States Should Permanently Lift Practice Barriers for Nurses

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Connecting state and local government leaders

COMMENTARY | Nurses can be a key force in helping to bridge gaps in health care access. But many states deny them the ability to practice to their full capabilities.

Many Americans suffer from a lack of access to quality health care. In recent years, the availability of health care resources has decreased especially for communities of color and low-income communities. This problem will only worsen as projections show that by 2034 there will be a shortage of primary care physicians by 2034.

The most obvious solution to this problem is for states to lift practice barriers for advanced practice registered nurses and allow them to practice to the full extent of their education and training. This includes certified nurse midwives, clinical nurse specialists, certified registered nurse anesthetists and certified nurse practitioners (NPs), all who received advanced education and training.

Advanced Practice Registered Nurses hold at least a master’s degree in addition to the basic four year nursing education and licensing required to be a registered nurse. They are prepared to diagnose and provide primary and preventive care and prescribe medications and tests when needed. They also engage in continuing education to remain up to date on developments in the field. In some states, NPs must obtain a registered nursing license, complete an accredited graduate-level program, and pass a national certification exam.

Despite their rigorous education and training, nurses in 26 states are limited in their scope of practice. While these practice barriers vary from state to state, the consequences are the same: It’s harder for nurses to serve those who need them most, including people bearing the brunt of the Covid-19 pandemic.

If given full practice authority, these nurses can provide care to more people who need it. Specifically, advanced practice registered nurses have the ability to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of their state board of nursing. In fact, the Federal Trade Commission supported expanding scope of practice seven years ago.

In the 24 states and the District of Columbia where nurses with advanced education and training have full practice authority, quality of care has improved and gaps in access to primary care narrowed. Moreover, people living in states that allow nurse practitioners to evaluate and diagnose patients, prescribe medications and treat patients without a physician in the room have twice as much access to primary care as those in states that don’t. They are also more likely to seek out routine medical care and rate their quality of care higher.

Furthermore, at the start of the Covid-19 pandemic, seven states temporarily removed practice barriers for nurse practitioners, nurse anesthetists and certified nurse midwives to strengthen health workforce capacity. These emergency actions expanded access to Covid-19 diagnosis and treatment while supporting other care and enabling people to stay home and avoid hospitals and nursing homes—all without evidence of sacrificing quality.

Opposition From Medical Associations

Practice restrictions on nurses have remained in many states largely because of opposition from special interest groups. Some medical associations have aggressively lobbied state legislatures against lifting nursing practice barriers, claiming it would harm quality. They also warned that giving nurses more freedom to practice runs counter to what patients want and expect, would threaten their health and safety and increase health costs.

But the data simply don’t bear this out. The states that still do not recognize full practice authority for nurses with appropriate education and training are more likely to have geographic health disparities, higher burden of chronic disease and higher costs.

Allowing advanced trained nurses to practice to their full potential would expand access to 31 million more people living in primary care shortage areas. These nurses are also more likely than physicians to care for Medicaid and uninsured patients and work in settings that predominantly serve people of color and those with lower incomes.

The federal government has taken steps to remove nurse practice barriers. The Veterans Administration health system did this in 2017. The Biden administration has permanently lifted barriers for nurses to prescribe buprenorphine for opioid addiction to expand treatment. However, more can be done at the federal level to help nurses reach more people.

More states are permanently removing barriers for some or all nurses with advanced education and training, including most recently Delaware. But the pace is too slow, and concern remains that states that temporarily lifted barriers will revert when the pandemic eases, decreasing access to care. And state-imposed barriers may deter nurses from locating to areas that need them.

Ten years ago, the National Academy of Medicine called for removing institutional and regulatory obstacles to nursing practice. Since then, the previously strong body of scientific evidence supporting full scope of practice for nurses has become even more compelling. Our new report echoes our initial call to lift these barriers. To improve access to quality care, particularly for underserved communities, we hope this time we see real action.

Nationwide, nurses do what they can to help people live their healthiest lives. But in so many communities, they could do so much more to expand access, improve quality and reduce inequities. 

Not using any provider to their full potential is an unjustifiable waste—too often driven by professional turf concerns. It is a disservice to providers who want to and can do more. But more importantly, it’s a disservice to the populations that need care and can’t get it. 

Mary Wakefield, Ph.D., RN, is a visiting professor at the University of Texas at Austin and co-chair of the National Academy of Medicine’s Committee on the Future of Nursing 2020-2030, which just released a report on nursing’s role in advancing health equity. She served as administrator of the Health Resources and Services Administration during the Obama Administration. John W. Rowe, MD, is the Julius B. Richmond Professor of Health Policy and Aging at the Columbia University Mailman School of Public Health and former president and CEO of Mount Sinai New York University Health. He is a member of the National Academy of Medicine’s Committee on the Future of Nursing 2020-2030.

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