,” said former MANA president Toni Schmittling, DNAP, MBA, CRNA. “By signing this important legislation, Michigan recognizes that CRNAs are qualified to make decisions regarding all aspects of anesthesia care based on their education, licensure, and certification.”
Anesthesia services are provided predominantly by CRNAs in Michigan’s critical access hospitals, which offer surgical services in 99% of its rural hospitals. They comprise 68% of the state’s anesthesia care providers.
“The AANA applauds Gov. Whitmer for recognizing the important role CRNAs have in the delivery of safe anesthesia care in Michigan,” said AANA President Dina Velocci, DNP, CRNA, APRN. “Increased demand, limited resources, and a state with diverse populations, both rural and urban, dictate that a system capable of meeting the needs of all Michigan residents be maintained. By signing the opt-out letter, this has been achieved.”
Throughout the COVID-19 pandemic, nurse anesthetists across the country have, in addition to providing top-of-the-line anesthesia care, served as experts in airway management, hemodynamic monitoring, management of patients on ventilators, and overall management of critically ill patients. Instrumental in addressing the deadliest part of COVID-19, CRNAs have become highly sought-after anesthesia care providers.
There have been many reports about health care workers, especially nurses, leaving the profession because of emotional and even physical abuse wrought by pandemic-fueled overwork, lack of resources and combative COVID patients in hospitals.
But University of Michigan School of Nursing faculty Deena Kelly Costa and Christopher Friese argue in a New England Journal of Medicine Perspective piece that the problem isn’t necessarily a nursing shortage caused by the pandemic: It’s a shortage of safe hospital working environments–a problem that predates the pandemic.
You argue there’s not a nursing shortage but a shortage of hospitals that provide safe working conditions. What would you like patients to understand about working conditions that they don’t currently know?
Deena Kelly Costa, Ph.D., RN, FAAN
Since March 2020, the public has been inundated with images of nurses working in unsafe conditions during the pandemic—garbage bags as PPE, reusing masks, reports of wildly unsafe workloads. But unsafe staffing and work conditions predate the pandemic.
Better nurse staffing saves lives and ensures hospitals can function; investing in safe working conditions for nurses is a public health priority. Seminal work in the early 2000s demonstrated that every one patient added to a nurse’s workload in acute care settings was associated with a 7% increase in risk of death for patients. Yet, since then, California is the only state to enact legislation to mandate patient-to-nurse ratios. Massachusetts has ICU nurse staffing regulations but a similar bill mandating specific ratios in other care settings did not pass about five years ago for various reasons.
You’ve listed several measures that could help attract and retain nurses on the state and federal levels. Which of these measures is most attainable in the short term and could make the biggest impact?
Reducing regulatory and documentation burden is likely the quickest short-term approach that would have the greatest impact in retaining nurses. The COVID-19 pandemic has doubled or even tripled acute care nursing workloads.
Christopher R. Friese, Ph.D., RN, AOCN®, FAAN.
There is considerable evidence supporting limits to the number of patients a nurse can care for in the hospital setting. Legislation can take time, but in the short term, the Centers for Medicare and Medicaid Services could penalize hospitals that do not meet established patient-to-nurse ratios or exceed maximum amounts of mandatory overtime. This has been done in nursing homes, so there is precedent.
“Seminal work in the early 2000s demonstrated that every one patient added to a nurse’s workload in acute care settings was associated with a 7% increase in risk of death for patients. Yet, since then, California is the only state to enact legislation to mandate patient-to-nurse ratios.”
States may have more flexibility for nimble policy implementation. For example, there is considerable data demonstrating the negative impact COVID has had on women’s careers, and more than 90% of U.S. nurses are women. To encourage nurses to remain in the profession and not quit due to family care pressures, states could incentivize hospitals to offer on-site child care, dependent care programs, or other grants to encourage safer workplaces. This approach is similar to how employer-sponsored insurance emerged as an employee retention tool in the mid-1950s.
Every year, tens of thousands of students are turned away from nursing schools. How big a problem is this, and what’s the solution?
Structural barriers in the education system create a bottleneck. Many nursing schools must cap enrollment due to shortages of qualified faculty to teach in undergraduate and graduate programs. And more than a third of current nursing faculty plan to retire in the next few years, which will worsen the bottleneck. It can be challenging to attract experienced nurses to teach in associate or bachelor degree programs since often the schedule and pay aren’t as competitive as full-time clinical positions. This hurts our ability to grow the supply of high-quality registered nurses.
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States could help with state tuition forgiveness programs for nurses and nurse educators, low-interest rate loans for state nursing school students, or expansion of the graduate nurse education demonstration project, which funds nurse practitioner education, to increase the number of qualified nurse practitioners who could in turn become educators.
In Michigan, nurse industry groups argue that enacting the bipartisan Safe Patient Care Act and easing the scope of practice restrictions on Advanced Practice Registered Nurses would accomplish these safety goals. These measures are opposed by some hospital and physician groups. Where do these stand?
Michigan has one of the strictest scope of practice regulations in the country, meaning that APRNs must be overseen by physicians to a greater extent than in most other states, and can’t function independently to the full extent of their education and training. Thus, some nurses leave Michigan to practice in other states with friendlier scope of practice regulations. If Michigan were to implement full practice authority to APRNs, as was temporarily done during the pandemic by Gov. Whitmer’s office and as is currently proposed in Senate Bill 680, this could attract APRNs to Michigan, which would boost the supply of nurses in the state and possibly assist with other staffing shortages that have recently been documented.
The bipartisan Safe Patient Care Act would require hospitals to disclose staffing ratios and adhere to specific patient-to-nurse ratios as well as eliminate mandatory overtime and enact restrictions on overtime. In many other labor environments, such as the airline industry or police and fire departments, there are regulations around hours worked, overtime, etc. They currently do not exist in nursing, and are needed to protect patients and retain and recruit nurses. This bill hasn’t yet passed.
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)
Alabama patients now have increased access to safe, affordable care with the signing today of HB 268 by Governor Kay Ivey. The law provides that, in addition to physicians and dentists, Certified Registered Nurse Anesthetists (CRNAs) may provide anesthesia care under the direction of or in coordination with a physician, podiatrist, or dentist.
The law further clarifies that the CRNA scope of practice includes ordering of medications and tests before, during, and after analgesia or anesthesia in accordance with the anesthesia plan.
“Removing barriers to CRNA practice will allow Alabama healthcare facilities to maximize their workforce and increase access to safe, affordable care for our patients,” said Wesley Canerday, CRNA, president of Alabama Association of Nurse Anesthetists (ALANA). “By signing this important legislation, Alabama recognizes that CRNAs are qualified to make decisions regarding all aspects of anesthesia care based on their education, licensure, and certification.”
Anesthesia services are provided solely by CRNAs in many of Alabama’s critical access hospitals offering surgical services, and in a majority of its rural hospitals.
The law also specifies that anesthesia care, when an anesthesiologist is not present, is provided by CRNAs “in coordination with” a physician, podiatrist, or dentist, defined as a working relationship in which “each contributes his or her respective expertise in the provision of patient care, which includes the discussion of patient treatment, diagnosis, and consultation.”
“The American Association of Nurse Anesthesiology (AANA) applauds Gov. Ivey for recognizing the important role CRNAs have in delivery of safe anesthesia care to the residents of Alabama,” said AANA President Dina Velocci, DNP, CRNA, APRN. “Increased demand, limited resources, and the rural nature of the state dictate that a system capable of meeting the needs of all Alabama residents be maintained and this law provides that.”
As advanced practice nurses, CRNAs are members of one of the most trusted professions according to Gallup. CRNAs provide anesthesia care across all settings and in all patient populations and are the primary anesthesia providers in rural and underserved areas and on the battlefield in forward surgical teams. Because of their expertise in anesthesia delivery and management of critically ill patients, CRNAs have been a highly sought-after healthcare provider during the COVID-19 pandemic.
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.
”Three decades of evidence have shown that nurse practitioners with full practice authority play a vital role in improving health outcomes, especially in underserved communities, Ramos observed in his remarks. Focusing on the connections between FPA, access to care, and health outcomes, the Dean presented his case to the state’s Joint Legislative Committee on Access to Healthcare and Medicaid Expansion at the North Carolina General Assembly and urged them to pass the SAVE Act to grant full practice authority for NPs providing primary care. Ramos, who is also the vice-chancellor of nursing affairs for Duke, was among eight experts presenting varied views on full practice authority.
“Full practice authority isn’t new. This isn’t innovative. We have 30 years of evidence from 24 states, D.C., and several US territories about the benefit of granting full practice authority to NPs.”
In speaking to the joint committee presided over by Sen. Joyce Krawiec, Ramos addressed the role that nurse practitioners have in transforming health care access and outcomes in North Carolina, including the opportunity to expand care in rural areas that face health care shortages. The joint committee is hearing from experts as they consider passing the SAVE Act, which was first introduced in 2021 to expand full practice authority for primary care NPs in North Carolina. A similar version of the SAVE Act has been introduced in previous legislative sessions, but no action was taken on the legislation.
Role of FPA in Access to Care and Health Outcomes
“Nurse practitioners should be able to practice at the highest level of their competencies, education, and licensing,” Ramos said. “Full practice authority isn’t new. This isn’t innovative. We have 30 years of evidence from 24 states, D.C., and several US territories about the benefit of granting full practice authority to NPs. This improves health outcomes and expands health care to underserved populations and will benefit the people of North Carolina.”
Across the state, 97 of 100 counties face a health professional shortage.
Ramos reflected on his role as dean of the top school of nursing in the state and the second-ranked school in the U.S., and the intense pride he has seeing Duke graduates strengthen their career opportunities with the education they gain at Duke. “The nurse practitioner workforce growth is faster in states with full practice laws than in states with restricted practice,” said Ramos, who is interested in attracting NPs to practice in the state.
Ramos observed that the first states to authorize full NP practice authority began doing so in 1994 — nearly three decades ago — and that, once passed, full NP practice authority has never been repealed. “Full practice authority for primary care NPs improves care access, improves care outcomes, and improves workforce supply,” said Ramos, who also addressed a systematic review of 33 studies that showed no evidence for better NP care outcomes in states with more practice restrictions.
NPs with FPA Increase Efficacy of a State’s Health Workforce
In addressing the critical nursing workforce shortages across the U.S., Ramos notes that NP workforce growth is faster in states with full practice laws compared to states with restricted practice. Across the U.S., during the COVID-19 pandemic, states issued temporary waivers of NP practice restrictions. “This enabled more time-responsive NP practice and care provision as well as a streamlined process for NP orders in the absence of physician signature requirements and an increased capacity of the health care workforce to respond to COVID-19,” Ramos said.
Ramos observes that the reliance of nurses in this manner during a pandemic and health care crisis demonstrates the clinical, scientific, and relational expertise that support nurse influence in improving health outcomes, and it demonstrates the confidence that the health care systems and public have in nurses, who have been considered the most trusted and most ethical profession for more than 20 years.
In conclusion, Ramos pointed out to the committee that:
NP practice restrictions contribute to inadequate care access and primary care workforce shortages, particularly in rural areas.
NP practice restrictions can be a barrier to improving health outcomes and reducing health outcomes and reducing health-related economic costs.
NP practice restrictions requirements can lead to an unsafe and fragile care model, including risks such as the possibility of immediate NP loss of ability to care for patients if a physician can no longer provide supervision for any reason, including moving, retiring, and so on.
NP practice restrictions weaken health workforce responsiveness to emergencies.
Physician supervision agreements can contribute to unnecessary and excessive costs.
The SAVE Act (House Bill 277/Senate Bill 249) did not receive a committee hearing during the 2021 legislative long session. However, following the conclusion of the committee’s work later this spring, the bill could move forward when the legislature returns for the 2022 short session on May 18, 2022.
