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.”