Breaking Down Institutional Barriers to Advanced Practice Registered Nurse Practice

Abstract

Advanced practice registered nurses (APRNs) significantly contribute to health promotion, disease prevention, and disease management. Yet, barriers to APRN practice exist, including regulatory, state, and institutional barriers, that hinder their ability to practice to the full extent of their education, licensure, and certification. Nurse leaders can play an important role in helping reduce unnecessary institutional barriers to APRN practice.

AS HEALTH CARE PROFESSIONALS, advanced practice registered nurses (APRNs) contribute to promoting health and providing care for patients in a variety of health care settings. However, barriers to practice inhibit the ability of APRNs to practice to the full extent of their education and licensure. Nurse leaders can play an important role in helping reduce unnecessary institutional barriers to practice. The purpose of this article is to review the reported barriers APRNs identified in a recent national survey of more than 7000 APRNs from all 50 states that exist within health care systems and to highlight implications for nurse leaders.

STATE PRACTICE ENVIRONMENT TYPES FOR APRNs

APRNs, including nurse practitioners (NPs), certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNSs), and certified nurse-midwives (CNMs), face barriers to practice that impede their ability to provide care commensurate with their educational training. The American Association of Nurse Practitioners (AANP) classifies state laws and regulations impacting APRN practice and identifies the practice environment within the state as full, restricted, or reduced.¹ In full practice authority (FPA) states, licensure laws permit APRNs to (1) evaluate patients, (2) diagnose patient problems, (3) order and interpret diagnostic tests, and (4) initiate and manage treatments including prescribing medications and controlled substances under the licensure authority of a state board of nursing.¹ Half of the 50 US states (n = 25) are classified as FPA (Figure). In reduced practice states, practice and licensure laws reduce the ability of APRNs to engage in at least one of the 4 elements of APRN practice. Some state laws require career-long regulated collaborative agreements with other health providers for APRNs to provide care, or 1 or more elements of APRN practice are limited.¹ Currently, 15 US states are classified as reduced practice states (Figure). The remaining 11 states are classified as restricted (Figure). Reduced practice states and restricted practice states are similar in that practice and licensure laws restrict the ability of APRNs to engage in at least one domain of practice in these states. State law may require career-long supervision, delegation, or team management by other health providers, most commonly physicians, for APRNs to provide care.¹ In a reduced practice state, collaborative agreements are required, whereas in a restricted practice state, supervisory agreements are required. Despite the uniformity in NPs' educational preparation across the country, this variation in state-level scope of practice regulations, which determine the type and breadth of services NPs can provide, continues to exist as a significant barrier to APRN practice.² Even variations in institutional or organizational practices pose barriers for APRNs, such as health care systems that provide medical assistants to support care for physicians but not for APRNs.²

Figure.: State practice environments for advanced practice registered nurses. Adapted with permission of the American Association of Nurse Practitioners.¹

TYPE OF APRN PRACTICE BARRIERS

APRNs face practice barriers even in states with FPA because of federal statutes from the Centers for Medicare & Medicaid Services and nongovernmental policies and practices across a diverse group of institutions and organization, including, but not limited to, hospitals and other health care facilities; public and private insurance companies, managed care organizations, and payers; and other entities. Hospital and other institutional and organizational barriers can result from a number of policies and practices. Examples of these types of barriers include the granting of hospital admitting and other privileges, organizational bylaws, reimbursement, and provider credentialing policies and practices.^3–8 Often the cost of state-mandated collaborative or supervisory services is unregulated and can be cost-prohibitive.^9–11

An integrative review of organization facilitators and barriers to optimal APRN practice identified that other barriers include lack of understanding of the APRN role, lack of professional recognition, poor physician relations, and poor administrator relations.¹² Common restrictions involve requirements for physician cosignatures for prescriptive and hospital admission capabilities, the inability of APRNs to be listed as a provider of record or carry their own patient panel, and electronic health records that do not capture APRN care.¹² These practices interfere with patient communication and ability of APRNs to provide proper follow-up care, limit patient choice of providers, and render APRN care invisible.^13–15

Overcoming current barriers affecting APRNs has been identified as a major challenge facing the nursing workforce by the recent Future of Nursing 2020-2030 report.¹⁶ Barriers to APRN practice reduce the productivity capacity of these health care professionals. Not permitting APRNs to practice to the full extent of their licensure and education decreases the types and amounts of health care services that can be provided for people who need care.¹⁶ As noted in the Future of Nursing 2020-2030 report, these barriers also have significant implications for addressing the disparities in access to health care between rural and urban areas. A recent UnitedHealth report on primary care and NP scope of practice laws identified that if all states were to allow NPs to practice to the full extent of their advanced training and national certification, the number of US residents living with a primary care shortage would decline from 44 million to fewer than 30 million (70% reduction).¹⁷

NATIONAL APRN SURVEY

A national survey was launched in July 2020 to describe state practice barriers prior to the COVID-19 pandemic, determine the effects of COVID-19 pandemic-related suspension of practice restrictions or waiver of select practice agreement requirements in states with reduced or restricted practice, and explore the effects of the COVID-19 pandemic on APRN practice.¹⁸ A total of 7467 APRNs responded from all 50 states, including NPs (n = 6478; 86.8%), CRNAs (n = 592; 7.9%), CNMs (n = 278; 3.7%), and CNSs (n = 242; 3.2%). A number of barriers to APRN practice prior to the pandemic were identified, with most respondents (n = 6334; 84.8%) identifying that practice barriers limited the ability to provide care during the pandemic. The majority of respondents were from reduced practice authority states (n = 3496; 46.8%), followed by states with restricted practice authority (n = 2617; 35.0%), and states with FPA (n = 1354; 18.1%). A majority of respondents (n = 5228; 70.9%) were employed 5 or more years. Practice settings included urban (n = 3094; 42.2%), suburban (n = 2326; 31.7%), and rural (n = 1914; 26.1%). Respondents identified working in outpatient settings (n = 4445; 59.5%), inpatient settings (n = 1430; 19.1%), or both (n = 1596; 21.4%).¹⁸

A number of state and regulatory barriers to practice were identified including restricted hospital admitting privileges (n = 2446; 32.8%), restricted home health approval (n = 2485; 33.3%), requiring a physician signature to order durable medical supplies (n = 2273; 30.4%), requiring physician cosignature on APRN orders (n = 1708; 22.9%), restricted health insurance credentialing of APRNs (n = 1465; 19.6%), requiring physician supervision for procedures within an APRN scope of practice (n = 1227; 16.4%), and the requiring of a physician signature on pre- and postoperative assessments conducted and written by an APRN (n = 829; 11.1%), among others (Table 1).¹⁸ Even among APRNs working in FPA states, similar barriers were reported. For example, a total of 437 respondents from 22 FPA states (Alaska, Arizona, Colorado, Connecticut, Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, South Dakota, Vermont, Washington, and Wyoming, along with the District of Columbia) reported that home health approval was restricted and was a barrier to practice. From these same 22 FPA states, 352 respondents identified restricted hospital admitting privileges as a barrier to practice. There were also 101 respondents from 19 states (Arizona, Colorado, Connecticut, Hawaii, Iowa, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, South Dakota, Vermont, Washington, and Wyoming) who identified that procedures within APRN scope of practice required physician supervision in their practice setting. Forty-three respondents from 15 states (Colorado, Connecticut, Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Nebraska, Nevada, New Mexico, Oregon, South Dakota, Vermont, and Washington, along with the District of Columbia) reported that laboratory or imaging study results were only reported to a physician, creating a barrier to practice (Table 1).¹⁸ Overall, most respondents (n = 6334; 84.8%) identified that practice barriers and restrictions in place prior to the pandemic further limited their ability as an APRN to provide care during the COVID-19 pandemic.

Table 1. - APRN Barriers by Practice Authority as Reported by APRNs^a

Barrier	Restricted	Reduced	FPA
85% reimbursement	X	X	X
Admissions and orders for long-term care require MD signature	X	X	X
All new hire physicians and work compensation injuries must be co-signed by MD	X
Can pronounce death but unable to sign death certificate	X		X
Collaborating/supervising physician practice/population restriction	X	X	X
Disability forms need MD signature	X	X	X
Documentation requirements related to reimbursement for medical direction of anesthesia (eg, Tax Equity and Fiscal Responsibility Act [TEFRA])	X	X	X
Home health approval restricted	X	X	X
Insurance requires MD to be PCP		X
Patients have higher co-pay to see APRN		X
Payment requirement to collaborating/supervising physician	X	X	X
Pharmaceutical companies require MD signature for samples	X
Pronouncing death prohibited (including fetal death)	X	X
Social Security disability forms not honored without MD signature			X
Unable to bill for EKGs, so these have to be sent to collaborating MD		X
Unable to clear child for hearing aids without MD signature		X
Unable to obtain informed consent for procedures		X
Unable to order cardiac rehabilitation		X
Unable to order hospice	X	X	X
Unable to order imaging for patients with abnormal mammogram	X
Unable to order skilled care/visiting nurse		X
Unable to order physical therapy	X
Unable to perform pulmonary function tests			X
Unable to perform sports physicals		X
Unable to practice telemedicine outside of state (New Hampshire)			X
Unable to refer to pulmonary rehabilitation		X
Unable to sign an emergency psychiatric hold			X
Unable to sign birth certificate	X	X	X
Unable to sign DNR document		X
Unable to sign for pulmonary rehabilitation	X
Unable to sign “return to play” after concussion		X
Visiting Nurse Service will not take orders, only take MD referrals		X

Abbreviations: APRN, advanced practice registered nurse; DNP, do not resuscitate; EKG, electrocardiogram; FPA, full practice authority; MD, medical doctor; PCP, primary care physician.

^aFrom Kleinpell et al.¹⁸

Practice barriers most frequently reported among all states, including FPA, reduced, and restricted states, included hospital admitting privileges, home health approval, and orders for durable medical supplies.¹⁸ These barriers create unnecessary difficulty in the provision of continuity of care and quality of care.

Other reported barriers even in FPA states included a physician signature was required for certain medications, APRNs were restricted from ordering rehabilitation services postdischarge, inability to order do-not-resuscitate orders, among others, based on institutional regulations rather than state regulations (Table 2).¹⁸

Table 2. - Institutional APRN Barriers as Reported by APRNs^a

Barrier

Anesthesia or emergency airway management requires MD supervision

Discharges from the PACU or other units require MD signature

Hospital bylaws restrictions on practice

Laboratory or imaging results only given to collaborating/supervising physician (not to APRN)

MD has to repeat all physical examinations and sign all notes

Orders for blood products requires MD signature

Orders for durable medical supplies require an MD signature

Pre- and postoperative assessments require MD signature

Prescriptions require an MD signature (or cosignature)

Procedures essential to anesthesia (eg, regional/peripheral nerve blocks, invasive line placement) require MD supervision

Procedures essential to quality care and within APRN scope require MD supervision

Referral or consultation declined by other providers (only because you are an APRN)

Abbreviations: APRN, advanced practice registered nurse; MD, medical doctor; PACU, postanesthesia care unit.

^aFrom Kleinpell et al.¹⁸

STRATEGIES FOR NURSE LEADERS TO IMPACT APRN PRACTICE

Understanding the context for advanced practice nurses is important for nurse leaders to ensure that all individuals are practicing at the top of their license. It is important for nurse leaders to understand the state laws regarding APRN licensure and scope of practice. As identified in the Future of Nursing 2020-2030 report, until all APRNs are permitted to practice to the full extent of their education and training, significant and preventable gaps in access to care will continue.¹⁶

The APRN Consensus Model was enacted to provide guidance for states to adopt uniformity in the regulation of APRN roles, licensure, accreditation, certification, and education. The APRN Consensus Model outlines that APRN education, certification, and licensure must be congruent in terms of role and population foci.¹⁹ Nurse leaders can help ensure that APRNs who are hired into the health care system are practicing based on the APRN Consensus Model—for example, that an APRN with education and certification as an adult gerontology acute care nurse practitioner is not hired to work in an outpatient primary care clinic. Nurse leaders can find the APRN Consensus Model online (http://www.aacn.nche.edu/education/pdf/APRNReport.pdf) and state scope of practice information can be found online through the American Association of Nurse Practitioners (https://www.aanp.org/advocacy/state/state-practice-environment), or through the National Council of State Boards of Nursing (https://www.ncsbn.org/npa.htm), or the individual state board of nursing Web site.

Nurse leaders can play a significant role in reducing outdated and unnecessary health system practice barriers for APRNs. Nurse leaders should:

• Identify existing institutional barriers to APRN practice;
• Actively support and target the removal of institutional barriers to APRN practice;
• Understand and implement the APRN Consensus Model in the regulation of APRNs in their respective institutions;
• Be knowledgeable about APRN practice restrictions within their state; and
• Consider involvement in state and national organizations positioned to make policy changes impacting APRN practice.

As outlined in Table 2, these barriers might include requiring health care professionals to send consultative or procedural notes to the provider who referred the patient, including APRNs, or eliminating the option to decline accepting a referral based on the referring health care provider type. Nurse leaders can help review and identify institutional barriers to APRN practice in their respective health care systems and actively advocate for their removal. Nurse leaders can also assist in changing bylaws and restrictive practices that exist.

There are also institutional strategies that can improve the APRN role, thus also improving patient care. These strategies include involving APRNs in the credentialing and privileging process within the organization; creating an APRN practice committee or formal structure to support APRN hiring, orientation and onboarding, and competency assessment; ensuring tests or medications ordered or assessments conducted within the APRN scope of practice do not require a physician oversight or cosignature; developing institutional support for billing and reimbursement to capture optimal APRN revenue, continued practice development, and involvement in key organizational committees or workgroups; and APRN outcome assessment. Nurse leaders should also support lobbying efforts within their state to remove unnecessary barriers to APRN practice.

SUMMARY

Eliminating restrictions on APRN scope of practice to enable them to practice to the full extent of their education and training will increase the types and amount of high-quality health care services that can be provided to those with complex health and social needs and improve both access to care and health equity.^16,20 Nurse leaders have an instrumental role in addressing institutional or health system barriers to APRN practice and can help in reducing unnecessary barriers to enable APRNs to practice to their full potential, benefiting health systems and patients, families, and communities.