Nursing News

States Consider Expanding Role of Advanced Practice Nurses


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By Jennifer Larson, contributor

Advanced practice nurses across the United States may gain more independence in their practice, as bills make their way through legislatures in more than 20 states this year.

Legislators in states from California to Florida are considering approving bills that would expand the scope or authority for advanced practice nurses in some fashion. Currently, nurse practitioners’ scope of practice is governed by each state, so there is a wide variety of types of services that they may provide, hence the various legislative proposals.

Supporters say that patients would benefit from expansions, given the current health care climate, which is registering a growing shortage of primary care providers in some areas.

“There is an increasing demand for providers,” said Mary Jean Schumann, MSN, RN, director for nursing practice and policy for the American Nurses Association. “Advanced practice-prepared nurses are well-prepared to do that. They can handle 80 percent of what a physician sees.”

Tracy Klein, RN, MS, FNP, an advanced practice consultant for the Oregon Board of Nurses, said that the movement toward more autonomy for advanced practice nurses would be better characterized instead as “the removal of political restrictions which prohibit nurse practitioners from functioning at the current capacity of their education and competency.”

She noted that in her home state, nurse practitioners have operated as independent primary care providers with full prescriptive authority for more than two decades.

“We have demonstrated that the provision of health care which is safe and accessible is well within our already established scope of practice,” she said.

Some states, such as Ohio, may consider bills that would give nurses more independent authority to prescribe controlled substances. Other states will examine legislation that proposes allowing nurse practitioners to practice with less physician supervision.

Supporters say that patient care is the priority behind the push for the legislation.

As the U.S. population ages, experts predict there will be a greater demand for providers to care for older adults. In fact, the American Medical Association released a statement earlier this week warning that the current health care workforce will not be able to meet the health care needs of this growing segment of the population in just a few years.

That will require more chronic disease management, more collaboration with other health care disciplines and, perhaps, more palliative care, said Schumann. She said those will all likely push the demand for nurse practitioners who could, for example, prescribe pain medications to terminally ill hospice patients.

“There is no excuse for a person to have to die a painful death,” she said. “Who would wish that on anyone? So we’re going to have to see the scope of practice expand because there’s no way physicians are going to be able to manage all that.”

Nancy Chornick, Ph.D., RN, director of practice and credentialing for the National Council of State Boards of Nursing, added that patients in rural areas would especially benefit.

“Patients will benefit with increased access to care, such as in the case of the walk-in care centers that are developing across the country and in underserved rural areas,” she said.

Klein agreed, saying that the removal of restrictions for advanced practice nurses just makes sense from a patient-care perspective.

“States who restrict nurse practitioners from being able to, for example, order physical therapy or provide for home health, only hurt the patient and delay timely care,” Klein said.

Currently, the states with the most expansive scopes of practice for nurse practitioners are Alaska, Arizona, New Hampshire, New Mexico, Oregon and Washington, according to an issue paper released in January by the California HealthCare Foundation. NPs in those states may practice autonomously without physician oversight and prescribe mediations without physician involvement.

Supporters of legislation affecting advanced practice nurses may find themselves confronting roadblocks to success in specific states. Some doctors and state medical associations, such as the Ohio State Medical Association, have registered their reluctance to support such legislation—or their outright disapproval.

But Chornick said that’s not always the case.

“I know of many independent practicing APRNs who have an excellent collaborative relationship with not only physicians but other members of the health care team,” she said. “I don’t know why a doctor would be opposed to APRNs when it means safe care and an increased access to safe care for many individuals.”

Zenei Cortez, RN, president of the California Nurses Association, said, “For some doctors, they are not worried. They are glad that RNs will see patients and will refer patients to their doctors only when needed. But for some doctors, they see advanced practice RNs as a threat to their profession.”

They shouldn’t be worried, Schumann said. “There’s more than enough need to go around,” she said.

The California HealthCare Foundation’s issue paper noted that “inconsistencies in NP scopes of practice among states may impede the uniform expansion of NP services, prohibit NPs from providing in full measure the medical care for which they are trained, and inhibit the robust use of NPs in helping alleviate shortage of primary care providers.”

Schumann hopes in the future to see a new regulatory process implemented that would provide consistency from state to state. The ANA has been working on that for several years and she hopes to see the fruit of their labor later this year.

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