Survey Shows Continuing Barriers to APRN Practice
Although advanced practice registered nurses (APRNs) continue to deliver positive patient outcomes, these health care professionals experience significant barriers to independent practice, according to a new survey conducted by researchers at the National Council of State Boards of Nursing (NCSBN). The results of the APRN survey were published in the January 2019 issue of the Journal of Nursing Regulation.
“The NCSBN article underscores what we have known for years,” said Taynin Kopanos, vice president of state government affairs for the American Association of Nurse Practitioners (AANP). “In states where NPs are required to have physician agreements in order to legally practice nursing, access to care is negatively impacted.” She added that NCSBN highlighted the economic burden these agreements can be to nurse practitioners and the health care system.
Barriers to APRN Practice
Full Practice Authority
Twenty-one states have granted full practice authority to advanced practice registered nurses, which includes nurse practitioners (NPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse-midwives (CNMs), according to the NCSBN study. In the other states, APRNs face regulatory barriers.
AANP reports 22 states, the District of Columbia, and two U.S. territories allow NPs full practice authority. An estimated 270,000 NPs are licensed to practice in the United States. In 2018, more than 1 billion patients visited an NP for care.
CRNAs administer more than 45 million anesthetics to patients annually, according to the American Association of Nurse Anesthetists (AANA) 2018 Member Profile Survey.
“The most important [reason APRNs need full practice authority] is appropriate access to care for Americans across the country,” said Garry Brydges, DNP, MBA, CRNA, ACNP-BC, FAAN, president of AANA.
Additionally, Brydges predicts a provider shortage as a wave of baby boomer APRNs and physicians retire, which will further exacerbate access to care issues.
“Our nation faces a challenge in securing timely access to affordable, quality health care,” Kopanos added. “Closing this gap between the level of care NPs are prepared to provide and what state law allows NPs to provide is critical, and a no-added-cost solution to these challenges.”
Brydges reported patient satisfaction and outcomes of care are similar between APRNs and physicians, whether a state offers full practice authority or not.
Maryann Alexander, Ph.D., RN, FAAN, chief officer for nursing regulation at the National Council of State Boards of Nursing in Chicago, and co-author of the study, added that APRNs are as safe as physicians in the care they provide.
“States that have adopted full practice authority have higher concentration of NPs in rural and underserved areas, rate higher on state health care rankings, and have been associated with decreased hospital readmissions for Medicaid, improved access to preventative care and lower health care costs,” Kopanos reported.
Collaborative Practice Agreements (CPAs)
“Collaborative practice agreements, certainly, restrict APRNs from performing to their full scope and what they were trained for,” Brydges said. “Collaborative practice agreements cost money.”
The NCSBN survey found the cost of establishing a CPA to practice in states requiring such documents was up to $50,000 paid to the physician.
“Sometimes it is cost-prohibitive for the nurse practitioner or other nurses to go to [an underserved area] because of the cost of the collaborative practice agreement,” Alexander said.
Those APRNs practicing in rural areas and in APRN-managed private clinics were one-and-a-half to six times more likely to be assessed fees for a CPA, the NCSBN study found. Those nurses who were subject to fees for establishing a CPA, minimum distance requirements, and supervisor turnover reported a 30 percent to 59 percent increase in restricted care.
“We felt we needed to demonstrate why physicians like these collaborative practice agreements,” Alexander said. “They always say it is a safety factor, when, in fact, it’s an economic factor. It’s an economic factor that presents a barrier to access to care.”
Brydges agreed, calling that safety claim a “misnomer.”
APRNs in all roles may be required by state law to have a collaborative practice agreement with a physician, but typically it is for NPs in independent practice. When APRNs are employed by a health system, the health system may pay for the agreements.
“These collaborative practice agreements make it sound like they collaborate, which they don’t,” Alexander said. “Most of these APRNs and physicians never see one another. The nurse may refer patients, and some [states] require the physician to do a chart review.”
Brydges explained that in all instances, advanced practice nurses are trained to recognize when a patient needs subspecialty care, and the APRNs refer or call on a network of experts they have developed.
“Within your scope of practice is to recognize when you need to refer someone,” Brydges said. “It’s important to recognize APRNs are not practicing in vacuums. They are constantly collaborating with other APRNs and subspecialty physicians.”
The NCSBN authors indicated that such unnecessary regulation contributes to inequities in care by diverting health services away from and increasing costs in traditionally underserved areas.
Where do we go from here?
Many state legislatures across the country are starting their annual sessions. Some, including Florida, Massachusetts, North Carolina, and Pennsylvania, have legislation pending that would address full practice authority for advanced practice nurses.
Alexander said that NCSBN plans to share the results of the research study with legislators and to advocate for full practice authority.
“They do not understand the full impact of these collaborative agreements,” Alexander said. “This can have implications not only on the nurses financially, but it can be a barrier to access to care.”
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