The push to modernize nursing regulations during the pandemic

Highlights

• •APRNs stand ready and willing to improve access to care across.
• •Federal HHS Secretary calls for lifting restrictions during COVID-19.
• •The Southeast U.S. remains the most restricted area for APRNs.
• •Now is the time to push forward on permanently removing APRN practice barriers.
• •Increased engagement of nurses in professional advocacy is needed.

Advanced Practice Registered Nurses (APRNs) are ready, willing, but restricted; there is no better time for the sleeping giant of 3.8 million registered nurses to wake up and take part in a massive push to retire outdated restrictions on APRNs once and for all (American Association of Colleges of Nursing, 2019). More has been done, arguably, to curtail the over-regulation of nursing in the past month than in the last 10 years combined. In the midst of the COVID-19 chaos, President Trump and many governors have enacted swift, unprecedented regulatory change through executive orders (e.g., to expand telehealth delivery and ensure reimbursement for these services through Medicare and state-issued Medicaid; Centers for Medicaid and Medicare Services [CMS], 2020).

While executive orders can be an effective temporary measure, there is still much to be done. With the support of an engaged public, permanent legislative change is now possible. It's time to untie the hands of the 404,437 APRNs in the U.S. (Phillips, 2020). A recent, desperate call from an NP unable to hire more nurse practitioners (NP)s to help her care for COVID-19 vulnerable patients due to state restrictions was heartbreaking (James, 2020). States that are lagging behind need to be brought into the 21st century. But first, we as nurses, must realize that we have the political power to drive these reforms. We simply have to take action.

The Multistate Landscape

The COVID-19 crisis has demonstrated that nurses must be able to swiftly and flexibly cross state lines for work. Yet, the lack of a multistate licensure for advanced practice registered nurses, combined with unnecessary restrictions on APRNs’ scope of practice, has impeded mobilization of the nursing workforce. The APRN Compact is effectively on standby, meaning fluid interstate movement of APRNs is not currently possible.

While the compact was approved in 2015, for it to go into effect, a minimum of 10 states have to pass the proposed model legislation. Only three states (Idaho, North Dakota, and Wyoming) have enacted the APRN Compact to date (National Council of State Boards of Nursing [NCSBN], 2020); in comparison, 30 states have enacted a multi-state license for registered and practical nurses. States that mandate APRN supervision or collaboration with a physician are not eligible to participate in the APRN Compact at all.

On March 24th, Federal Health and Human Services Secretary Alex Azar sent a letter to all the nation's governors recommending they promptly “relax scope of practice requirements for healthcare professionals” (NCSBN, 2020a). The federal government temporarily suspended physician supervision of CRNAs at the national level as well (CMS, 2020). A month later, all but seven (including Georgia) of the 28 states that limit NP practice have partially or fully waived APRN practice agreement requirements with physicians (American Association of Nurse Practitioners, 2020). In fact, 22 states have achieved Full Practice Authority (FPA) status for NPs, according to the AANP (2020). Despite this, the Southeast (SE) remains the most restricted region in the country, with all 12 SE states either having a “restricted or reduced practice” designation—thus precluding interstate deployment of nurses to SE COVID-19 hot zones. What exactly is holding back Southern states? Georgia politics may offer some insight.

Georgia Health Politics

Georgia is widely considered the most restrictive state for nursing: We were the last state to grant prescriptive authority to APRNs and are currently the only state in which APRNs cannot order advanced imaging without restriction. Here, legislators and the Governor's office have long yielded to the influence of state medical associations. Efforts to remove APRN scope of practice barriers are continually framed as “scope of practice fights,” rather than collaborative initiatives to improve access to care.

On Crossover Day, the last day for legislation to move from one chamber to the other at the Georgia State Capitol, two part-time APRN coalition lobbyists, two APRNs (out of about 15,000), and four volunteer high school students were alone in fighting for passage of a bill to remove Georgia APRN radiology restrictions (HB 1092). We were up against a full cadre of medical lobbyists working in unison and calling out legislators from the chamber to the Capitol hallways for private discussions about the bill. The opposition claimed that allowing APRNs to order advanced imaging would increase costs and threaten patient safety. There is no evidence to support these claims from any of the 49 states that allow APRNs to order these tests; but organized medicine is adept at coalescing around any perceived threat to their profession. Against all odds, the bill passed the Georgia House with a level of support that was truly unexpected. The two nurses in attendance shed tears of relief at its passage. HB 1092 will move onto the Georgia Senate when they reconvene in mid-June.

In spite of occasional victories such as this, there continues to be a relative lack of political engagement from Georgia nurses. Efforts to modernize our state Nurse Practice Act—the living document that controls all aspects of state nursing practice—will surely fail if nurses do not actively support the effort. Nurses must complete an honest self-assessment: Are we giving this cause the time and attention it deserves?

Nursing advocacy initiatives are underfunded. Many nurses do not understand that being actively involved in state and local organizations has the utmost impact on their practice environment. National nursing organizations can offer support, but the real work needs to be done close to home. Sadly, an overwhelming majority of Georgia nurses are neither members of state or local nursing organizations, nor have they ever contacted their state legislators. During presentations, when I ask groups of nurses to raise their hand if they know the names of their legislators, time and again only a few hands go up.

Moving Forward

Georgia nursing advocates are stepping up efforts to increase engagement from frontline nurses and allies. Next steps include lobbying support from the public and groups such as Americans for Prosperity and the American Association of Retired Persons. The Georgians United for Healthcare movement, a coalition of pro-nursing organizations, has already launched a campaign to fund public service announcements illustrating how practice barriers limit citizens’ access to care.

Nationwide, APRNs will need to demonstrate support from physician colleagues when advocating for reform. Florida State Representative Clay Pigman, an emergency medicine doctor, offers an excellent example of the effectiveness of physician champions. He sponsored Florida APRN legislation, passionately calling for the retirement of mandated physician supervision requirements; and the bill successfully passed (Downey, 2020).

I hope nurses and physicians across the country will come together to lead grassroots health policy efforts. We need more nurses taking the first steps by joining their state and local organizations, getting to know their legislators, and gaining confidence in legislative advocacy. That includes running for public office. Our communities desperately need improved access to healthcare—they are counting on us. There seems to be no better year than 2020, the Year of the Nurse and Midwife, to push forward (WHO, 2020).