F.A. Davis Current Issues for Advanced Practice Nursing

Current Issues for Advanced Practice Registered Nurses

Susan Sportsman, PhD, RN, ANEF, FAAN Managing Director Collaborative Momentum Consulting

2 TOP CONCERNS in today’s healthcare environment Ask most Advanced Practice Registered Nurses (APRNs) in today’s healthcare environment about their top concerns, and two prominent issues invariably come to the forefront: 1. Regulatory barriers that limit the ability of APRNs to provide care based on their educational preparation, training, and certification. 2. Heightened stress stemming from the challenges posed by the post-pandemic work environment. The regulatory barriers are a long-standing issue for APRNs. However, the post-pandemic work environment has compounded the difficulties created by practice barriers, resulting in additional stress which can disrupt the APRN’s sense of well-being and compromise patient care.

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Regulatory Barriers 1. The first nurse practitioner educational program in the U.S. was instituted in 1965, which required an expanded state license for this new advanced practice role. Often these licenses required supervision by physicians. Beginning in the 1980s, as the Master of Science in Nursing degree became more popular and advanced roles were clarified and expanded, APRNs began to advocate for full practice authority in individual states. Currently, the practice of APRNs (Nurse Practitioners, CRNAs, Clinical Nurse Specialists, and Certified Nurse Midwives) may be state regulated in one of three ways: § Full Practice Authority (FPA ) Allows an APRN to 1) evaluate patients; 2) diagnose patient problems; 3) order and interpret diagnostic tests; 4) initiate and manage treatments including prescribing medications and controlled substances under the licensure of the authority of a state board of nursing. § Reduced Practice States Practice and licensure laws reduce the ability of APRNs to engage in at least one of the 4 elements of their practice. Some state laws require regulated career-long agreements with other health providers, primarily physicians. These agreements are typically collaborative in nature. § Restricted Practice States In these states, APRNs must work under the supervision of a physician. These supervisory agreements to pay for physician supervision are often prohibitively expensive for the nurses in these relationships. (Kleinpell, 2020) Barriers beyond state practice acts also include federal statutes from the Center for Medicare and Medicaid Services, as well as regulations from hospitals, public and private insurance companies, managed care organizations, and managed care entities (Kleinpell, 2022). Over the last 20+ years, aided by the recommendation of the 2011 Institute of Medicine report (now the National Academy of Medicine), The Future of Nursing , which advocates that all nurses should practice to the full extent of their authority, much political action by professional nursing organizations and other stakeholders has shifted the focus of a majority of state APRN licensure from Restricted or Reduced Practice to Full Practice Authority. The American Association of Nurse Practitioners’ Practice Brief on March 2023 reports that 30 states and U.S. territories have instituted Full Practice Authority. During this time, other states have made substantial or at least incremental steps toward Full Practice Authority (Martin, et al.,2023). Perhaps in response to the pushback against the strides being made to grant APRNs full practice authority, recent years have seen the implementation of transition-to-practice regulations, which require newly graduated APRNs to practice under the supervision or mentorship of an experienced clinician. The transition period may vary, ranging from 750 hours to several years. These additional regulations are intended to reassure detractors of full practice authority, despite little evidence regarding the efficacy of transition-to-practice regulations (Green, 2022). During the 2020-2022 time period, when COVID-19 was rampant throughout the U.S., many governors and state legislatures, in an effort to meet the demand of the nation’s healthcare crisis, issued executive orders providing waivers for the temporary removal of license restrictions for APRNs. Perhaps the most important waivers through executive action removed requirements of physician collaboration. These waivers emphasized the value of the APRN’s practice when able to perform with autonomy (Martin, et al., 2023).

Stressful Work Environment 2. The movement of APRN licensure trends toward Full Practice Authority before and during the pandemic is a positive step for the profession. However, the stressful work environment exacerbated by the COVID-19 pandemic has taken its toll on APRNs in much the same way as it has on nurses with other credentials. APRNs, whether they work in acute care settings, primary care, long-term care facilities or other outpatient facilities, have cared for patients with COVID. They have dealt with inadequate staffing, patient death, long work hours, and risk to their own health. Strategies to support all nurses within the work environment are needed. One stressful component of the APRN practice which seems to be different from RNs in other roles is the non- regulatory barriers to their practice exacerbated by the COVID-19 pandemic. Kleinpell and colleagues (2022) implemented a national survey in July 2022 to describe the effects of the suspension of practice restrictions or waivers in states with reduced or restricted practices and the general effect on the APRN practice. A total of 7,467 APRNs participated, most of whom had 5 or more years of practice in both inpatient and outpatient facilities in urban, suburban, and rural settings. Table A provides a comprehensive list of ways in which APRN practice is restricted in states with all three types of state regulation. After reviewing the list of areas in which APRNs are limited in their practice, not because of state licensing regulations, but because of a variety of rules made by numerous organizations, it is easy to see how stressful accommodating these seemingly illogical prohibitions can be. These limitations can be frustrating and time consuming for the APRN, resulting in increased stress in a chaotic environment, while increasing the cost of care and reducing the quality of care patients receive.

Table A: Institutional Barriers to APRN Practice in States with ALL Forms of Licensure

BARRIER

RESTRICTED REDUCED

FPA

Unable to sign an emergency psychiatric hold

x x

Social Security disability forms not honored without physician signature. Can pronounce death but unable to sign death certificate Unable to clear child for hearing aids without physician signature. Unable to order imaging for patients with abnormal mammogram.

Patients have higher copay to see APRN. Home Health approval restricted Hospital bylaws restrictions on practice Insurance requires physician to be PCP. 85% reimbursement compared for physician

x x x x x

x x

Laboratory or imaging results given only to collaborative/supervising physician (not to APRN)

Ordering blood products requires physician signature.

Pharmaceutical companies require physician signature for samples.

x x x x x

Pronouncing death prohibited (including fetal death).

x x x

Restricted health insurance credentialing

Admissions and orders for long-term care require physician signature. All new hire physician and work compensation injuries must be co-signed by physician. Collaborating /supervising physician practice/population restriction

Disability forms must be signed by physician.

x x x x x

Unable to bill for EKGs, so these have to be sent to collaborating MD.

Unable to order hospice.

Unable to order cardiac rehabilitation.

Unable to obtain informed consent for procedure. Unable to order skilled care/visiting nursing.

Unable to perform sports physicals.

Unable to practice telemedicine outside of state (New Hampshire).

x x

Unable to sign birth certificate. Unable to sign DNR document.

x x x

Unable to sign “return to play” after concussion. Unable to sign for pulmonary rehabilitation.

(Kleinpell, et al.,2020)

Conclusion 3. Making changes to licensing restrictions requires continued organized political action by professional nursing organizations and other stakeholders. Making changes to organizational restrictions requires internal and external pressures to change. All nurses, whether APRNs or not, should be aware of the restrictions in institutions with which they are associated and work to use their influence to make changes to improve the work life of APRN colleagues, as well as the effectiveness and efficiency of patient care. References 4. Carthon M.B., Brom H., Nikpour J., Todd B., Aiken L., Poghosyan L. (2020) Supportive practice environments are associated with higher quality ratings among nurse practitioners working in underserved areas. Journal of Nursing Regulation. 2020;13(1):5–12 Green S.B. (2022) Inside the Beltway. National Association of Pediatric Nurse Practitioners February. Transition to practice. https://www.napnap.org/inside-the-beltway-february-2022/ Accessed 2023. Kleinpell, R., Myers, C., Schorn, M., (2023) Addressing barriers to APRN practice: Policy and regulatory implications during COVID-19. Journal of Nursing Regulation. 14(1) 13-20. April 5th. Kleinpell R., Myers C.R., Schorn M.N., Likes W. (2021) Impact of COVID-19 pandemic on APRN practice: Results from a national survey. Nursing Outlook. 2021;69(5):783–792. Kleinpell, R., Myers, C., Likes, W, Schorn, M., (2020) Breaking down institutional barriers to advanced practice registered nurse practice. Nursing Administration Quarterly 46(2) 137-143, April/June 20. Martin, B., Buck, M., Zhong, E. (2023) Evaluating the impact of executive orders lifting restrictions on Advanced Practice Registered Nurses during the COVID_19 Pandemic. Journal of Nursing Regulation. 14(1) 50-58. April 5th.

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