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Independent practice coming into focus for APNs

Monday August 19, 2013
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Pat Barnett, RN
For advanced practice nurses in New York and New Jersey, it is anything but a sprint to the finish line of independent practice. APNs in both states, along with nursing sources on the national level, tell Nurse.com that progress is happening, but slowly.

Are we there yet?
Full scope of practice means different things to different people. To some, it’s providing services to the full extent of an APN’s education and experience, even if it requires collaborative agreements with physicians. In New York and New Jersey, it means allowing APNs to practice independently without these agreements. The National Council of State Boards of Nursing, which refers to APNs as advanced practice registered nurses, agrees, said NCSBN’s Maryann Alexander, RN, PhD, FAAN, chief officer, nursing regulation.

"The NCSBN criteria for determining whether a state allows autonomous practice is that the state nurse practice act/regulations do not require any physician supervision or collaborative practice agreement," she said. "Autonomous prescribing is similar. The state practice act does not require MD supervision or collaborative practice agreement for prescribing."


Stephen A. Ferrara, RN
Rebecca Rigolosi, RN, DNP, ANP-BC, immediate past president of The Nurse Practitioner Association New York State, researched how states achieved legislation for independent NP practice, from 2007 through 2012, for her DNP capstone project. She said there are three levels of NP practice scope: full practice authority, in which NPs are completely independent; reduced practice authority (as in New York and New Jersey), where NPs have collaborative agreements; and restricted practice, which requires supervision or delegation.

Where are we in New York?
Efforts have been underway in New York to increase access to NPs with the introduction of the Nurse Practitioners Modernization Act (A4846A Gottfried/S4611A Young) — a dual-house bill that eliminates the requirement of the written practice agreement between an NP and a physician, according to Stephen A. Ferrara, RN, DNP, FNP-BC, FAANP, executive director of NPA New York State.

For the current legislative session, the bills were re-introduced in January and are sitting in the Higher Education Committee in both the Assembly and Senate, he said. In a strong show of support, Gov. Andrew M. Cuomo convened the Medicaid Redesign Team in 2011 comprising stakeholders, including a representative from NPA New York State.

"One of their top recommendations was to have nurse practitioners practice at the 'top of their licenses,’" Ferrara said. "Nurse Practitioner Association New York State is cautiously optimistic that full practice authority for nurse practitioners is attainable within the next 12 to 18 months."


Susan C. Reinhard, RN
Some hurdles remain, though.
"Despite the growing acceptance and recognition that NPs receive among patients, there is still a considerable knowledge gap about NPs among many legislators," he said. "NPs can and should be active participants within their state NP association to bring coordinated educational and grassroots campaigns to their local [legislators]."

Where are we in New Jersey?
Pat Barnett, RN, JD, CEO of the New Jersey State Nurses Association, said the organization started a few years ago working on removal of the joint protocol, which is the restriction in New Jersey that impacts APN practice.

"APNs are not supervised in New Jersey," she said. "They are, however, required to have a joint protocol, which is a written agreement between the physician and APN. The requirement is that they have to sign the agreement once a year, and the physician has to review one [patient] chart through the course of the year."

Barnett said Senate Bill 2354, the Consumer Access to Health Care Act, and its companion bill in the Assembly, Bill 3512, address removing joint protocol.

There is a lot of grassroots work to be done to garner support before trying to push the bill through, Bennett said.

"What we’re trying to do is just educate people right now," she said. "It doesn’t do any good to rush a bill to a vote when people don’t understand it. So, we’re educating legislators. We’re meeting with consumer groups, unions, businesses — educating them about what the bill does and doesn’t do."

But education takes time. "The bill will not be pushed in 2013," Barnett said.

Power of grassroots efforts
Rigolosi said her research taught her achieving legislation for independent practice does not happen overnight.

"It really takes a consistent and continuous effort by a lot of different people to make this happen," she said. "You have to pound pavement. You have to get your faces out there — meeting the legislators, building a foundation with them."

Introducing state legislation is an initial step. It’s that grassroots effort that states have used successfully to get the support needed to make these bills law, according to Rigolosi.

"I think especially in New York and New Jersey now — and I can speak to this uniquely because I am a member of New York and New Jersey nurse practitioner associations — I am certainly seeing a push for this grassroots effort," she said.

National momentum
There is some national groundswell in the name of more independence for APRNs. In 2008, The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education was published and endorsed by 48 nursing organizations, according to Alexander.

"The model specifies uniform regulations for the licensing, accreditation, certification and education of APRNs as well as the intended scope of their practice," she said. "Since that time, NCSBN embarked upon their 'Campaign for APRN Consensus.’"

State organizations trying to push this forward are not alone. As part of this initiative, NCSBN works with the state boards of nursing, as well as other coalitions within a state, when APRN legislation is being proposed or has been introduced into a state legislature.

Among other organizations in the mix is the Center to Champion Nursing in America, an initiative of AARP and the Robert Wood Johnson Foundation, which coordinates the Future of Nursing: Campaign for Action.

"Nationally, there are a variety of nurse-led models of care delivery that allow APRNs to practice in a way that gets consumers the care they need," said Susan C. Reinhard, RN, PhD, FAAN, senior vice president, AARP Public Policy Institute and chief strategist, Center to Champion Nursing in America, Washington, D.C. "In particular, let me point to the Veterans Health Administration and the Indian Health Services, among other federal entities, where APRNs can practice to the full extent of their education and training, delivering federal healthcare services across the country despite the patchwork of inconsistent laws and regulations in states."

Integral in all this is The Institute of Medicine’s "The Future of Nursing: Leading Change, Advancing Health" report, which supports removing scope of practice barriers that hinder APRNs from practicing to the full extent of their education and training.

The progress from national, regional and local efforts is incremental, yet significant, Reinhard said.

"We believe the tide is turning," she said. "This year 14 states introduced bills to ensure that NPs could practice to the full extent of their education and capabilities without unnecessary and restrictive physician supervision."

Lisette Hilton is a freelance writer.


To comment, email editorNY@nurse.com.
NP residency aims to support independent practice

Rutgers University School of Nursing, Camden, N.J., is developing a residency program model to help NPs transition to independent practice, according to Dean and Professor Susan Salmond, RN, EdD, ANEF, FAAN.
New NPs, she said, often get into narrow roles where they don’t practice to their full scope. “There are some people that only take histories and physicals,” she said. “Or, they’re only seeing very routine patients rather than some of the more complex patients. So they’re only using portions of what that skill set is.”
Salmond and colleagues are looking at six-month and yearlong residencies, which would include hands-on clinical practice, continued mentorship and some class review.
“We have the outlines of a curriculum, some of the pieces of a business plan, and we’re looking at sites and trying to get funding to try to pilot it,” she said. “It’s not to say that you can’t do it without [such a residency], but I think it would be beneficial.”

By Lisette Hilton, freelance writer.