While fewer than half of U.S. states allow advanced practice registered nurses (APRNs) to work to the full extent of their education and training, 2017 saw several states, and one federal agency, expand APRN practice authority.1 As of early 2017, the Department of Veterans Affairs (VA) has allowed nurses (except nurse anesthetists) in VA facilities in every state to work to the full extent of their training, even if the state does not have advanced practice laws for nurses.2

This move was lauded by Pamela Cipriano, PhD, RN, FAAN, president of the American Nurses Association (ANA), who said in a statement that it "removes barriers that prevent APRNs from providing a full range of services and will assist [the] VA in its ongoing efforts to address staff shortages and improve veterans' access to care."3

Other state law changes in 2017 for APRNs include the following:

* In South Dakota, NPs can provide primary care without the supervision of a physician after completing 1,040 physician-supervised practice hours.

* Arkansas now allows NPs to independently sign a variety of documents including handicap placards, disabled parking permits, sports physicals for student athletes, and death certificates.

* In Nevada, NPs can sign any document a physician is required to sign.

ADVOCACY EFFORTS

Advocacy efforts to convince more states to change or amend laws governing APRNs also intensified in 2017. A new website-ScopeofPracticePolicy.org-launched by the National Conference of State Legislatures (NCSL) and the Association of State and Territorial Health Officials tracks state laws on scope of practice for several health professions, including APRNs. A policy brief published by the NCSL in August 2017 explains that the goal behind the website is "to provide policymakers with a tool to explore the range of scope of practice legislation introduced around the country[horizontal ellipsis] [and to help] state leaders as they consider ways to meet the health care needs of their constituents at the right place, right time and right cost."4

"Allowing nurses to be a part of the primary care team saves money, improves health care access and care, and allows physicians to concentrate on more complex patient cases," says Susan B. Hassmiller, PhD, RN, FAAN, senior advisor for nursing at the Robert Wood Johnson Foundation (RWJF) in Princeton, New Jersey. Hassmiller was study director of the Institute of Medicine's 2010 Future of Nursing: Leading Change, Advancing Health report, which recommended, among other key strategies, that all states allow nurses to practice to the full extent of their education and training.5

Many rural parts of the United States were already challenged by a shortage of primary care physicians when the Affordable Care Act was signed into law in 2010, resulting in more than 30 million people gaining health insurance, some for the first time. In a 2011 article in the New England Journal of Medicine, several health policy experts, including Hassmiller, wrote: "We believe that if we are to bridge the gap in primary care and establish new approaches to care delivery, all health care providers must be permitted to practice to the fullest extent of their knowledge and competence."6

While the pace of expanding APRN practice authority has been slower than some advocates would wish, Winifred Quinn, PhD, director of advocacy and consumer affairs at the Center to Champion Nursing in America, says that the pace has picked up considerably since the 2010 launch of the Campaign for Action, a joint initiative of AARP and the RWJF to implement the Future of Nursing report recommendations. Although so far, fewer than half of all states have updated or changed their laws to expand APRN practice authority, Quinn is hopeful. "It took 40 years for 14 states to modernize their scope of practice laws," she says. "Since the campaign started, nine states have fully modernized their laws and another 10 have incrementally improved them."

Among its activities, the Campaign for Action lobbies lawmakers before legislative sessions. Quinn predicts that the recent state law changes and the VA's new expanded APRN regulations will influence legislators to consider making changes to their states' laws governing APRN authority. Expanding consumer access to APRNs is also likely to make a difference. A recent article in Forbes reported that 82% of employers now cover patient visits to retail clinics, most of which are directed by APRNs.7 Expect even more innovation going forward. Last year the ANA hired a vice president of nursing practice and innovation to help design and cultivate innovation. "We aim to turn an idea into a solution that adds value from a consumer perspective," says Seun Ross, DNP, MSN, the ANA's director of nursing practice and work environment.

MAKING A DIFFERENCE

Allowing nurses to work at the top of their training not only improves primary care access but may even provide new forms of care. For example, more than a dozen medical centers now have mobile stroke units outfitted with a computed tomography scanner and a medical laboratory where APRNs can assess stroke symptoms, work with fire/rescue paramedics, and take calls when there is a suspected stroke. An ongoing multicenter clinical trial funded by the Patient-Centered Outcomes Research Institute in Washington, DC, is looking into the effectiveness and cost-effectiveness of having nurses, most of them APRNs, on board a specialized ambulance and connected via telemedicine to a neurologist back at the hospital.8

In over 3,000 school-based health centers across the country, APRNs with staff support from physicians provide medical care to students and often community members. But in a growing number of health centers, APRNs recognize that social determinants of health, such as poverty, toxic stress, and homelessness, are having an impact on students; as a result, they have expanded the care they provide in ways that go beyond stethoscopes and health screenings.

* In Portland, Oregon, NP Jennifer Lendos found that many students who come to her public school clinic were asking for food. Working with the city's main food pantry, Lendo now gives all students who come to see her a two-question survey: Are you hungry now? Have you ever been hungry? If a student answers yes to either question, she or he is referred to a school counselor who provides the student and family with information about local food banks. "Often, when I see them again for a health matter," Lendos says, "they report back that their family now has a more regular food source."

* Kay Sophar, an NP who heads up the wellness center at Northwood High School in Silver Spring, Maryland, a school with a 78% poverty rate and reported shootings and rapes each year, teaches a mindfulness class students can choose to take if they're sent to detention. "After one class, students began asking to be sent to detention so they could take the class again," says Sophar, "which prompted us to offer mindfulness classes any student could attend." The wellness center is planning to add a mindfulness class taught in Spanish.

* In El Monte, California, NP Laura Garcia-Chandler found that many of the elementary school students coming to her health center had stressful home situations and lived in neighborhoods so dangerous they were afraid to go outside to play. So she started a healing garden to give students a calm, green place to be. Once the garden was complete, students and their parents asked to help grow it, "to have greater ownership in a place that helps heal," she says.

"Nurses are proactive when they can make a difference," says John Schlitt, president of the School-Based Health Alliance in Washington, DC. "Allowing them to work at the top of their training improves professional satisfaction for nurses and has the potential to vastly improve the health of many people in their care."-Fran Kritz

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