The Legal Status of APRNs

In our final article on Advanced Practice Registered Nurses (APRNs), we will be explaining the legal status of APRN practice. The rules for what APRNs can and can’t do as part of their patient care varies from state to state.  We’ll take a look at other states, though our focus is on Kansas, of course.  And, we’ll be looking at how the changes in APRN rules could help alleviate one of the biggest problems facing states such as Kansas:  poor access to healthcare.  Guest Editor Michelle Knowles, FNP, APRN joins us for this final segment on APRNs.

When it comes to healthcare, what you hear about most often in the news is the rising cost of health insurance.  But if you are in need of healthcare, the biggest problem is finding a provider. The United States has a shortage of physicians.  A study in 2015 projects a shortfall of around 90,000 physicians by 2023. Rural areas and low-income urban areas have even fewer physicians. Luckily, advanced practice nurses are working in those areas and providing care to patients.

If you look back at our first article on the History of APRNs, you’ll see it’s not a new problem, and one that APRNs were designed to help fix.

The biggest barrier to using APRNs in all states to help with the healthcare provider shortage is the variation from state to state regarding what an APRN is allowed to do by law. All APRNs have standardized education and training, but when some states limit what an APRN can do, it interferes with access to care. Some states have full autonomy for APRNs, while others have collaborative (restricted) or supervisory laws. It becomes confusing to the patient.

APRN Autonomy

So, what does APRN Autonomy or Full Practice Authority mean?  Simply put, it gives APRNs the legal rights to perform advanced nursing care within their area of expertise without the collaboration or supervision of a physician, and licensed exclusively by the state Board of Nursing.  You’ll hear it called various terms such as APRN independent practice, autonomy, full practice authority and a few others.  Allowing APRNs to function autonomously makes sense and has been proven to be the best use of our healthcare workforce. It gets rid of outdated beliefs and laws that restrict APRNs from providing services that they are fully qualified to provide. In some states, to practice advanced nursing, an APRN must be “attached” to a physician.  In some states, the physician must directly supervise any actions by the APRN, and in some states it’s “slightly” relaxed, and the physician can decide how much collaboration is required.

This makes for a bit of a gap in how healthcare works.  In states where an APRN must be attached to a physician, it means that final decisions concerning medical care must be signed off by a physician who may or may not have ever met the patient.  This causes delays in care, increases costs to the patient or insurance company and makes coordination of care confusing to pharmacists and others. For example, instead of the APRN simply writing a prescription, it has the physician’s name on it also.  Same with laboratory or other diagnostic tests, which may delay the results getting back to the person who actually ordered it. It becomes a wasteful situation for everyone involved.

Not all states require APRN’s to be legally bound to a physician, though.  Currently, the there are 22 states that legally allow for autonomous practice by APRNs, including our neighbors, Nebraska and Colorado:

  • Alaska
  • Arizona
  • Colorado
  • Connecticut
  • District of Columbia
  • Hawaii
  • Idaho
  • Iowa
  • Maine
  • Maryland
  • Minnesota
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Mexico
  • North Dakota
  • Oregon
  • Rhode Island
  • Vermont
  • Washington
  • Wyoming

You’ll notice a trend:  most of the states that allow for autonomy have larger rural areas.  Because APRNs can practice on their own, they can serve small towns more easily, and at a lower cost.  In states without APRN autonomy, these small town APRN providers must partner with a physician that may be hundreds of miles away.

APRN autonomy has worked for many states.  This hasn’t gone without notice, as the National Governors Association released a position paper giving state governments large amounts of extremely positive data concerning how APRN autonomy can help improve access to healthcare in their state.  In 2014, the Federal Trade Commission issued a paper warning state governments to reconsider any action that puts restrictions on APRN autonomy.

There’s also a small business side effect to states that require APRNs to be attached to a physician.  If something should happen to the physician (they retire, are unable to practice, or move out of state), the APRN’s business now has a mad scramble to replace that physician immediately.  In some areas of the country, this may be an extremely difficult task – it’s hard to find a physician that wants to increase their workload.  If they are unable to find a replacement, the business will be forced to close, removing yet another healthcare option from an area.

Nationally, the Department of Veteran’s Affairs recently granted autonomous practice to certified nurse practitioners, clinical nurse specialists and certified nurse midwives (APRNs) in the VA system. Regardless of state law, veterans in the VA system can receive care from APRNs with autonomous practice, which will increase access to care for millions of veterans.

The Status of APRNs in Kansas

Despite a very large rural population, Kansas still requires APRNs and APRN practices to have a written collaborative agreement with a physician.  For years, the Kansas APRNs have tried to change the outdated laws. In 2014, for instance, a bill was introduced to eliminate the need for APRNs to be attached to a physician. The bill died in committee, without ever reaching a vote.

There’s a lot of resistance in some areas to APRNs being able to practice on their own, despite success in so many other states.  There are a lot of reasons for that, of course.  Most of the reasons center around perceived competition for healthcare dollars. Will the laws eventually change?  The answer is most likely, yes.  The overwhelming evidence regarding safety of APRN practice, along with the shortage of available healthcare providers in rural and low-income urban areas continues to grow.  Groups like the Kansas Advanced Practice Nurses (KAPN) Association continue to increase public awareness and introduce legislation to help create an environment for changing outdated laws that restrict access to healthcare for Kansans. You can help, of course.  Check out the KAPN Association website for ways you can help work with legislators to get the laws changed, or consider donating to help keep the process moving forward.

Simply put:  APRN autonomy isn’t a simple business or competition issue.  It’s a matter of improving access to healthcare in Kansas.

Davis Sickmon is a writer, sometimes college instructor, entrepreneur, and IT professional. More information about Davis can be found at his personal website.

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