By Debra Wood, RN, contributor Mar 11, 2019
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
“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
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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.
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.”
satisfaction and outcomes of care are similar between APRNs and physicians,
whether a state offers full practice authority or not.
Maryann Alexander, PhD, 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.
practice agreements (CPAs)
agreements, certainly, restrict APRNs from performing to their full scope and
what they were trained for,” Brydges said. “Collaborative practice agreements
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
“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.
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
agreed, calling that safety claim a “misnomer.”
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
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
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.
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.”
authors indicated that such
unnecessary regulation contributes to inequities in care by diverting health
services away from and increasing costs in traditionally underserved areas.
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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