Nurse practitioners gain ground on full practice authority

When nurses in Virginia decided to lobby for fewer restrictions on nurse practitioners (NP), they knew any changes to the existing law would require a hard-fought battle with physician groups and legislators opposed to expanding nursing practice authority.

Home to one of the oldest legislatures in the western hemisphere, the state leaned more conservative. The Medical Society of Virginia had a significant influence in the political arena and would resist changes to the current law, which required NPs to have collaborative agreements with physicians to practice.

Cynthia Fagan, DNP, RN, FNP-BC

In 2018, the Virginia Council of Nurse Practitioners worked with lawmakers to introduce a bill that would allow NPs to practice independently after 1,040 hours — the equivalent of six months — of collaboration with a physician.

The council expected to negotiate with physician lobbyists, and nurse practitioners were willing to increase the number to 3,000 hours of collaboration. But in the eleventh hour a subcommittee chair introduced a substitute bill with a requirement for 9,000 hours — or five years — of collaboration.

“I think the medical association thought we would reject this bill, but the change would still allow about 50% of the nurses in the state to become autonomous because they had been practicing for more than five years,” said Cynthia Fagan, DNP, RN, FNP-BC, government relations chair for the Virginia Council of Nurse Practitioners. “We decided to support the bill.”

Although Virginia is the only state that requires nurse practitioners to collaborate with a physician for 9,000 hours before working independently, Fagan considers the new law a victory for two reasons.

  1. NPs can eventually transition to practice independently with full practice authority.
  2. Legislators struck a stipulation on the substitute bill dictating only NPs certified in the area of the collaborating physician specialty could transition to obtain autonomous practice. The change would have discounted hours for many nurses, Fagan said.

National progress on full practice authority

Virginia is now one of 28 states where nurse practitioners can practice independently, and one of 10 states that have removed restrictions on NPs in the past 10 years.

Expanding NP practice authority became a high priority nationally in 2010 when the Institute of Medicine issued a report with eight recommendations to improve healthcare in the United States. One of the recommendations focused on increasing access to care by allowing nurses to practice to the full extent of their education and training.

In states that have lifted restrictions on nurse practitioners, nurses have learned from both successes and failures about how to influence policy decisions.

In Virginia, one of the keys to success was finding a legislator who could champion the changes. Roxann Robinson, a Republican in the Virginia House of Delegates, was ideal for this role because she was an optometrist who had faced similar challenges with ophthalmologists, Fagan said.

Volunteer leaders like Fagan also realized juggling advocacy work with full-time jobs was limiting their effectiveness, and the Virginia Council of Nurse Practitioners hired a full-time executive director in 2017 who could dedicate more time to the …read more

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