California Nurse Practitioners: The Fight for Full Practice Authority

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.

Dr. Ricky Norwood, Assistant Clinical Professor at the University of California, Davis (UCD)

Dr. Norwood is an assistant clinical professor in the nurse practitioner and physician assistant degree programs at the Betty Irene Moore School of Nursing at UC Davis. He has two decades of experience in nursing and served in the Army for a distinguished 21 years, finally retiring as a Major. In addition to his academic responsibilities of teaching and mentoring students, he serves the Sacramento County Health Department and has received numerous awards and honors, including the Meritorious Service Medal; the National Defense Service Medal; the Army Commendation Medal; and the Brigadier General Lillian Dunlap Award for Clinical Leadership and Clinical Excellence, among others.

What is your view on moving toward full practice authority for California’s NPs?

I believe it is absolutely imperative that California implements full practice authority for nurse practitioners (NPs). NPs are highly educated and skilled practitioners and their experience, dedication, motivation and genuine care for patients are second to none. To not allow NPs to practice to the full scope of their educational level and skills is a disservice to not only the patients, but also to the overall healthcare system. NPs are valuable members of the healthcare system and oftentimes are the sole healthcare provider, especially in many rural areas.

As a practicing DNP-FNP, I take great pride in providing professional, quality, evidenced-based primary care to my patients. My patients’ satisfaction rate is among the highest in my workplace and my patients’ no-show rate is among the lowest because they appreciate me placing them in the center of care. My patients are very appreciative and grateful to have a healthcare provider who genuinely cares about their physical and mental healthcare concerns. As a DNP-FNP, there is nothing that is “mid-level” about my education and healthcare practice.

What have been the biggest challenges in this fight?

While serving as an active duty Army Nurse Corps officer and later as a civilian Air Force contractor as an Army retiree, I enjoyed full practice authority in the military and Department of Defense (DoD) healthcare system. In the military, NPs work side-by-side with their physician counterparts delivering quality healthcare to military members and their families. The recognition of NPs being professional, highly educated and experienced made it easy for physicians and other healthcare providers to respect and trust NPs at every echelon of care. The military/DoD model that grants NPs full practice authority should be the gold standard for not only California, but for the rest of the country. Full practice authority allows for greater patient care and safety, coordination, communication, organizational cohesiveness, and espirit de corps.

While practicing as a civilian NP in the great state of California, I have felt limited by California’s NP practice laws because I have always wanted to start a healthcare business of my own and not having full practice authority restricts me from doing so. My educational background and healthcare experience have prepared me very well to provide professional quality healthcare to patients, but because of the restrictions of California’s NP practice, I can’t practice to the full scope of my educational preparedness. However, I don’t let this restriction stop me from taking a stand in lending my voice and time to affect change that is desperately needed and certainly deserving for NPs. I have full faith and confidence that California will attain full practice authority before long…this is not the end of the story.

What are some actionable steps NPs and others can take to advance the cause?

It is important for NPs to take the lead in educating and informing our physician colleagues and partners about NPs’ scope of practice and our educational levels. Physicians who have a full understanding of NPs’ educational background would have a greater appreciation and acceptance of NPs. NPs should recruit their physicians and colleagues from other healthcare disciplines to advocate for NPs. This would be an excellent way to increase the acceptance of NPs and highlight NPs’ added value to the healthcare system.

Additionally, NPs must also take the lead in educating our patients and the general population about their roles and responsibilities. It is almost mind-blowing to know that a lot of people still don’t know what NPs do or their roles in the healthcare system. A strong public relations campaign is needed with NPs leading the charge to educate physicians, patients, and the general public. There are many things NPs can participate in such as having information booths at local public events, sponsoring community activities, and volunteering at local churches and community centers to provide health-screenings and advice.

Dr. Kimberleigh Cox, Associate Professor at the University of San Francisco (USF)

Dr. Cox is certified in both the adult (ANP) and adult psychiatric care (PMHNP) specializations. She’s an expert in cognitive-behavioral modalities and treating vulnerable populations, particularly those with co-occurring mental disorders and substance abuse. In addition to her contributions to addiction medicine, she’s a strong advocate for providing community and behavioral health services, serving people through her teaching, clinical work, and volunteering. She’s also the recipient of numerous awards, including the USF Dean’s Medal for Professionalism.

What is your view on moving toward full practice authority for California’s NPs?

The ability of nurse practitioners to utilize their full scope of holistic practice, advanced clinical training, and patient-centered nursing care is invaluable. [FPA is] necessary for providers to promote optimal health, prevent illness, reduce health disparities, and improve access to care. NPs are especially relevant in California to address the health needs of our underserved patients and at-risk populations. As a dually-trained adult and psychiatric mental health nurse practitioner who has worked with vulnerable populations for the greater part of two decades, I have had the opportunity to serve in a variety of settings caring for homeless adults and those with mental health and substance use disorders. I am a passionate advocate, clinician, and teacher who espouses the need for improved access to evidence-based, integrated healthcare for all populations.

I have also been inspired to educate the next generation of nurses to better manage in any care setting. Ultimately, mental health parity can be significantly improved with nurse practitioners who are able to employ their full set of skills, education, and scope of practice. NPs have a unique opportunity to bridge the gap for access to safe, high-quality, and integrated health care.

Has there ever been a time where you felt limited by California’s NP practice laws?

In California, we work under standardized protocols which require physician collaboration, approval, and signatures. An MD name is also required on our transmittal forms for prescriptions. Throughout my career, there have been times when the regulatory barriers impeded my ability to practice fully. Sometimes the lack of patient, organizational, and physician understanding of the NP role has limited my ability to fully care for patients. Patients, or sometimes even doctors ask me, “When will you consider going to medical school to becoming a real doctor?” Trying to explain the capabilities of a doctorally prepared APRN is sometimes met with confusion, uncertainty, or blank stares. For example, there are patients who want to only deal with the “actual doctor” and don’t understand our role.

There were also times when I was caring for patients in residential programs, but I was only permitted to fulfill the psychiatric aspects of my role—not the urgent or primary care needs. This was due to the organization’s lack of a [supervising] physician at the time. Patients had to attend outside primary care appointments, which many times could have been easily and safely managed onsite. This led to a myriad of problems including missed visits due to a patient’s mental health symptoms, transportation issues, lengthy wait-times for addressing needs, brief visits with inconsistent care providers, and unnecessary time and expenses. NPs bringing care to underserved patients within their communities was one of the primary reasons for the position’s inception and yet decades later, these systemic and regulatory requirements often continue to limit access to care.

At times, I have considered venturing into independent private practice to assist with the significant need for mental health providers who hold both psychotherapeutic skills and prescriptive authority, but the current CA practice landscape presents cost-prohibitive and regulatory barriers with physician consulting requirements, consultant fees for supervision, and MD names on the scripts.

On the other hand, it’s not all doom and gloom. Over the years I have also had some amazing, exceptionally skilled NP role models, along with some really supportive and forward-thinking physician colleagues, all of whom have shown me what truly integrated healthcare can look like when we all put patients first and support each other in our roles.

What are some actionable steps NPs and others can take to advance the cause?

The differing state regulatory requirements and lack of national consistency are limitations to full practice authority for NPs. It’s important to educate people about the NP role and advocate for reduced barriers, as well as a uniform national policy. This would help reduce these practice issues and pave the way for improved understanding, awareness, and accessibility in healthcare.

Dr. Susanne Johnson Phillips, Clinical Professor & Associate Dean of Clinical Affairs at the University of California, Irvine (UCI)

Dr. Phillips earned her DNP at Yale University in health policy and leadership. She’s the recipient of numerous honors, including the AANP’s 2017 State Award for Excellence in Advocacy; UCI’s 2016 NP Faculty of the Year; and the California Association for Nurse Practitioners’ 2011 NP of Distinction award, among many others. She focuses her research on scope of practice issues (including prescriptive authority), nurse-managed health centers, women’s health, and policy issues.

What is your view on moving toward full practice authority for California’s NPs?

Progress toward full practice authority has been in effect since 1997 when we achieved controlled substance prescriptive authority. Since that time, the California Association of Nurse Practitioners has sponsored, co-sponsored, or been actively involved in amending over 25 individual bills demonstrating positive incremental change and removal of practice barriers for NPs and other APRNs in our state. Since 2007, we have put forward three separate full practice authority bills which, although ultimately not successful in changing state law, we were very successful in building a coalition of supportive stakeholders through AARP California, including physician groups. Strong, supportive engagement of well-funded stakeholders, including healthcare providers, consumers, healthcare agencies, businesses, and others will ultimately tip the scale.

What have been the biggest challenges in this fight?

Like other states, our biggest challenge has been financial funding of opposing stakeholders (e.g., physician associations). Although California is very progressive politically, the CMA/AMA political funding machine provides a significant and ongoing challenge in our state. California is one of the largest states with over 23,000 licensed NPs in the state. It is likely not a coincidence that the states with the largest number of licensed NPs are all restricted practice states.

What are some actionable steps NPs and others can take to advance the cause?
A SINGLE step that would have the largest impact in advancing this cause would be for every licensed NP in the state to become a member of the state NP organization (e.g., California Association of Nurse Practitioners or CANP). Of course, grassroots advocacy involvement is extremely important; however, funding is critical to this cause. Stakeholders must join AARP to increase the political and advocacy power in Sacramento. CANP will remain active and will advance practice one step at a time—but we need all nurses and their patients to be involved. We are not averse to incremental change, but after 20 years, it is time to see some significant movement.Dr. Morgan Miller, Professor and Program Coordinator at UNIVERSITY

Dr. Miller has 35 years of experience in nursing and works at an acute care NP. (S)he has conflicted views about moving toward full practice authority and has concerns about colleague backlash. Therefore, NPS has used a pseudonym to protect his or her identity. Please note that this phone conversation has been reconstructed from notes, edited for length and clarity.

What are your views on granting full practice authority to NPs?

People get upset with me because I’m not completely for independent practice. There’s such a disparity among schools. At our school, we’re phasing out our master’s program, and I’m a little divided internally on that. There are some nurse practitioners who are prepared to be independent, but that’s not always the case. For example, I work for an emergency medical group that staffs ERs and we can’t hire NPs because they can’t do the same things as PAs.

In your years working as an acute care NP, have you ever felt constrained at all in what you can do?

I don’t. I work in a practice setting where I have full scope in both my jobs. In the ER group, I’m in an urgent care environment by myself or with a PA; in the family practice, I’m by myself all the time and treated as an equal, allowed to function independently.

Even in rural areas, you should still have some type of oversight. We don’t have the breadth of training and especially with the proliferation of NP programs, I’m just shocked at the lack of hands-on training. That’s from my experience proctoring students. Six months ago, I reluctantly took a student in her last semester at a for-profit online NP program and I realized she wasn’t much better than an RN. I was trained in a medical model and we’re expected to function as medical providers. When that’s not taught, those NPs can be weak. By comparison, PA programs get definitive medical rotations and NPs don’t. For me, I probably wouldn’t go to an NP unless they had 5-10 years of experience. It takes at least a year to get new grads ramped up.

Also, some pediatric NPs go back to school to get a family NP certificate to secure a job. Ultimately, they might take an FNP job and they’ve never even put pants on an adult as a nurse! We actually had this brilliant student and we had to construct our own residency program in order to get her to be productive. Residency programs for NPs really don’t exist, and that’s a big part of why I’m conflicted about providing full practice.

I’m in charge of a REDACTED degree program that’s completely online, but that content is appropriate. I think you can also take an online nutrition or pharmacology class, but the clinical piece: I don’t think the online model produces functional nurse practitioners, at least until the DNP becomes standard in the United States, which includes another 1,000 hours, and programs should provide a residency.

Doctors come out of medical school and hit the ground running because of the medical model, whereas nurse practitioners expect to be mentored or coached. My colleagues might not agree with me, but I think it’s a matter of safety. There’s one path to practice for doctors but there are multiple ways for NPs.

So you believe that there should be more clinical hours, a widespread adoption of the DNP, and a medical model with residency for NPs. Anything else?

NP programs do a soft job and students’ exposure to certain subjects is minimal because they don’t have adequate clinical rotations. That student I mentioned earlier was part of a for-profit program and she had only a few hours learning how to perform physicals with no simulation lab experience. We need a national consensus model for training, or I think we’ll start seeing more malpractice suits. As NPs, we’re trained in the breadth, not the depth. I think that all states should get together and establish stronger standards with a DNP, residencies, and training requirements.

Are you familiar with New York’s model of practice with its probationary period of practice?

I think they’ve done a better job because of Columbia University. If I see a Columbia grad, I know they’re really good. It would be great for NPs to have a year or 2,800 hours of proctored practice, essentially a residency. We have a high-fidelity simulation lab with actors and our nursing students get a lot of experience.

We’ve also diluted the DNP with programs in areas like nursing informatics or leadership, all to make it more attractive to students. Medical schools don’t operate this way. I think we’re doing the public a disservice.

Do any of the credentialing exams weed out the underprepared NPs?

You could pass an NP exam with a prep course! I thought the NP tests weren’t as difficult as the CCRN exams. When we talk about entry to practice, nobody talks about this mess that’s been created on the back end and harmonizing skills.

Most of the studies I’ve seen have advocated for full practice because NPs provide cost-efficient and effective care. What do you think about that?

I think that it’s only a matter of time [for malpractice suits to increase] because of the proliferation of low quality and for-profit programs. I’ve been a nurse for 35 years and an NP for 25, and I realized how much I rely on my physician colleagues. I think we need to establish new standards for entry to practice and practice hours.

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.

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.

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