Inconsistent State Regulations
State regulations often restrict the ability of nurses to provide care legally. State legislation regarding the legal scopes of practice for nurses—which defines the activities that a qualified nurse may perform—vary widely. Some state legislation is very detailed, while in other states, there are vague provisions that are open to interpretation. Some states have kept pace with the evolution of the health care system by changing their scope-of-practice regulations to allow nurse practitioners (NP) and certified nurse midwives, for example, to see patients and prescribe medications without a physician’s supervision or collaboration. Most states, however, have not made these changes. As a result, what NPs and, more broadly, APRNs are able to do after graduation varies widely across the country for reasons that are not related to their ability, education, or training, but rather to the political decisions of the state in which they work.
Both educational and national certification standards—which most, if not all, states recognize— support broader practice by APRNs. No studies suggest that APRNs are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs. In fact, evidence shows that nurses provide quality care to patients, including preventing medication errors, reducing or eliminating infections, and easing the transition patients make from hospital to home. Yet most states continue to restrict the practice of APRNs. However, various stakeholders are working to develop ways to eliminate variations in scope of practice regulations across states. In 2008, several nursing organizations came together and developed a consensus model for standardizing the regulation of APRNs, including education, accreditation, certification, and licensure. This model will help encourage the development of consistent regulations that recognize the competence of APRNs across states.
Current laws in many states are hampering the ability of APRNs to contribute to innovative health care delivery solutions. Some NPs, for example, have left primary care to work as specialists in hospital settings. Others have left NP practice altogether to work as staff RNs. State regulations have limited the expansion of retail clinics, where NPs provide a limited set of primary care services directly to patients. Depending on the state, restrictions on an APRN’s scope of practice may limit or prohibit the authority to prescribe medications, admit patients to hospitals, assess patient conditions, and order and evaluate tests, thereby restricting access to care.
The trend over the past 20 years has been a growing receptivity on the part of state legislatures to expanded scopes of practice for nurses. Quite simply, there are not enough primary care physicians to care for today’s aging population, and the patient load will dramatically increase as more individuals gain insurance coverage. The experience of states that have led these changes offers important reassurance to physicians who continue to believe that patient care may be adversely affected or that expanded nursing practice autonomy threatens the professional and economic roles of physicians. States with broader nursing scopes of practice have experienced no deterioration of patient care.
The Federal Government’s Role in Reform
The federal government has a compelling interest in the regulatory environment for health care professions because of its responsibility to patients covered by federal programs including Medicare, Medicaid, the Veterans Administration, and the Bureau of Indian Affairs. Equally important is the responsibility to all American taxpayers who fund the care provided under these programs to ensure that their tax dollars are spent efficiently.
Congress, the Federal Trade Commission, the Office of Personnel Management, and the Centers for Medicare and Medicaid Services each have specific authority over or responsibility for decisions that either could or must be made at the federal level to be consistent with state efforts to remove scope-of-practice barriers. While no single actor or agency can independently make a sweeping change to eliminate current barriers, the various state and federal entities can each make relevant decisions that together can lead to needed improvements.
Because one of the greatest barriers to nurses’ capacity to transform the health care system is the patchwork of state regulations, the committee finds that the federal government is particularly well situated to enact effective reform of the practice of APRNs by disseminating best practices from across the country and creating incentives for their adoption.
Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence. The U.S. is transforming its health care system to provide quality care leading to improved health outcomes, and nurses can and should play a significant role. The current conflicts between what APRNs can do based on their education and training and what they may do according to state and federal regulations must be resolved so that they are better able to provide seamless, affordable, and quality care. Scope-of-practice regulations in all states should reflect the full extent not only of nurses but of each profession’s education and training. Elimination of barriers for all professions with a focus on collaborative teamwork will maximize and improve care throughout the health care system.