California Nurse Practitioners: The Fight for Full Practice Authority

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Throughout my career, there have been times when the regulatory barriers impeded my ability to practice fully.
Dr. Kimberleigh Cox, University of San Francisco

One of the most contentious issues in healthcare today is whether nurse practitioners should be granted full practice authority (FPA). NPs’ ability to provide services in accordance with their level of training and certification isn’t equally guaranteed across American states; in fact, California—the most populous U.S. state with nearly 40 million people—keeps NPs under “restricted practice authority,” which requires them to have an agreement with a supervising physician to prescribe medicines, interpret diagnostic tests, and offer other essential services. A majority of NPs feel that this environment curtails their ability to provide healthcare by adding unnecessary bureaucracy and confusing patients about the roles of their NPs. In short, these clinical inefficiencies are alarming, especially given the projected future shortage of medical and nursing personnel in the Golden State.

By illustration, the California Health Care Foundation (Aug. 2014) reported that the state only had between 35 and 49 primary care doctors per 100,000 Medi-Cal enrollees, falling significantly short of the federal recommendations (85 to 105 primary care providers). Uncovered California, a three-part video series, echoed those findings and examined how NPs in particular can expand primary care access for low-income residents of the state. The videos point out that in 2010, the Institute of Medicine and the Robert Wood Johnson Foundation, among many others, advocated for NPs to have independent practice (i.e., FPA). This would allow NPs to examine, diagnose, and prescribe medicine without physician oversight. As it stands, the CA Nursing Practice Act states that NPs can provide basic primary care, but they need doctor approval—often referred to as a “collaborative agreement”—to prescribe pharmaceuticals, order basic medical tests and devices, certify disability, or otherwise manage patient care. Physicians in California can supervise no more than four NPs concurrently.

The most recent setback for California NPs came with the state assembly’s defeat of Senate Bill 323 in 2014, a measure introduced by Senator Ed Hernandez that would have granted NPs FPA. Not surprisingly, the bill faced lobbying and stiff opposition from the California Medical Association, which argued that this move would put patients at risk and complicate healthcare delivery. The organizations supporting S.B. 323 included the AARP, the California Primary Care Association, and the Western University of Health Sciences. It’s worth noting that the national FPA model is supported by the National Governors Association, the Bipartisan Policy Center, the Federal Trade Commission, the Department of Veterans Affairs, and many other groups.

In short, despite the evidence that NPs provide affordable, safe, and quality healthcare, there’s still reluctance to grant these invaluable healthcare professionals the authority to work autonomously in accordance with their level of education and credentialing. In four interviews with prominent NP professors in California—three who support FPA and one who is conflicted about the issue—this article examines the arguments for and against autonomous practice.

Interviews with Four Experts: Spotlight on California’s Nurse Practitioners

Full practice authority allows for greater patient care and safety, coordination, communication, organizational cohesiveness, and espirit de corps.
Dr. Ricky Norwood, Retired U.S. Army Major and Assistant Clinical Professor at UC Davis

In April 2017, NursePractitionerSchools.com (NPS) conducted four interviews with NP professors in California—three by email and one by phone. The first three interviews are printed with minor edits for length, and the final interview is reconstructed from notes, weighing the one NP professor’s thought-provoking counterarguments to granting FPA.

Conclusion: Full Practice Authority in California?

Strong, supportive engagement of well-funded stakeholders, including healthcare providers, consumers, healthcare agencies, businesses, and others will ultimately tip the scale.
Dr. Susanne Johnson Phillips, Professor at University of California, Irvine

In 2017, NPS has interviewed 16 NP professors on the issue of practice authority within specific states or specializations (e.g., Michigan NPs, PMHNPs, AGNPs, etc). Nearly all of them have shared stories about the inefficiencies and ballooning frustration over not being permitted to practice to the full extent of one’s education, training, and credentialing.

As mentioned above, a majority of the existing evidence points toward granting NPs full practice authority in California and nationally. For example, the Bay Area Council Economic Institute (2014) estimated that expanding NPs’ scope would save California $1.8 billion over ten years, increasing patient access to healthcare and decreasing the overall cost of treatment. It would also increase the number of healthcare providers in high-need rural areas and provide for two million more preventative health visits annually.

That said, not everyone is convinced. In addition to physicians’ groups, there are some NPs who feel that advancing too quickly to a full practice environment could compromise patient safety. Practitioners such as Dr. Miller call not only for the widespread adoption of the DNP, but also for an increase in the number of NP clinical hours; for measures to discourage the proliferation of subpar APRN programs; and for the inclusion of a residency requirement for NP training.

Overall, it’s important to understand both sides of this argument in the interest of decreasing costs, improving health outcomes, and creating a seamless model of healthcare delivery that works for both patients and providers. Time will tell how this fight plays out in California, but for now it seems that NPs on both sides of the aisle are dissatisfied with the current state of practice.

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Jocelyn Blore

Jocelyn Blore

Editor

Jocelyn Blore is the Managing Editor of NursePractitionerSchools.com. After graduating from UC Berkeley, Jocelyn traveled the world for five years as freelance writer and English teacher. After stints in Japan, Brazil, Nepal, and Argentina, she took an 11-month road trip across the US, finally settling into lovely Eugene, OR. When Jocelyn isn’t writing about college programs or interviewing professors, she satirizes global politics and other absurdities at Blore’s Razor (Instagram: @bloresrazor). Thank you for being interested.