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).
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