Nurse Practitioner and CRNA Scope of Practice: 2018 Updates
Advanced practice nurses are moving closer to autonomous practice, as states remove scope-of-practice barriers. These actions are improving patient's access to care while enhancing nurse practitioner jobs, CRNA jobs, and other advanced practice registered nurse (APRN) roles.
Full-practice authority and nurses working to their level of education and competence was a key recommendation of the 2010 Institute of Medicine landmark report, The Future of Nursing: Leading Change, Advancing Health. Today, the Future of Nursing Campaign for Action continues to work to implement the document’s suggestions.
A number of legislative changes have recently been enacted because of this concerted effort. In 2017, more than 20 states eliminated some of the restrictions on advanced practice registered nurses, and several more have done so in the first half of 2018.
APRNs are masters- or doctorate-prepared nurses with advanced skills who coordinate and provide patient care, including nurse practitioners (NPs), certified registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), and clinical nurse specialists (CNSs). Their exact scope of practice is defined at the state level, and each professional nursing organization advocates with state and federal officials to ensure that they can practice to the full extent of their training.
The recruiters at Staff Care report that nurse practitioner jobs and CRNA jobs are the most in-demand advanced practice specialties for locum tenens assignments.
Nurse Practitioner Scope Of Practice Updates
In this era of physician shortages, the expansion of nurse practitioner scope of practice is expected to improve patient's access to care, including in these states which have recently taken action:
Virginia lawmakers passed legislation (HB 793), signed by Gov. Ralph Northam, which allows nurse practitioners with at least five years of full-time clinical experience to practice without a formal physician collaboration agreement. Nurses with that much experience must apply for “independent practice authority and complete the attestation,” according to the Virginia Council of Nurse Practitioners. The law takes effect July 1, 2018, and the state must create regulations by January 1, 2019.
Alabama eased restrictions on nurse practitioners. In March 2018, Gov. Kay Ivey signed a bill (HB 429), which will allow nurse practitioners to refer patients to physical therapy, and sign death certificates and allocations for handicap parking placards.
Although nurse practitioners in South Carolina still need to contract with a physician, a bill (S.345) signed by Gov. Henry McMaster will allow physicians to contract with more nurse practitioners and eliminate a distance limitation on where the physician can be located. It is expected to improve access to care for people in rural areas.
The West Virginia Insurance Discrimination Bill (HB 4175) became law and took effect in June 2018.
“This bill prohibits an insurance company, managed care organization or the Public Employees Insurance Agency from requiring a nurse practitioner to hold a collaborative agreement in order to obtain insurance payment for providing care, making it easier for patients to choose an NP for their care,” said Tay Kopanos, vice president of state government affairs for the American Association of Nurse Practitioners (AANP).
Indiana HB 1119 passed. It authorizes advanced practice nurses to sign physician orders for scope of treatment (POST) forms.
In Vermont, HB 684 passed and was signed into law by Gov. Scott.
“The law removes the requirement for APRNs, including [NPs and] CRNAs, to “‘submit for review individual practice guidelines and receive board approval of the practice guidelines,’” said the American Association of Nurse Anesthetists (AANA) President Bruce Weiner, DNP, MSNA, CRNA. “An APRN coalition, including the Vermont Association of Nurse Anesthetists, defeated hostile amendments by APRN opponents, including putting APRNs under the medical board and increasing restrictions on APRN practice.”
Guam 201-34, the Full Practice Authority law, was signed in February 2018. It allows full and direct access to advanced practice nurses, expanding nurse practitioner scope of practice.
More than 248,000 nurse practitioners are licensed in the United States, reported Joyce Knestrick, Ph.D., APRN, CFNP, FAANP, president of the AANP, in testimony to Congress in April 2018.
Nurse practitioner jobs and CRNA jobs remain plentiful with no drop-off expected. In April 2018, the U.S Bureau of Labor Statistics anticipated a healthy 31 percent increase in nurse practitioner jobs and CRNA jobs between 2016 and 2026.
Much of the demand is due to an aging population, as older adults typically use more healthcare services than younger people. Additionally, the country has a shortage of primary care providers. Nurse practitioners can fill much of that void.
CRNA Scope Of Practice Updates
In addition to the legislative advances affecting APRNs in states like Indiana, Vermont, and Guam, mentioned above, AANA continues to push for legislative changes to allow full practice authority for nurse anesthetists
“The AANA and state nurse anesthesia associations around the country continue to advocate for the need to lower barriers to health care, promote quality anesthesia care, cost-effectiveness, and increased access to care for the patients that certified registered nurse anesthetists (CRNAs) care for every day,” Weiner said. “Several states were successful in removing barriers to CRNA practice, which improved access to care.”
In Maryland, Gov. Larry Hogan signed HB 863 in May. It eliminates the requirement that CRNAs must have a written collaborative agreement with a physician, expanding CRNA's scope of practice. Weiner said it will “improve access to care.”
In 2016, the U.S. Department of Veterans Affairs granted three types of advanced practice nurses to practice to the full extent of their education and training in VA facilities, but it left out CRNA jobs. AANA continues to press for full-practice authority. An Office of Inspector General report found that the VA health system has an anesthesia provider shortage at 31 of its 141 surveyed facilities, or 22 percent.
Meredith Courville, the communications advisor for the Center to Champion Nursing in America in Washington, DC, said that “most state legislatures have wrapped up for 2018, and although a few are still in session, we are not anticipating any significant scope wins.”
“AANP screened over a thousand bills and actively tracked or engaged in 150,” Kopanos said.
Advance practice nurses are continuing the fight.
“CRNAs and other APRNs continue to work with state legislators to help educate them on the value of advanced practice nurses and the role they play in the delivery of healthcare in rural and underserved areas,” Weiner concluded.
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