Implementation of the Affordable Care Act (ACA) enabled more than 30 million people to have new access to primary care services (Dillon & Gary, 2017). Several barriers prevent Advanced Practice Registered Nurses (APRNs) from being able to respond effectively to rapidly changing health care settings and an evolving health care system. The Institute of Medicine (IOM) made the recommendation in its 2010 landmark report, The Future of Nursing, that scope-of-practice (SOP) barriers should be removed to allow APRNs to practice to the full extent of their education and training (IOM, 2010). Removing barriers to practice will empower NPs to effect positive change in our struggling health care system, in addition to providing additional access to care for minorities and underserved patient populations (Dillon & Gary, 2017). Results of a study by the United States (U.S.) Department of Health and Human Services (2015), suggest that SOP is an important driver of many practice outcomes for ARNPs. States could take better advantage of the broad capacities of ARNPs by loosening SOP restrictions and considering other policy levers available including addressing organizational practices, education and training, and evaluating billing practices and the rates at which ARNPs are reimbursed compared to their physician colleagues. Current policy for ARNP SOP is fragmented, Oklahoma is one of only 12 states that requires cumbersome physician oversight of ARNPs. SOP regulations at the state level limit the range of health care services that APRNs can deliver and the extent to which they can do so without physician supervision or collaboration (Dillon & Gary, 2017).
What are the possible effects on the state of Oklahoma if the state legislature were to expand scope of practice (SOP) to full practice authority (FPA) for advanced practice registered nurses (APRNs)?
- “A number of barriers prevent APRNs from being able to respond effectively to rapidly changing health care settings and an evolving health care system” (IOM, 2010).
Key characteristics of the problem include:
- A collaborative agreement is required between an ARNP and a supervising physician in order for the ARNP to prescribe drugs and other medical supplies (Okla. Nursing Practice Act §567.3a).
- SOP regulations at the state level limit the range of health care services that APRNs can deliver and the extent to which they can do so without physician supervision or collaboration.
- Commercial health plan reimbursement varies, and there are those that do not recognize ARNPs as primary care providers (Dillon & Gary, 2017).
- Approval of FPA has taken a state-by state approach due to individual state boards which is costly and labor-intensive and delays the implementation of a national policy that would benefit patients (Dillon & Gary, 2017).
What information do systematic reviews provide about three viable options to address the problem?
- Removing barriers to practice will empower NPs to effect positive change in our struggling health care system, in addition to providing additional access to care for minorities and underserved patient populations (Dillon & Gary, 2017).
- States and insurance companies must follow through with specific regulatory, policy, and financial changes that give patients the freedom to choose from a range of providers, including APRNs, to best meet their health needs (IOM, 2010).
- Removing current collaborative practice requirements would enable full benefit of ARNP services in hospitals, nursing homes, home health care, and hospice environments (Dillon & Gary, 2017).
- Each of the following three options was assessed in terms of its likely benefits, harms, costs (and cost-effectiveness), its key elements if it had been tried elsewhere, and stakeholder views about and experiences with it:
- Review of the literature demonstrates that allowing APRNs full SOP has the potential to improve access to care, utilization, provider supply, and patient experience with care (Martsolf & Kandrack, 2017).
- ARNPs are recognized in the literature and by several national organizations as being able to provide quality and cost-effective primary care and are seen as part of the workforce needed to meet increased demand on the health care system (Brom, Salsberry, & Graham, 2018).
- ARNPs offer a pathway to primary care, especially in underserved areas, remove delays in care, and allow patients to choose the health care provider they want to see (AANP, 2017).
- The body of literature supports the position that ARNPs provide care that is safe, effective, patient-centered, timely, efficient, equitable and evidenced based (AANP, 2015).
- ARNP care is comparable in quality to that of their physician colleagues. Patients under the care of NPs have higher patient satisfaction, fewer unnecessary hospital readmissions, fewer potentially preventable hospitalizations and fewer unnecessary emergency room visits than patients under the care of physicians (AANP, 2015).
- Since the ARNP role was created in 1965, more than 50 years of research has consistently demonstrated the excellent outcomes and high quality of care provided by ARNPs (AANP, 2015).
- ARNPs with FPA are required to meet educational requirements for licensure; maintain national certification; consult and refer to other health care providers, when warranted by patient needs; and remain accountable to the public and the state board of nursing for providing the high standard of care set nationally (AANP, 2019).
What key implementation considerations need to be borne in mind?
- Little empirical research evidence could be identified about implementation barriers and strategies. Four of the implementation barriers identified were:
- As per the regulatory theory, the interest group who are most influential are able to influence regulatory legislation in their favor. Organized medicine remains a strong interest group advocating against FPA for NPs (Brom, Salsberry, & Graham, 2018).
- Federal barriers, such as those imposed by the Social Security Act, which governs Medicare and Medicaid, were written in 1965. The Act often refers to the word physician as the only health care provider and gives permission to physicians and only to physicians to provide care (Dillon & Gary, 2017).
- FPA faces barriers from the insurance payer market. Commercial health plan reimbursement varies, and there are those that do not recognize ARNPs as primary care providers (Dillon & Gary, 2017).
- The state-by-state approach is costly and labor-intensive and delays the implementation of a national policy that would benefit patients (Dillon & Gary, 2017).
- Nurses should have a voice in health policy decision making, as well as being engaged in implementation efforts related to health care reform. Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care (IOM, 2010).
American Association of Nurse Practitioners. (2015). Quality of nurse practitioner practice. https://www.aanp.org/images/documents/publications/qualityofpractice.pdf.
Brom, H. M., Salsberry, P. J., & Graham, M. C. (2018). Leveraging health care reform to accelerate nurse practitioner full practice authority. Journal of the American Association of Nurse Practitioners, 30(3), 120–130. https://doi.org/10.1097/JXX.0000000000000023
Dillon, D., & Gary, F. (2017). Full Practice Authority for Nurse Practitioners. Nursing Administration Quarterly, 41(1), p.86-93. DOI:10.1097/NAQ.0000000000000210
Institute of Medicine. (2010). Report brief: The future of nursing: Leading change, advancing health. https://www.nap.edu/resource/12956/Future-of-Nursing-2010-Report-Brief.pdf
Martsolf, G. R. & Kandrack, R. (2017). The Impact of Establishing a Full Scope of Practice for Advanced Practice Registered Nurses in the State of Indiana. Santa Monica, CA: RAND Corporation. https://www.rand.org/pubs/research_reports/RR1864.html
U.S. Department of Health and Human Services. (2015). Impact of State Scope of Practice Laws and Other Factors on the Practice and Supply of Primary Care Nurse Practitioners. https://aspe.hhs.gov/system/files/pdf/167396/NP_SOP.pdf