Nurses Gain Ability to Practice to Full Scope of License

By Jane Kirschling, PhD, RN, FAAN
Dean and Professor, School of Nursing, University of Maryland
Director, Interprofessional Education, University of Maryland, Baltimore

Last May, Maryland became the 21st state to allow Advanced Practice Registered Nurses (APRNs) to practice to the full scope of their licenses, thereby allowing patients to receive all of the services that APRNs are educated and clinically trained to deliver. Signed into law by Governor Larry Hogan, the measure repealed a portion of the Maryland Health Occupations code that required APRNs to list a physician “sponsor” as a condition of licensure so that they could “collaborate and consult” on patient issues. 

Removal of this barrier to full practice opens the door for Advanced Practice Registered Nurses to better serve the needs of patients and their families and this change is expected to increase access to care throughout Maryland, particularly in rural and historically underserved areas.

As background, APRNs are required to complete a master’s or doctoral degree program and to have additional advanced clinical training beyond their initial professional registered nurse preparation. Didactic and clinical courses prepare them with the specialized knowledge and clinical competency to practice in primary care, acute care, and long-term health care settings. APRNs include Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse-Midwives.  Regardless of the specific area of expertise, all must be certified in their specialty by a national nursing organization.

APRNs currently provide high-quality care in a variety of settings including clinics, hospitals, emergency rooms, urgent care sites, private physician or nurse practitioner practices, nursing homes, schools, colleges, and public health departments. Nurse Practitioners (NPs), the most common type of APRN and representing well over half of all advanced practice nurses, are qualified to provide a range of both primary and acute health care services; they can diagnose and treat medical conditions.  In addition, they place a particular emphasis on the health and well-being of the whole person, with a focus on health promotion, disease prevention, and health education and counseling.  As such, they can help to guide patients in making smarter health and lifestyle choices, which in turn can lower patients’ out-of-pocket costs. In a review of studies comparing the primary care provided by NPs to primary care provided by physicians (MDs), researchers found that patients of both groups had comparable health outcomes. NPs were found to outperform MDs in measures of consultation time, patient follow-up and patient satisfaction.

By eliminating Maryland’s requirement for “attestation agreements” with physicians, APRNs will now be able to practice fully in accord with how they are trained and certified.  For example, this means that a parent can choose to take his or her child to an advanced practice nurse to give them the complete medical evaluation required for attending a child care center in Maryland. Previously, Maryland required that the exam be administered and certified by a physician, even if the child was already being seen by a pediatric nurse practitioner. Or, an APRN can perform the exam necessary to determine whether a child can be authorized to be home or hospital schooled.

The long-term implication of allowing full scope of practice extends well into the future.  Not only is our population as a whole living longer and requiring care for decades beyond what was previously needed, both younger and older patients are experiencing more chronic disease.  The need for skilled practitioners has been further exacerbated as more Americans are able to access health insurance through the Affordable Care Act and seek health care services.  All of this comes at a time when the nation faces shortages of health care providers. These shortages are especially prevalent in primary care and have a significant impact on access. Rural communities, such as those on Maryland’s Eastern Shore, are especially vulnerable to such access issues.

With the demand for primary care providers increasing, it is not surprising that various stakeholders encouraged the easing of restrictions on APRNs to help meet the need for care. In 2012, the National Governors Association released a report indicating that one important way in which states could increase access to primary care for their residents was by easing scope of practice restrictions and modifying reimbursement policies to increase the role of nurse practitioners in providing primary care.

A significant tipping point in the debate over the scope of practice for advanced practice nurses came when the highly respected Institute of Medicine (IOM), part of the National Academy of Sciences, issued its report on The Future of Nursing: Leading Change, Advancing Health.  The IOM provided a detailed examination of the ways in which nurses’ roles, responsibilities and education need to change to meet the needs of an aging, increasingly diverse population, and to respond to a complex, evolving health care system.

The recommendations in the report focused on the critical intersection between the health needs of patients across the lifespan and the readiness of the nursing workforce. These recommendations supported efforts to improve health care by enhancing nurses’ contributions to the delivery of care. Recommendation number one of eight recommendations was to “remove scope-of-practice barriers” – which brings us back full circle to the context for and the importance of Maryland’s historic action.

After the release of the Institute of Medicine report, a national campaign was launched, with the support of the Robert Wood Johnson Foundation and the AARP, to implement the IOM recommendations in every state. This included not only the removal of scope of practice barriers, but also increasing the number of nurses with baccalaureate and doctoral degrees, implementing nurse residency programs, and expanding opportunities for nurses to lead and manage collaborative efforts with physicians and others to improve practice environments and health systems.

Individual state action coalitions were launched and now include all 50 states and the District of Columbia. The Maryland Action Coalition (MDAC) was launched by then University of Maryland School of Nursing Dean, Janet Allen, and Johns Hopkins School of Medicine Associate Director of Clinical Research, Patricia Travis. Today, Dr. Travis and I continue to co-lead this important effort. The coalition has grown and is comprised of a diverse set of stakeholders working to ensure we have enough highly-educated and trained nurses to meet Maryland’s growing health needs.

Despite the hard work of MDAC and others that resulted in the achievement of full scope of practice for Advance Practice Registered Nurses, there is still much that remains to be done.  Last summer, MDAC held a strategic planning and leadership summit, resulting in a new strategic plan with goals including: advancing nursing leadership among all Maryland nurses across diverse settings and populations, transforming and advancing nursing education and promoting lifelong learning, and continuing to explore barriers to nursing practice and care. [To learn more about the Maryland Action Coalition visit http://campaignforaction.org/state/maryland.%5D

With the significant action of Maryland’s legislature and its Governor, our citizens can look forward to greater access to care, especially in underserved areas of the State.  This was truly a “win, win” for legislators, educators, health systems, and most importantly, patients and their families.  However, it is really only the beginning of the work that needs to be done.  Here in Maryland, we will be continuing a broad-based discussion about how to increase the number of highly training nurses throughout our State.  And in Washington, Congress will consider whether to make a change in scope of practice rules on a national level that would allow full practice by Advanced Practice Registered Nurses working for the U.S. Department of Veterans Affairs at one of the 1,700 V.A. sites around the country delivering care to over 8.7 million servicemen and women.

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