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.
Defining FPA
“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.
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.
Ohio Experience
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 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.”
Overcoming Obstacles
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.
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.
Maintaining Momentum
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.”
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.
Defining FPA
“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.
Ohio Experience
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.”
Overcoming Obstacles
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.
Maintaining Momentum
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.”
Whether you are an experienced nurse practitioner with years of clinical practice already under your belt, or you’re a student preparing for a fulfilling career devoted to helping people, you’re likely to face some unexpected challenges and some exciting opportunities in the work you have chosen. The role of the nurse practitioner is rapidly evolving, responding both to changes in the health care industry and to the evolving needs of the communities you serve. This article explores some of the most significant trends nurse practitioners are facing today.
An Expanding Role
The global health care shortage is not news, but what is news, perhaps, is how significant and widespread it is. In fact, in the United States alone, it is estimated that the shortfall in the number of physicians needed by 2033 will approach 140,000.
And that reality is rapidly and dramatically expanding the role of and the demand for skilled nurse practitioners. Where nurse practitioners might have once worked primarily in collaboration with a physician, increasingly, nurse practitioners are taking the lead in patient care. In many states, this includes overseeing and implementing treatment plans and even coordinating end-of-life care.
Holistic Care
In addition to operating more independently than ever before, nurse practitioners are also finding themselves drawing on an array of skills, resources, and knowledge to provide more comprehensive care.
For example, as demand and cost pressures on the system mount, health care providers and patients alike are seeking more holistic strategies to promote wellness and prevent disease. This often includes, for instance, an emphasis on fitness and nutrition, constituting a significant shift in standard medical practices.
Historically, health care providers have been dissuaded or even prohibited from offering nutritional advice, as it may have been considered outside of the clinician’s scope of practice.
In addition to cultivating specialized knowledge to provide higher quality and more comprehensive care, nurse practitioners are also increasingly being looked to as multigenerational health care providers. In such cases, nurse practitioners may provide many of the services of a primary care physician, general practitioner, or family physician.
For this reason, a large number of nursing schools are offering students the opportunity to train as family nurse practitioners (FNP), enabling them to offer optimal patient care across all stages of the lifespan, from birth to death. Licensure as an FNP can be a particularly attractive option for those who seek to develop long-term, trusting relationships not only with individual patients but with an entire family.
Serving At-Risk Communities
Disparities in access to consistent, affordable, and high-quality health care have long been known and lamented. However, health care systems are increasingly turning to nurse practitioners to stand in the breach, filling a desperate need for health care providers in underserved communities.
That means that nurse practitioners may routinely find themselves asked to serve in remote, rural communities or impoverished urban areas where the need for qualified health care providers is greatest. In fact, nurse practitioners who have pursued specializations in community or public health can find themselves in particularly great demand and may build rewarding careers as traveling nurse practitioners, serving communities in need for weeks or even months at a time before moving on to the next post.
Increased Opportunity
When it comes to both training and practice, nurse practitioners have more options and opportunities than ever before. In addition to choosing specific areas of specialization, such as adult or pediatric care, nurse practitioners can also select from an array of subspecialties which will increase their marketability.
However, the degree of clinical autonomy nurse practitioners enjoy will vary from state to state. In some U.S. states, licensed nurse practitioners enjoy what is known as full-practice authority (FPA), meaning that they can prescribe medication, order tests, and define and implement patient care strategies without requiring a physician to sign off on the plan. In other states, though, nurse practitioners still need a physician’s authorization before a treatment plan can be implemented.
Nevertheless, the opportunities for nurse practitioners to earn FPA are growing. For instance, attaining an Advanced Practice Registered Nurse designation can give you full practice authority in many states, including some states where a physician’s sign-off would otherwise be required. Most exciting of all, organizations such as the American Association of Nurse Practitioners are working to establish a nationwide certification protocol to enable qualified nurse practitioners to enjoy full practice authority in all U.S. states and territories.
The Takeaway
It is an exciting time to be a nurse practitioner, a time of high demand, increasing independence, and tremendous opportunity. Nevertheless, the challenges are significant, principally due to an ongoing labor shortage and continuing disparities in health care access. In a time when both the need and the reward are great, nurse practitioners are perfectly positioned to fill the gap.
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