C159 Policy, Politics & Global Health Trends

Policy, Politics, and Global Health Trends: Restricted and Reduced Practice State Policies for Advanced Practice Nurses

Through the various state Boards of Nursing, every state in the United States of America has their regulatory policy governing the scope of practice for advanced practice nurses. These are public policies that impact the nursing profession and the communities that benefit from the services of advanced practice nurses. A public policy could be defined as a professional regulatory provision, legislation, or practice framework put in place by a government for the benefit of its population (Kilpatrick, n.d.). The three scope of practice policies in the United States are restricted practice, reduced practice, and full practice authority (AANP, 2020a). This paper discusses state restricted/ reduced practice public policy for NPs and argues why it requires policy change. This is a public policy that impacts the nursing profession as well as the population requiring primary health care in the states with the policy.

Restricted/ Reduced Practice as a Nursing Profession Policy Issue

The public policy of restricted/ reduced practice for NPs is a nursing profession public policy that has a great impact on not only the practitioners themselves, but also the general population requiring primary health care. This paper argues that this policy requires a change to the more progressive full practice authority or FPA. It also puts together restricted and reduced practice as one retrogressive policy, and uses NPs as representative of all advanced practice registered nurses or APRNs for this discussion. It is essential to note that the state scope of practice policy greatly impacts the clinical and professional practice of advanced practice nurses. This it does by determining what the NP can and cannot do in practice, regardless of whether they are trained and are competent in that which they are being restricted from doing. The common thing about restricted practice and reduced practice is that for the NP to be allowed to practice in the state, they must enter into a collaborative agreement with a practicing physician. In this agreement, the NP actually pays the physician to supervise them and approve (or overrule) their ordered investigations and prescriptions. This is a great barrier to practice because despite the fact that the APRN is trained and highly educated to postgraduate level, they cannot be allowed to use this knowledge independently (Peterson, 2017; Duncan & Sheppard, 2015). In fact, they cannot even claim reimbursement under their name with the restricted/ reduced practice policy. All reimbursement comes in the name of the supervising physician, and this means the contribution of the APRN to primary health care is masked by the collaborative agreement.C159 Policy, Politics & Global Health Trends

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According to the AANP (2020a), reduced practice regulatory policy involves the reduction of the ability of the NP to practice at least one element of their specialty for which they were nonetheless trained. The NP is required by law in this policy to maintain the collaborative agreement throughout their career to enable them to see patients, order investigations, and prescribe medications. On the other hand, restricted practice also limits the NP’s ability to engage in the practice of one or more elements of practice, even though they have the necessary education and training for them. With restricted practice policy, the NP is required to be supervised throughout their career, and only carry out delegated clinical work given by the supervising physician. An example of the states where the policy of restricted practice is still in force is the state of North Carolina (AANP, 2020a). Like in other states with restricted/ reduced practice policy, the NPs there have been fighting to have the policy changed in favor of full practice authority (Harkey et al., 2017). Full practice authority (FPA) policy involves no requirement for collaborative agreement or supervision. It is the state practice environment in which the APRN is free to autonomously practice to the fullest extent of their education, training, and kills.

Reason for Selection, Relevance to the Nursing Profession, and Financial Impact on NPs

The reason why the author selected this topic is that the policy of restricted/ reduced practice does not only affect the practitioners alone. The populations expected to be served by these advanced practice nurses are even more affected. This can be understood properly when one revisits the Alma Ata Declaration of 1978 on the need for primary health care for all (Topp & Abimbola, 2018). The declaration envisioned a future global dispensation where all global citizens including the poor would have ready access to the most basic primary health care. Advanced practice nurses are trained to deliver primary health care to especially those who are marginalized in the population. The care they offer is comparatively cheaper compared to that given by physicians. However, studies have shown that it is of the same quality as that given by physicians and sometimes even better. With a restricted/ reduced practice policy, these marginalized communities that would have benefited from the services of an autonomous NP get to be denied this service. The NP in a restricted/ reduced practice state cannot do as much as they would have done if they were in a FPA state.

The relevance of this choice to the nursing profession cannot be overemphasized. The Institute of Medicine (IOM) and the Robert Wood Johnson Foundation in 2010 made revolutionary recommendations in their report labelled Future of Nursing: Leading Change, Advancing Health. Amongst other things, they recommended that all barriers to practice by nurses be removed and that nurses be allowed to practice to the fullest extent of their knowledge and education (Hooper, 2016). The policy of restricted/ reduced practice is a significant barrier to APRN practice (Peterson, 2017; Duncan & Sheppard, 2015). This chosen policy of restricted/ reduced practice therefore clearly goes against the spirit of making over and strengthening the practice of nursing.

The policy of restricted/ reduced practice also has a significant financial impact on the population of NPs practicing in states having the policy. According to the AANP (2020a), these states include Michigan, North Carolina, South Carolina, Texas, California, and Florida amongst others (restricted practice). They also include Ohio, Utah, Kansas, Delaware, New Jersey, and Louisiana amongst others (reduced practice). The collaborative agreement between the NP and the supervising physician requires that the NP pays the physician. Also, by the very fact that their practice is restricted or reduced, the NPs cannot do as much as they would have done. This translates to less revenue for them in reimbursements.

Values and Ethical Principle Vis-à-Vis the Chosen Policy

The values of the author that impact on their position on the public policy issue of NP restricted/ reduced practice are informed by Utilitarianism. This means that the policy should bring the greatest benefit to the greatest number of people (Brännmark, 2017). This policy denies the most vulnerable the benefit of accessing basic primary health care (PHC) by restricting NP practice through legislative and regulatory means. The bioethical principle that underpins this perspective of the author is nonmaleficence or primum non nocere (Haswell, 2019). The policy breaches this ethical principle that requires the avoidance of harm to others (especially patients who require care). In this case, persons who need PHC are denied that access by this policy and may suffer morbidity and even mortality as a result.

The Suggested Policy Brief

To successfully advocate for the amendment of the restricted/ reduced practice policy on NP practice in any state, the elected legislators in the state House of Representatives must be approached and lobbied. This is because they are the only ones who can sponsor amendment Bills to change the policy that is anchored in legislation. Specifically, the policy on scope of practice is operationalized by the Nursing Practice Act in every state. Changing the policy to full practice authority (FPA) will therefore entail a laid down legislative process that may also include public participation. For high chances of success, it would be better to direct this kind of health advocacy initiative to elected state House Representatives who belong to health committees in the House (such as the Health and Human Services Committee). In this section of the paper, the author will take the example of the state of Florida. This is one of the states with restricted practice policy for advanced practice nurses, the worst of all the scope of practice policies (AANP, 2020a).C159 Policy, Politics & Global Health Trends

The Decision Maker

In this case, the representative who will be chosen and who will receive the policy brief for submission to the House as a sponsored amendment Bill is Democratic Rep. Shevrin Jones for District 35. The two main reasons that will inform this choice are that:

  1. He is a member of the Florida Health and Human Services Committee for 2019-2020.
  2. He is a committee member who has a professional background close to healthcare, having graduated with a Bachelor of Science in biochemistry and molecular biology (Ballotpedia, n.d.).

Why the Restricted/ Reduced Practice Policy Issue Requires Attention

This policy issue of restricted practice/ reduced practice requires the attention of this Representative because (i) it is more retrogressive than beneficial; and (ii) the opposition to its amendment is driven by medical vested interests. First and foremost, the majority of opposition to the repeal of a restrictive policy to practice for NPs and implementation of FPA comes from state Medical Boards. These are professional bodies for physicians, some of whom erroneously believe that NPs are taking away their duties and that they are not trained for such duties and responsibilities. Nothing could be further from the truth. Multiple studies have shown that APRNs are just as competent as physicians in treating patients, sometimes even better because of their nursing-derived compassion (Peterson, 2017). The second reason why this decision maker should give this public policy issue attention is that it causes maleficence more than beneficence to the general population. In other words, it serves no useful purpose because NPs are not asking to practice anything they have not been trained to do. Ortiz et al. (2018) found that expanding the scope of practice for NPs did not reduce in any way the quality of patient outcomes. This is scholarly evidence that supports the fact that full practice authority is beneficial to the public that is served by NPs.

Challenges of Addressing the Policy Issue

The main challenges or barriers that may present obstacles to addressing the restricted/ reduced NP practice policy matter are the following:

  • APRN role confusion by physicians and state Medical Boards.
  • The reality of few elected representatives with a nursing background.
  • Lack of legislative input for state Boards of Nursing and the National Council of State Boards of Nursing or NCSBN.

Role Confusion

As has been alluded to above, the main opposition to expanded scope of practice for NPs has traditionally come from state Medical Boards for physicians and their professional organizations. This opposition has been interrogated before and what has come out clearly has been a lack of understanding of the kind of education and training a NP with a DNP goes through for instance. When asked, most physicians admit that they do not know how NPs – whom they consider as nurses – would be able to assess patients, order investigations, interpret laboratory and imaging results, and write prescriptions. These are roles that they consider to be the preserve of physicians who are trained for them (Robeznieks, 2020). The truth, however, is that these are just opinions and ego-driven deductions that have not been proven by any studies. If anything, the available studies show that NPs are just as effective as physicians in the management of patents, if not better. It will require a lot of diplomacy, convincing, and education to change these physician opinions.C159 Policy, Politics & Global Health Trends

Few Elected Nurses as Representatives

There is a reason why professional nursing organizations have always encouraged nurses to seek elected office in state and federal electoral contests. Having nurses in the Houses of Representatives where laws are made will give a voice to nursing issues where it matters. These representatives with a nursing background will be in a better position to sponsor Bills and convince their colleagues of the importance of FPA by giving them facts. Presently, however, the number of elected representatives with a nursing background is very low. This is therefore another challenge in addressing this policy issue.

Lack of a Legislative Mandate for State Boards of Nursing and the National Council for State Boards of Nursing or NCSBN

A majority of the members of state Boards of Nursing are practicing registered nurses and APRNs. This would be a good thing because they would be expected to push for the welfare of nurses at the policy level. However, it would seem that the mandate of these state Boards of Nursing is just regulatory and enforcement. Members are appointed by the Governor and only implement what has been passed already as law in the Nursing Practice Act. The boards have absolutely no input in the legislative process that enacts the policies that govern nursing scope of practice. This is the same case with the National Council of State Boards of Nursing or NCSBN. This is a challenge because if these bodies with a majority membership of nurses cannot have legislative input, then repressive and unfavorable policies for nursing practice will continue to be made above them.

Primary Options for the Decision Maker

The most important primary option that the decision maker (elected Representative Shevrin Jones) has is to come up with a draft amendment Bill to the Florida Nurse Practice Act and lobby his colleagues to support it. He would then have to present it to the House Speaker for debate after ascertaining that he has the support of the majority of the legislators. This amendment will have the singular aim of repealing the sections that put in place the policy of restricted practice for APRNs in Florida. The amendment would propose that NPs and other APRNs be allowed to practice to the fullest extent of their training, education, and skills. This would be full practice and prescriptive authority. This intervention by the decision maker is tangible because it follows the laid down legislative process in the state House of Representatives. This is the only path that can lead to a change in the restricted practice policy on the scope of practice for NPs in the state.

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A Persuasive Course of Action for the Decision Maker

The persuasive course of action for the decision maker (who is an elected Representative in the Florida House of Representatives and a member of the Health and Human Services committee) will be to follow house procedure. The course of action will entail the following, after successfully lobbying colleagues (The Florida Senate, 2020):

  1. The drafting of the Florida Nurse Practice Act amendment Bill by Rep. Shevrin Jones as the sponsor of the Bill.
  2. Referral to the House committees that have the mandate to discuss the subject of the Bill, such as the Health and Human Services Committee for deliberation.
  3. Voting on the Bill by the full house (House of Representatives).
  4. Sending of the Bill to the Senate for review and deliberation, if it passes the vote in the House of Representatives. If consensus is reached, then the Bill is passed. There may be a provision for public participation if the House and Senate rules provide for it.
  5. Engrossing and signature into law by the Governor.

The ways to avoid the challenges or barriers discussed above would include (i) soliciting for the input of the Florida State Board of Nursing by inviting them to give a presentation of their view on the matter in the House or Senate; and (ii) inviting the Florida Medical Association to the House or Senate to do the same too.C159 Policy, Politics & Global Health Trends

Evaluating the Success of the Policy Brief

Success of the policy brief will be evaluated depending on the flow of information from the top of the legislative ladder. This evaluation will entail the:

  • Concurrence and passage of the Bill by both houses, information which will be communicated by the speaker of the House.
  • Formal communication from the Legislature to the Florida State Board of Nursing of the successful amendment of the Florida Nurse Practice Act and coming into force of full practice authority.
  • Implementation by individual healthcare organizations and private office practices of the new policy on the ground.

A Plan for Working with the American Association of Nurse Practitioners (AANP) to Address the Policy Issue Discussed Above

It is evident in any large scale endeavor such as the change of a policy matter that one has to get the support of several stakeholders for any chance at success. In this particular case, support would be sought from the American Association of Nurse Practitioners (AANP) which is the professional organization for all NPs in the country. This organization has not just expressed interest in this selected nursing profession policy issue. It is actually the main advocacy force pushing for the expansion of the scope of practice for NPs in those states that still have restricted or reduced practice policy.

The AANP was founded in 1985 as a vehicle to provide a unified voice for all NPs licensed to practice in the United States. Currently, it boasts a membership of more than 115,000 NPs from across the country but represents the interests of the more that 290,000 NPs registered and licensed to practice in the United States. It specifically recognizes the important role that NPs play in the provision of primary health care for rural and marginalized communities in the country (AANP, 2020b). This role became even more important after the enactment of the Patient Protection and Affordable Care Act (ACA) 2010. This Act or law (the so-called “Obamacare”) afforded healthcare coverage to an additional 22 million poor Americans who could not afford healthcare insurance up to then (Kominski et al., 2017). Because physicians prefer to work in cities where their specialties are more lucrative, there has been a gap for family medicine and primary care clinicians in the rural areas and among marginalized communities in the country. This is why removing the policy of restricted/ reduced practice for NPs is important for the AANP.

Three Community-Based Participatory Research (CBPR) Principles to be Used to Work with the AANP

To address the policy issue on expansion of scope of practice for NPs, three CBPR principles would be useful in collaborating with the AANP for that goal. CBPR is a methodology for solving problems that affect populations or communities that places emphasis on involving the affected in the implementation of the solution. In this case, it is the entire population of 290,000 NPs across the country that is affected by this restriction in the scope of practice. The decision maker in this case chooses to collaborate with the AANP which is the umbrella body for NPs so that they can work in collaboration to implement FPA in place of restricted and reduced practice in the barrier states such as Florida. In this context, therefore, the three CBPR principles that could be used to work with the AANP to look for a solution to this NP scope of practice public policy issue are (Health Outreach Partners, 2011) are:

  1. Accepting that the AANP as an organization is the unit of identity for its members, whose views and opinions must be taken into account at all times.
  2. Harnessing the strengths and the knowledge of the community of NPs to turn universal FPA into a reality.
  3. Paying attention on the relevance of the public policy on the rural and marginalized communities that require affordable primary health care.C159 Policy, Politics & Global Health Trends

Approaching the AANP for collaboration would start with the invitation for presentation of views to the House Committees on health as already extensively discussed above. It is during these sessions that the decision maker will establish contacts with the leadership of the AANP. After that, communication will be directly through the AANP leadership that will then pass it down to their members.

Goal Alignment and Action Steps

The goal of the AANP for the selected public policy issue of restricted scope of practice and the author’s goal for the same are perfectly aligned. This is evidenced by the fact that:

  • The author’s values are driven by Utilitarianism and beneficence, while the AANP is also concerned that its NPs are being prevented from helping the majority poor from accessing primary health care.
  • The author believes that one should only be limited by their abilities, and the AANP also believes that NPs should be allowed to practice to the fullest extent of their postgraduate education and training.

The action steps needed to achieve the goal above are sensitization of the public and other stakeholders of the importance of the policy issue, advocacy initiatives aimed at policy makers at the legislative level, and multidisciplinary collaboration and information sharing to repeal the policy and replace it with FPA.

Roles and Responsibilities of AANP Members, Elements of Evaluation Plan, and Evaluation of the Success of the Plan

The roles and responsibilities of the AANP members (the NPs) in terms of capacity building and problem-solving will include:

  • Providing peer-reviewed scholarly evidence for their effectiveness in delivering treatment solutions just like physicians (or better), in the context of primary health care.
  • Asking for invitations to attend physician conferences such as those organized by the American Medical Association. The aim will be to be given the opportunity to address the audience of physicians and explain the education and training process for NPs. This will be a very important problem-solving measure.

The key elements of developing a collaborative evaluation plan using CBPR principles would include a systems approach to the solution (involvement of all players and giving feedback), diplomacy for wider acceptance by stakeholders such as physicians, and collection of the opinions of the served communities on FPA by using a data collection tool such as a questionnaire. Lastly, evaluation of the success of the plan would adopt a bottom-up approach. What will happen will be the implementation of a short qualitative survey of a sample rural or marginalized community such as that of predominantly African Americans or Hispanics. The aim will be to determine if the granting of FPA to NPs and abolishment of restricted practice in states such as Florida has a significant positive impact on their access to healthcare at the grassroots level. These communities are known to have unfavorable social determinants of health such as low socio-economic status and lack of access to quality affordable healthcare.

Strengths and Weaknesses of the Different Approaches and the Preferred Approach

The strength of the top-down approach is speed of implementation. This is because decisions that flow from the top are implemented by subordinates and will therefore not be delayed. The strength of the bottom-up approach is that the real problem is exposed by allowing the real people affected by the policy to present their opinions and views on the matter. The weakness of the top-down approach is that it may produce a solution that does not quite reflect the correct situation on the ground (in the affected population). On the other hand, the weakness of the bottom-up approach is that a large amount of information is gathered and all of it may not be relevant. It therefore necessitates data cleaning and analysis to come up with the most relevant information. In all, the preferred approach by the author is the bottom-up approach. This is because it presents the most accurate picture of the problem from the very population that is affected by the policy.C159 Policy, Politics & Global Health Trends

 References

American Association of Nurse Practitioners [AANP] (October 20, 2020a). State practice environment. https://www.aanp.org/advocacy/state/state-practice-environment

American Association of Nurse Practitioners [AANP] (2020b). Nurse practitioners in primary care. https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioners-in-primary-care

Ballotpedia (n.d.). Shevrin Jones. https://ballotpedia.org/Shevrin_Jones

Brännmark, J. (2017). Respect for persons in bioethics: Towards a human rights-based account. Human Rights Review, 18, 171–187. https://doi.org/10.1007/s12142-017-0450-x

Duncan, C.G. & Sheppard, K.G. (2015). Barriers to nurse practitioner full practice authority (FPA): State of the science. International Journal of Nursing Student Scholarship, 2. https://journalhosting.ucalgary.ca/index.php/ijnss/article/view/56778

Harkey, K., Little, S., & Lazear, J. (2017). The struggle for full practice in North Carolina. The Journal for Nurse Practitioners, 13(2), 131–137. http://dx.doi.org/10.1016/j.nurpra.2016.08.025

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. http://dx.doi.org/10.12968/joan.2019.8.4.177

Health Outreach Partners (October 1, 2011). Applying principles of community-based participatory research to your program. https://outreach-partners.org/2011/10/01/applying-principles-of-community-based-participatory-research-to-your-program/#:~:text=The%20key%20principles%20of%20CBPR,as%20a%20unit%20of%20identity.&text=Building%20on%20the%20strengths%20and,in%20all%20phases%20of%20research

Hooper, V.D. (2016). The Institute of Medicine report on the future of nursing: Where are we 5 years later? Journal of PeriAnesthesia Nursing, 31(5), 367-369. http://dx.doi.org/10.1016/j.jopan.2016.08.013

Kilpatrick, D.G. (n.d.). Definitions of public policy and the law. https://www.musc.edu/vawprevention/policy/definition.shtml#:~:text=Public%20policy%20can%20be%20generally,governmental%20entity%20or%20its%20representatives.&text=A%20major%20aspect%20of%20public%20policy%20is%20law.

Kominski, G.F., Nonzee, N.J. & Sorensen, A. (2017). The Affordable Care Act’s impacts on access to insurance and health care for low-income populations. Annual Review of Public Health, 38. http://dx.doi.org/10.1146/annurev-publhealth-031816-044555

Ortiz, J., Hofler, R., Bushy, A., Lin, Y-L., Khanijahani, A., & Bitney, A. (2018). Impact of nurse practitioner practice regulations on rural population health outcomes. Healthcare (Basel), 6(2), 65-72. https://doi.org/10.3390/healthcare6020065

Peterson, M.E. (2017). Barriers to practice and the impact on health care: A nurse practitioner focus. Journal of the Advanced Practitioner in Oncology, 8(1), 74-81. https://doi.org/10.6004/jadpro.2017.8.1.6

Robeznieks, A. (October 30, 2020). Why expanding APRN scope of practice is a bad idea. American Medical Association (AMA). https://www.ama-assn.org/practice-management/payment-delivery-models/why-expanding-aprn-scope-practice-bad-idea

The Florida Senate (2020). How an idea becomes law. https://www.flsenate.gov/About/HowAnIdeaBecomesALaw

Topp, S.M., & Abimbola, S. (2018). Call for papers – the Alma Ata Declaration at 40: reflections on primary healthcare in a new era. BMJ Global Health, 3(2), 1-2. http://dx.doi.org/10.1136/bmjgh-2018-000791

C159 Policy, Politics & Global Health Trends