ACTIVITY AND PROGRESS

The Campaign reports that since the release of the IOM report, 44 state Action Coalitions have worked on its recommendation to remove scope-of-practice barriers (see Box 2-1) (CCNA, 2014a). At the time the report was published, 13 states were classified as meeting criteria for full practice authority. Since the Campaign began, 8 more states (Connecticut, Maryland, Minnesota, Nebraska, Nevada, North Dakota, Rhode Island, and Vermont) have changed their laws to give nurse practitioners (NPs) full practice and prescriptive authority, bringing the number of states with full authority to 21 (CCNA, 2015). Seventeen states are currently categorized as having reduced practice and 12 as having restricted practice (see Figure 2-1). Some states—for example, Kentucky, New York, Texas, and Utah—have made incremental improvements to their laws but are still categorized by AANP and the Campaign as having reduced or restricted practice for APRNs (AANP, 2015; CCNA, 2014b, 2015). The Campaign uses information from AANP's State Nurse Practice and Administrative Rules to track full practice authority, reduced practice, and restricted practice (AANP, 2015; CCNA, 2015).

These broad categorizations, while useful for classification purposes, mask a number of subtleties among state laws. Maine, for example, a state with full practice authority, has express legislative prohibitions against NP hospital privileges (Pearson, 2014). NPs in this state must be supervised when caring for patients in a hospital setting. In Ohio, a state without full practice authority, a bill was signed in 2014 that allows APRNs and physician assistants (PAs) to admit patients into hospitals.¹ Some states do not have legislative prohibitions per se, but other regulatory impediments exist. In Texas, for example, “hospital licensing law does not include APRNs as medical staff members who may admit and discharge patients; most hospitals grant privileges to APRNs as allied health providers” (Pearson, 2014, p. 255).

In addition to changes at the state level, several of the bulleted points under the IOM report's recommendation 1 (see Box 2-1) have been addressed through enacted or proposed legislative and regulatory changes at the federal level, as described below.

DISCUSSION

APRN practice authority has been expanded considerably in the 5 years since the release of The Future of Nursing. Many organizations, in collaboration with or in addition to the Campaign and its state Action Coalitions, have worked to remove barriers that restricted APRNs from working to the full extent of their training and education. Twenty-one states now have full practice authority for APRNs, although several large states have not yet achieved that goal. APRNs now have prescribing authority in 49 states, albeit with some restrictions for certain classes of medication. In those states where new scope-of-practice proposals have met opposition, the major points of contention include requirements for APRN oversight by medical rather than nursing licensing boards; clinical oversight by or collaboration with physicians; and restrictions on APRNs' provision of a range of services, including hospital admitting privileges. Finding common ground on these points is a challenging process, as evidenced by, for example, recent debates in California and Virginia. Nonetheless, these debates and incremental steps still arguably represent progress, as exemplified by the successful resolution of a years-long process to remove scope-of-practice restrictions in Maryland.

In California, a bill⁸ that would have authorized certified NPs who had practiced under the supervision of a physician for at least 4,160 hours to practice independently failed in 2013 after intense opposition from the California Medical Association (CMA). The CMA argued that, if passed, the bill would mean that “nurse practitioners will no longer need to work pursuant to standardized protocols and procedures or any supervising physician and would basically give them a plenary license to practice medicine” (California Medical Association, 2013). The bill did have the support of several other professional organizations and health insurers, but it was opposed by state and national physician organizations (Adashi, 2013).

In contrast, physician and NP groups collaborated to decrease restrictions in Virginia,⁹ which is classified by AANP as a restrictive practice state (AANP, 2015; Iglehart, 2013). In 2012, the Virginia state legislature unanimously voted to approve a bill that was the result of negotiations between the Medical Society of Virginia and the Virginia Council of Nurse Practitioners. The bill requires NPs to work as part of a patient-care team that is led and managed by a physician, but permits the supervision to occur via telemedicine and expands the number of NPs who can be supervised by a physician from four to six. The American Medical Association (AMA) viewed the compromise reached in Virginia as a possible model for other states; however, AANP was disappointed in the outcome.

Finally, the incremental gains made over a number of years in Maryland demonstrate the progress that can be achieved through persistent efforts. In 2008, scope-of-practice restrictions were loosened slightly when legislation¹⁰ was passed permitting APRNs to sign birth and death certificates, advance directives, and applications for handicapped license tags. In 2010, restrictions were further reduced when a decades-old collaborative agreement between the Boards of Nursing and Physicians was replaced by an attestation statement.¹¹ Finally, in 2015, the Certified Nurse Practitioners—Authority to Practice bill¹² was signed into law, removing the attestation requirement and giving NPs full practice authority.

Opposition by some physicians and physician organizations has been noted as a barrier to expansion of APRNs' scope of practice (Adashi, 2013; Hain and Fleck, 2014; Iglehart, 2013; Walters, 2015). Upon the release of The Future of Nursing, several national physicians' organizations raised concern about the report's recommendation regarding scope-of-practice expansion:

• American College of Physicians (ACP, 2010): “The IOM's emphasis on independent practice is at odds with the goal of ensuring that patients receive comprehensive and patient-centered care within the context of a health care team. . . . Today, no one clinician should practice independently of other clinicians.”
• American Medical Association (AMA, 2010): “A physician-led team approach to care—with each member of the team playing the role they are educated and trained to play—helps ensure patients get high quality care and value for their health care spending. . . . Nurses are critical to the health care team, but there is no substitute for education and training.”
• Council of Medical Specialty Societies (CMSS, 2010): “CMSS is concerned that the IOM report advocates for an expanded scope of nursing practice without specifying the standard minimum amount of supervised clinical experience and documented clinical competency that must be achieved before an APN would be permitted to treat and prescribe without physician guidance.”

In an effort to alleviate some of the tension between nurses and physicians, RWJF convened leaders of nurse and physician organizations in 2011 to develop a consensus document on interprofessional collaboration (Iglehart, 2013; RWJF, 2013). A draft report titled Common Ground: An Agreement Between Nurse and Physician Leaders on Interprofessional Collaboration for the Future of Patient Care was produced following a constructive dialogue. The draft report noted the shortage and maldistribution of primary care providers and emphasized the need for patient-centered care. It also acknowledged that nursing and medicine are not interchangeable professions and that the “captain-of-the-ship notion needs to be refined for the 21st century” (RWJF, 2013, p. 3). Efforts to refine and publish the report ended when a leaked early draft drew opposition from physician organizations.

Despite the failure of these efforts, participants—including representatives from AACN, the American College of Physicians (ACP), the American Nurses Association (ANA), the American Organization of Nurse Executives (AONE), the National League for Nursing (NLN), the Nurse Practitioner Roundtable, and other organizations—expressed hope that the focus would remain on how interprofessional collaboration is in the best interest of the patient. Further, participants noted that interprofessional collaboration already occurs in the health care system and that common ground is often found among health professionals, even if not among their associations. At the committee's May 2015 workshop, Steven Weinberger, Executive Vice President and CEO of ACP, continued to speak to the need for professional collaboration and for a focus on what is best for patients rather than professions:

I think we need to change the perspective from which we're looking at this. We're looking at this from the perspective of “What does the physician population need?” “What does the nurse population need?” We have to look at this from the perspective of “What does the patient need?” And let's get it away from the professions and say that for this given patient and this point in time, the best person to provide care is x, y, or z.

Despite the political conflict between nursing and physician organizations and amid the wide array of scope-of-practice restrictions, APRNs and physicians most commonly are working collaboratively on the ground. A recent qualitative study conducted in Massachusetts, a restricted practice state, found that despite the state's scope-of-practice restrictions, some NPs described having a scope of practice similar to that of their physician colleagues, and the “supervision” mandated by written agreements was variably enforced (Poghosyan et al., 2013). However, testimony provided for the present study suggested that such administrative restrictions may adversely affect patients by causing delays in referrals, orders for medical equipment, discharges to home or hospice, and other services (Lamprecht, 2015).

The Future of Nursing does not call for nurses to replace doctors. It does recommend that “advanced practice registered nurses should be able to practice to the full extent of their education and training” (IOM, 2011, p. 278). In new collaborative models of practice, it is imperative that all health professionals practice to the full extent of their education and training to optimize the efficiency and quality of services for patients. The term “independent practice” has become a charged term for some physician groups, which view it as implying solo or competitive practice. However, considerable testimony provided for the present study supported viewing this term as meaning the full practice authority to use one's education and training. Full practice authority for APRNs, as for all health professionals, is ideally part of an organized, collaborative system of care.

Research conducted with NPs and physicians since The Future of Nursing was released provides perspectives of practicing clinicians on some of these issues. While state and federal efforts to reduce scope-of-practice restrictions were ongoing, the Health Resources and Services Administration (HRSA) conducted a national survey of NPs in 2012 (HRSA, 2014a). Among those surveyed, 11 percent were working without a physician on-site, and 84 percent indicated they were practicing “to the fullest extent of the state's legal scope of practice” (pp. 9-10). Another survey of primary care NPs conducted in the same year found that 75 percent were practicing to the “full extent of their education and training” (the key message of the IOM report) (Donelan et al., 2013, p. 1900), and 8 percent of NPs worked in a primary care practice without a physician and billed for all their services under their own National Provider Identifier (NPI) (Buerhaus et al., 2015). Fully 96 percent of primary care NPs and 76 percent of primary care physicians surveyed in 2013 agreed that NPs should be able to practice to the full extent of their education and training, reflecting a broad, if uneven, consensus around this core message (Donelan et al., 2013). Primary care NPs and physicians largely agreed that increasing the supply of NPs could enhance access to and the timeliness of primary care, but they disagreed about issues of reimbursement and quality of services provided.

Evidence published since the release of The Future of Nursing underscores previous research supporting removal of restrictions on scope of practice, showing that APRNs provide high-quality care with good patient outcomes (e.g., fewer avoidable hospitalizations, readmissions, and emergency room visits) in a wide variety of settings (Donald et al., 2013; Kilpatrick et al., 2014; Kuo et al., 2015; Lewis et al., 2014; Newhouse et al., 2011; Stanik-Hutt et al., 2013). APRNs continue to have an especially important role in delivering primary care services in rural areas and in medically underserved communities where primary care shortages are documented and physician oversight may not be locally available (Buerhaus et al., 2015; DesRoches et al., 2013). While APRNs often assume substantial responsibilities in delivering high-quality health care, regulatory and payment practices remain barriers to their being able to practice to the full extent of their education and training (Poghosyan et al., 2013; Stange, 2014; Yee et al., 2013). These findings suggest that further removal of scope-of-practice restrictions could have a positive impact on health care access and quality.

While The Future of Nursing places a strong emphasis on the importance of building the APRN workforce to meet the growing demands for primary care in a time of insurance expansion and shortages of primary care physicians, the 2012 HRSA National Sample Survey of Nurse Practitioners found that only 39.2 percent of all licensed NPs were working in primary care; the proportion was higher (47.4 percent) when calculated as the percentage of NPs who were currently employed in patient care roles (HRSA, 2014a). These estimates were consistent with those from the 2008 National Sample Survey of Registered Nurses (RNs) (HRSA, 2010) and research supported by the Agency for Healthcare Research and Quality (AHRQ, 2011). Among the NP respondents to the 2012 HRSA survey employed in patient care roles, 59 percent of those who had graduated in 1992 or earlier were working in primary care, compared with 42 percent of those who had graduated between 2003 and 2007. Among more recent graduates since 2008, the proportion in primary care was 47 percent. Despite the drop in the proportion of NPs who practice primary care, however, the percentage is still far higher than the percentage of physicians entering primary care (Chen et al., 2013), and the total number of primary care NPs is rising. Researchers have projected that by 2025, the number of primary care NPs in the United States will increase to 103,000 from the 60,407 measured in 2012 (Auerbach et al., 2013; HRSA, 2014a).

The committee that conducted the present study acknowledges that shortages of primary care providers, both nurses and physicians, remain a challenge in the United States (AHRQ, 2011; HRSA, 2013, 2014b; Petterson et al., 2012). However, the committee does not believe that the move toward specialty care detracts from the original intent of The Future of Nursing recommendations; rather, that it offers additional context for the value and implications of scope-of-practice expansion, and it also offers new focus for the Campaign. In addition, it reinforces the importance of collaborative practice among a full array of health professionals as the model for health care for the future in both primary and specialty care.

As discussed in Chapter 1, passage of the ACA and a number of transformations in the health care system have created a new context emphasizing the goal of providing value-based care and engaging in collaborative practice for all patients. Providers and health systems are increasingly being held accountable for patient outcomes, with a new emphasis on the “Triple Aim” for health care—improved health, improved health care, and reduced costs. While it should be noted that cost did not factor into the recommendation of The Future of Nursing, there is in this changing context of affordability and value a renewed focus on achieving higher quality at lower cost and with greater efficiency. Scope-of-practice expansion may contribute to the aim of lowering costs, particularly in the context of interdisciplinary teams (Sinsky et al., 2013). It makes sense that in several models of care, particularly in primary care settings, there is greater emphasis on team-based care to ensure that important services are provided through collaboration among all team members and a sharing of power and trust among the professionals involved (Gardner, 2005; Sinsky et al., 2013; Wen and Schulman, 2014). MacNaughton and colleagues (2013) argue that understanding one's contribution within a team and being able to perform that role autonomously, while recognizing the unique roles of other team members, facilitates collaboration. Several new initiatives in education and practice are part of national efforts both to foster interprofessional education and practice and to break down the barriers that exist when professionals are educated in silos (see Chapter 5).

Much research has been done on a “fourth aim” beyond the Triple Aim—to improve “the work life of health care providers, including clinicians and staff” (Bodenheimer and Sinsky, 2014). Burnout among health care providers is associated with lower patient satisfaction and worse patient outcomes, including higher mortality rates (Aiken et al., 2002; Leiter et al., 1998; Poghosyan et al., 2010; Shanafelt et al., 2012; Stimpfel et al., 2012; Vahey et al., 2004). Several studies have shown that expanded team scope and roles and support for high-functioning teams enhance satisfaction among providers. Sinsky and colleagues (2013) reinforced this association of “joy of practice” and expanded roles for all team members with enhanced team satisfaction and better outcomes in an intensive study of high-functioning practices. This fourth aim for health care, which research shows is increasingly associated with the goals of the Triple Aim, is an important contextual change since The Future of Nursing was released, and it offers potential common ground for that report's goals for scope-of-practice expansion. It also suggests that those goals need to be part of a larger effort to expand the scope and role of many clinical team members so as to improve outcomes and reduce burnout. In reaction to The Future of Nursing, ACP (2010) said, “today, no one clinician should practice independently of other clinicians” (p. 1). Accordingly, this may be an opportune time for discussions about how mutual support of scope expansion can support team-based care and reduce provider burnout.

FINDINGS AND CONCLUSION

Significant progress has been made toward reducing scope-of-practice restrictions nationwide. As the health care environment continues to evolve and to demand more value-based care, the full contribution of APRNs and other health care providers is critical. As health care reform expands access to care, states with restrictive laws for NPs are limiting access and the potential for APRNs to contribute fully to health care and to the optimal functioning of the health care team. More states are allowing NPs full practice authority as primary care providers. Moving forward, more efforts are needed to work with a broader coalition of stakeholders and providers to converge around issues of scope-of-practice restrictions and advocate for legislation that supports full practice authority for APRNs.

RECOMMENDATION

Recommendation 1: Build Common Ground Around Scope of Practice and Other Issues in Policy and Practice. The Future of Nursing: Campaign for Action (the Campaign) should broaden its coalition to include more diverse stakeholders. The Campaign should build on its successes and work with other health professions groups, policy makers, and the community to build common ground around removing scope-of-practice restrictions, increasing interprofessional collaboration, and addressing other issues to improve health care practice in the interest of patients.

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