In the long struggle to gain full practice authority (FPA), nurse practitioners (NPs) can point to notable advances in the last few years. Now, patients in more than half of the states, the District of Columbia, and two U.S. territories have full, direct healthcare access from NPs.
In April 2022, New York and Kansas granted FPA to NPs. That brings to 26 the number of states where NPs can practice to the top of their license without restriction. In this article, we’ll look at how that progress was made, the impact of COVID, and how newly proposed federal legislation would strengthen NP practice. But first, let’s have a look at what FPA means.
“Full practice authority is essentially that the nurse practitioner can practice to the full extent of their education and training,” says April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, president of the American Association of Nurse Practitioners (AANP). “Nurse practitioners are trained to evaluate patients, make diagnoses, order and interpret tests, prescribe medications, coordinate care, and educate. We are educated and trained to do these things,” says Kapu.
In the past few years, the pace has “really picked up as we have seen more and more states move to full practice authority,” according to Kapu. She notes that four states moved to full practice authority through the pandemic: Delaware and Massachusetts in 2021 and New York and Kansas in 2022. “It’s because we demonstrate our commitment to quality and equitable care and ensuring care is provided in all communities.”
In states that have moved to full practice authority, “we’ve seen improved patient care outcomes. We’ve seen an increase in the workforce. We’ve seen an increase in nurse practitioners working in historically underserved urban and rural areas,” Kapu says.
FPA, COVID and Care
While devastating, COVID helped bring to light the high-quality care that NPs provide and boosted efforts to gain FPA. In some states where NPs worked under less than full practice authority, the governors signed executive orders waiving various restrictions, notes Kapu.
“That’s where we saw the opportunity for nurse practitioners to continue providing care. They provided very high-quality care. They were able to provide more accessible care. As you saw throughout the pandemic, they were in communities and churches, going door to door, seeing patients in their homes, and doing everything they did in the hospital and the ICUs. So we demonstrated that continued quality of care. And that is what quickened the momentum during the pandemic; the executive orders provided that opportunity,” Kapu says.
In Ohio, a reduced practice state, an emergency authorization during COVID allowed NPs to deliver care via telehealth, notes Evelyn Duffy, DNP, AGPCNP-BC, APRN-NP. However, she notes that NPs can still practice via telehealth, and that ability is no longer contingent on the emergency authorization. Based in Cleveland, Duffy is an NP in the University Hospitals Geriatric Medical Group and a professor at the Frances Payne Bolton School of Nursing.
An NP since 1981, Duffy notes that “we’ve come a long way in Ohio. We got full prescriptive authority at the end of the 1990s.”
However, like all Ohio NPs, Duffy needs a collaborative agreement with a doctor. “Ohio is in the reduced practice category,” she notes. “Not a lot obstructs me from doing what I want. The only thing that gets in the way is having to make that collaborative arrangement.”
Kapu stresses the need to get out the message that laws limiting NP practice need to be revised. Laws need to be updated to “allow NPs to practice to the extent of their education and training, not beyond that, but to the extent of their education and training, as they are very capable of doing and have decades and decades of evidence demonstrating their quality-of-care outcomes. So it’s getting that message out that all we have to do is update those laws. It’s no cost or delay and can be put into place, and you would see much-increased access.”
Kapu points to Arizona as an example of what may happen for states that grant FPA. Arizona, she notes, moved to FPA in 2001. Five years later, the NP workforce doubled, and rural areas saw a 70% increase in NPs.
FPA Federal Legislation
On the federal level, new legislation, the Improving Care and Access to Nurses (ICAN) Act, was introduced in September in the House of Representatives. Supported by the AANP and other major nursing organizations, the act would update Medicare and Medicaid to enable advanced practice nurses to practice to the top of their education and clinical training, according to a press release from the American Nurses Association.
Although getting FPA in all states has taken a little longer than wanted, “we have momentum,” says Kapu. “I believe we’ll get there, especially with the increasing access to care needs that we’re seeing in the United States today.”
Nursing education after COVID will rely more on technology and digital tools than ever. Simulation and online learning will be part and parcel of the curriculum for nursing students. It will also be more competency-based as the new AACNEssentials further integrate into nursing curriculums.
But what about the content of the curriculum?
Nursing education, according to Mary Dolansky, Ph.D., RN, FAAN, Sarah C. Hirsh Professor, Frances Payne Bolton School of Nursing and Director, QSEN Institute at the school, may include instruction on telehealth, an emphasis on systems thinking, stress on leadership, and a focus on innovation and design thinking.
Mary Dolansky, Ph.D., RN, FAAN, is a Sarah C. Hirsh Professor at the Frances Payne Bolton School of Nursing and Director, QSEN Institute at the school
A Look at Nursing Education After COVID
Understanding how to use telehealth in nursing is key, according to Dolansky. The Frances Payne Bolton School of Nursing at Case Western Reserve University, Cleveland, developed a series of four modules on telehealth so that all students received a basic foundation in telehealth nursing, including telehealth presence. It included teaching on using Zoom or the phone to assess and evaluate patients. She notes that interactive products that give students a feel for how such interactions occur and practice them can provide an excellent education.
Another aspect of post-COVID nursing education involves systems thinking, says Dolansky. This involves “really getting students to think beyond one-to-one patient care delivery and about populations. We need to create more curricula for nurses out in primary care sites and nurses out in the community, and that has not been a strong emphasis in schools of nursing. Instead, we focus mainly on acute care.”
More specifically, students should learn, for instance, how to use data registries to look at areas of patient need. One COVID example, notes Dolansky, would be to use registries to identify long-term COVID patients. Another could be to use a registry or database to discover what patients have followed up on their chronic disease since, during COVID, many patients stopped visiting healthcare providers.
In the post-COVID curriculum, developing leadership skills may become more critical. “What we observed in the COVID crisis,” says Dolansky, “was an opportunity for nurses to stand up and speak out more. We were the ones at the frontline and had the potential to be more innovative and responsive. Many great nurses did step up and speak up, but we need to ensure that every nurse can speak up for patients in future crises or even advocate for our patients now. Nurses can be the biggest advocates for patients.”
Every school of nursing probably has a leadership course, Dolansky notes. But ensuring that there are case studies from COVID as to how nurses did stand up and speak out and how that made a difference would be a fundamental curriculum change.
“We want to prepare our students that you will be a leader and you will be on TV talking about how you are innovating and adapting to the changing needs of the health of our population. And COVID was a great example for that.”
Post-COVID, nursing education needs to help students with innovation and design thinking, notes Dolansky. Over the past 10 years with QSEN, “what we’re trying to advocate is shifting the lens of a nurse from direct patient care delivery, which has been the focus of nursing, to shifting a little bit to systems thinking.”
Critical thinking, notes Dolansky, focuses on making decisions for an individual patient. Design thinking and innovation are more about “looking at the system in which we work and empowering the nurses to fix the systems. This is key to quality and safety, but it’s also key to the need for our nurses to contribute strongly to the health of the future population. They have to be at the table to respond to these crises. We need them to have the skill set of being a leader, standing up, being at the table and when they’re at the table, having ideas, being creative, and knowing how to test them. And having the technical skills to use the technology is probably where most of the solutions will be for the future.”
While revising the Essentials began before the pandemic, the experiences and learnings from the pandemic greatly impacted the work, notes a recent article in Academic Medicine. As a result, the Essentials includes population health competencies that specifically address disaster and pandemic response and will better prepare the next generation of nurses to respond safely in future events, the article says.
Now, a crosswalk has developed between QSEN competency statements and the 2021 AACN Essential Statements, notes Dolansky. However, she notes that the AACN is taking the QSEN foundation and moving it forward, stating to the public that “the nursing profession has these competencies that are providing safe quality care to the public.”Since 2012, the QSEN effort has been based on the Frances Payne Bolton School of Nursing.
“Own Their Competency”
In the culture of nursing education, students now need to be educated to “own their competency,” says Dolansky. “Students will see that competency development is part of their lifelong professional development.
The recent announcement by Pfizer of a potentially effective COVID-19 vaccine has led to great excitement, even though some nurses express misgivings about the speed of COVID-19 vaccine development. This vaccine development would not be possible, of course, without the participation of many thousands of volunteers in clinical trials. Unfortunately, minority participation in these COVID-19 trials has lagged.
“As we strive to overcome the social and structural causes of health care disparities, we must recognize the underrepresentation of minority groups in COVID-19 clinical trials,” notes a column in the August 27, 2020 issue of The New England Journal of Medicine.
A major reason for this underrepresentation involves “distrust of researchers, healthcare in general when it comes to communities of color,” notes Ernest J. Grant, PhD, RN, FAAN, president of the American Nurses Association (ANA). That distrust, he notes, harkens back to such appalling experiences as the “Tuskegee Study of Untreated Syphilis in the Negro Male,” where hundreds of Black men were recruited to study syphilis without treatment.
Dr. Grant suggests a number of ways to address the underrepresentation of minorities in COVID-19 clinical trials. One is to provide thorough education as people are being recruited into a trial. Another involves the recruiter. “There tends to be more of a trusting relationship if they see that it is a researcher that perhaps resembles them, or is from their culture,” according to Dr. Grant.
Another tactic involves recruiting a “community influencer or someone like a pastor or a community leader or doctor or nurse within the community that people respect.” Those influencers, he notes, can help dispel myths and address uncertainties potential minority participants may have.
Once a vaccine is available, minorities are at special need of receiving the treatment, especially because minorities are at greater risk of not surviving or having a more difficult time with the disease. The virus, notes Dr. Grant, tends to proliferate more when there are comorbidities that tend to be more prominent in black and brown individuals, such as hypertension and diabetes. “When a vaccine does come along, it would prove to be more beneficial and reduce their chances of succumbing to this virus,” he says.
ANA President as Study Participant
Practicing what he preaches, Dr. Grant is currently participating in a COVID-19 vaccine phase III clinical trial at the University of North Carolina. He will be followed for two years.
One reason for his participation, he says, is the knowledge that more minority participants are needed. Another is that as a leader of the nation’s nurses, “it’s my way of trying to give back to them, knowing that they will be some of the first individuals to take the vaccine once it is approved.”
Dr. Grant ask nurses to consider volunteering for a clinical trial, and then once a vaccine has been approved, to “educate themselves so that they can educate the public.” Nurses also need to be at the table, he notes, when decisions are being made about such things as vaccine distribution. Nurses, he says, “obviously play a very critical role in that process.”
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