South Carolina is one of the most restrictive states for advanced practice registered nurses (APRNs), requiring physician supervision for practice and prescriptive authority. With the passage of Senate Bill 345 in May 2018, this has changed. South Carolina's APRNs persisted for 7 years to gain support for elimination of multiple barriers to practice. This bodes well for the citizens of South Carolina, which ranks 44th in the nation for overall health.1 Parts or all of the state's 46 counties are designated as medically underserved.2

South Carolina opted out of the Medicaid expansion, leaving many of the state's working poor without access to healthcare except in EDs, costing the state a startling $140 million over 3 years.3 South Carolina also ranks 40th in primary care physician supply overall.4 Seven counties have fewer than five primary care physicians, one county has none, and eight counties have no obstetric-gynecologic physician providers.5

NPs in South Carolina: Then and now

It is important to understand the APRN practice environment in South Carolina to appreciate the dynamics, which led to efforts to change the state's Nurse Practice Act (NPA). Prior to passage of Senate Bill 345, South Carolina NPs, certified nurse midwives (CNMs), and clinical nurse specialists (CNSs) practiced within 45 miles of the supervising physician; only three APRNs could be supervised by a physician at any given time.

Additional barriers to providing comprehensive care included APRNs being limited to prescribing Schedule III and IV controlled substances in addition to being unable to order physical therapy, place patients in hospice, pronounce death, sign death certificates, provide medications at free clinics, certify a patient with a disability for a parking placard, or place a student on homebound schooling.

Coupled with poor health outcomes and increasing pressure to change practice as usual, the perfect storm erupted, creating change for APRNs in South Carolina. A South Carolina whitepaper on APRN practice, authored by the Advanced Practice Committee of the Board of Nursing, was presented to the full South Carolina Board of Nursing in 2012.6 NP, CNM, and CNS representatives from all regions of South Carolina formed The South Carolina Coalition for Access to Healthcare.

Board members Dr. Stephanie Burgess from the Midlands, Dr. Deborah Hopla from the Pee Dee region, Ms. Judy Zink (Chair) from the Upstate, and Ms. Lesley Rathbun from the low country met with representatives of the South Carolina Medical Association and the South Carolina Academy of Family Physicians during 2013 and 2014 to negotiate changes in the NPA. Negotiations failed; however, the coalition gained legislative support to introduce a bill in 2015 for full practice authority (FPA).

Advocacy

The coalition developed health fact sheets, prepared testimony and talking points, but despite these efforts, the legislation failed in 2016. Momentum increased over the next 2 years with increased legislative support buoyed by an annual APRN Lobby Day that produced a sea of white coats with at least 300 NPs, CNMs, and CNSs at the South Carolina Statehouse.

For the 2017 to 2018 legislative sessions, the coalition gathered letters of support from physicians, businesses, agencies, and patients as well as testimonials from APRNs. The coalition's proposed changes to the NPA would result in South Carolina SOARs: South Carolina Saves money, improves Outcomes, increases Access, and Reduces barriers to care for patients. The coalition matched APRNs with their local legislators for consistent messaging.

In 2017, a successful fundraising campaign allowed the coalition to secure a top-notch lobbying firm, which facilitated discussions between the coalition and physician groups. Following Governor Henry McMasters's press conference in February 2018 to support removing scope of practice barriers, Senate Bill 345 was written following significant compromise and business support.7 Primary sponsors who demonstrated courageous leadership included Senator Tom Davis and Representative Gary Clary.

In addition to support from nursing organizations, key stakeholders who supported the bill included legislators, individual physicians across the state, businesses, healthcare professional groups, and healthcare agencies.

Senate Bill 345: A victory for South Carolina

Persistence and patience paid off. On May 8, 2018, Senate Bill 345 passed with 99% of Senate and House Members in support.8 Although not FPA, significant advances were achieved, including the removal of physician supervision of NPs, CNMs, and CNSs, although a practice agreement is still required. The written practice agreement can stipulate the level of autonomy, collaboration, or oversight. In addition, consultation and advice may occur via telecommunication. The bill removed the requirement for the APRN to be within 45 miles of the physician with whom there is a practice agreement. A physician can now work with six, rather than three, APRNs.

Prescriptive authority was extended to Schedule II for opioids for 5 days (except for patients in hospice and palliative care) and other Schedule II controlled substances for 30 days. APRNs may conduct patient-care visits via telehealth, order physical therapy, place a patient in hospice, pronounce death, sign death certificates, provide medications at free clinics, certify a patient with a disability for a parking placard, and place a student on homebound schooling.

Improving health outcomes

Lessons learned included the art of compromise for practice issues such as the removal of archaic language, including physician supervision, distance requirements between the APRN and physician, and limited prescribing. Consistent and persistent patient-centered messaging, widening the base support to include businesses, hiring a savvy and credible lobbying firm, and frequent communication with APRNs across the state to apprise them of outcomes and calls to action contributed to success.

With passage of Senate Bill 345, APRNs are empowered to better care for South Carolinians and improve health outcomes. In the end, it is about serving patients to improve their health by authorizing well-educated APRNs to practice to the full extent of their educational preparation.

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