Arobust body of evidence supports that NP-led care is safe, cost-effective, and of high quality.1-3 National organizations endorse allowing NPs to practice to the full extent of their education and training as a way to reduce healthcare costs and improve access to care.4-6 Despite this evidence, licensing requirements for NPs vary from state to state, which creates legislated inequity in scope of practice. Scope of practice encompasses the services that competent healthcare professionals can perform within the context of their professional license.7 Twenty-two states plus the District of Columbia and Guam are designated as full-practice authority (FPA) for NPs, while the remaining states are classified as either reduced or restricted scope of practice.1 Legislative efforts are ongoing in these states to remove barriers restricting NPs' scope of practice. These legislative efforts are often met with opposition from medical organizations citing unsubstantiated claims of unsafe care.8 Additional factors that negatively impact scope-of-practice legislation include lack of role clarity and uncertainty about NP training and education.5
Thirteen states have adopted a transition to practice pathway to expand NP scope of practice. (See States with transition to practice pathways.) Of these 13 states, 9 have a pathway that results in satisfying the American Academy of Nurse Practitioners (AANP) definition of FPA: “State practice and licensure laws permit all NPs 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 the state board of nursing.”9 The remaining four states have pathways that increase autonomy for NP practice but ultimately do not satisfy the requirements to meet FPA designation.
During the 2018 state legislative session, Virginia's General Assembly approved “House Bill 793 (HB793) Nurse practitioners; practice agreements,” which supports a transitional licensing model for the advanced practice role of NPs with at least 5 years of full-time work equivalence in their certification area. This legislation created a transition to practice pathway for NPs. Although this pathway does not result in FPA, it was an incremental step toward increasing NP autonomy. The AANP endorses FPA legislation; however, neither the historical precedent nor the political will of Virginia supported drafting FPA legislation in 2018. This article presents Virginia's example as a case study for NP advocates working toward a similar legislative agenda in their respective states.
Kingdon's policy stream model
John Kingdon's policy stream model is useful in identifying how an issue becomes a policy agenda item.10 According to Kingdon, policy change comes about when three streams—problems, political will, and policies (solutions)—connect. Kingdon's model demonstrates that although the three streams may operate independently of one another, all three must come together for the window of opportunity to open and a policy to emerge. The case of Virginia will demonstrate how the issue of restricted scope of practice became a policy initiative based on the problem of limited access to care, which was impacted by the political will of the state to support a policy solution of increasing NP autonomy.
History has established that Virginia moves a political agenda in incremental fashion that aligns with the stepped approach to health policy changes in the US.11 The incremental approach toward reducing barriers to NP practice is similar to other states. In 1975, legislation was enacted in Virginia that required licensing for NPs be governed by the Joint Boards of Nursing and Medicine. Over the last 50 years, changes including certification for licensing, gradual expansion of prescriptive authority to include all scheduled medications, and updated supervisory language have all been legislated in Virginia. In 2016, “SB 620: Nurse practitioners” was introduced. This bill sought to eliminate mandated practice agreements in medically underserved communities. Although it was not an FPA bill, it did attempt to provide a pathway to autonomous practice for a select group of NPs in certain geographic areas in the state. The bill made it out of subcommittee but did not pass full committee. SB620 was met with strong resistance from the Medical Society of Virginia. The nursing community was encouraged by the subcommittee's passage of the bill.
HB793 was drafted in the same spirit of incremental change, and although it is not an FPA bill, nursing advocates felt it was the next logical step toward reducing barriers to practice. The window of opportunity was open as the discussion of Medicaid expansion; continued problems with access to primary care were of paramount concern to voters in Virginia. Consistent with Kingdon's model, nurses working on this legislation highlighted the potential impact of HB793 on access to care in Virginia (the problem). Approving HB793 would remove access barriers by providing a path for NPs to practice independent of a collaborative agreement (the policy solution). Within the historical context of Medicaid expansion in Virginia, the political will to solve this problem of access to care was intact, allowing for the three streams to merge and open the policy window in favor of HB793.
In addition to timing and flow of policy action, consistent and sustained action by advocates is also necessary. Successful policy depends not only on strong public interest but also low stakeholder conflict.12 Therefore, building a coalition of internal and external stakeholders preceded the 2018 General Assembly session. Stakeholder meetings were led by HB793's patron, Delegate Roxanne Robinson, and included hospital associations, AARP, major regional health systems, and representation from the Medical Society of Virginia and various nursing organizations. Individual nurses sought the support of external stakeholders including individual health systems, patients, and other healthcare providers. The series of stakeholder meetings provided opportunities in advance of the legislative session for sharing opinions and consensus building.
Other strategies used included the promotion of consistent messaging. One mechanism for creating a consistent message was using a policy brief developed in collaboration with a policy center.13 Letter-writing campaigns were encouraged with template messaging provided to all stakeholders, including consumers of healthcare. A strong social media campaign leveraged public visibility and fostered a sense of urgency around the issue. More traditional forms of media were leveraged including radio interviews featuring NPs and televised news segments. Using outcomes evidence as part of the messaging validated the nursing community's stance to external stakeholders and helped counteract claims to the contrary by the opposition. The media coverage was the final blitz of a nearly 2-year preparatory process for HB793. (See Virginia's legislative journey: The path to HB793.)
Passage of HB793
Virginia's legislature passed HB793, but not without controversy. The initial iteration of the bill supported by Virginia's professional nursing organizations required attestation of 6 months using a mandated collaborative agreement prior to transitioning to autonomous practice. During the subcommittee hearing, Delegate Scott Garrett, a practicing physician, introduced a substitution bill. The substitution included language about a plan for referring complex cases and emergencies, boundaries on using the title “doctor,” and requirements for initial practice agreements to include provisions for episodic review of records and possible site visits. This substitution changed the time requirement in an attempt to parallel a physician's residency training time, which aligned with organized medicine's frame. The NP community was concerned that using a 5-year full-time work equivalence would establish a difficult precedent for other states. The language in the substitute bill was particularly concerning to the AANP as it established the longest transition to practice time in the nation and the continuation of oversight by the Joint Boards of Nursing and Medicine (AANP, organizational communication, February 7, 2018). However, the Virginia Board of Nursing estimated that 60% of the 10,772 licensed NPs with prescriptive authority held their license for over 5 years, which would make them eligible to apply for an autonomous license if they chose (S. Willinger, personal communication, October 16, 2018). If eligible NPs chose to apply for autonomous practice, the number of available providers in the state would increase and improve access to care. To reach middle ground, nursing advocates accepted these conditions and compromised on a time period of 5 years of work equivalence. Compromise, while seemingly undesirable, can be a source of innovation and creative solutions.10 The potential for compromise is an important feature of an effective policymaking process. The health policy domain is replete with examples of incrementally developed policies that required compromise on both sides.10
After HB793 was passed, the Joint Boards of Nursing and Medicine consulted their respective advisory panels to discuss the promulgation of the bill. These meetings were open to the public and highly attended by both the nursing and medical communities. The language of HB793 was clear that attestation was an assessment of time, not a mechanism for measuring competence. The promulgation of HB793 created a streamlined process for this. The attestation form is easily accessible on the Department of Health Professions website for NPs to download. The Board of Nursing reports that as of October 2019, 556 NPs have applied for their autonomous practice license.14 To date, information on their practice setting and population focus has not been published. However, this information will likely be included in the mandated workforce study that was tied to the passage of HB793.
Looking ahead: Policy modification
The nursing advocate community made a deliberate decision to support the legislative substitution in the spirit of compromise and with the knowledge that the 5-year requirement would make the majority of licensed NPs in Virginia eligible for autonomous practice. This compromise was intentional and promoted receptivity with the goal of impacting future advocacy efforts. Allowing NPs to transition to autonomous practice will improve access to care in Virginia. This impact can be assessed by the mandated workforce study that was incorporated into HB793.
Virginia's geographic composition is diverse with the Southwest portion of the state being rural, while most of the Northern aspect of the state is urban. Historically, Virginia's workforce data studies have reported the distribution of NPs in rural, suburban, or urban areas.15 Virginia currently has 10 counties designated by HRSA as health professional shortage areas (HPSAs); this problem is not improving as all of these localities have demonstrated persistent need for 3 to 5 decades.16 There is a disproportionate distribution of HPSAs in the Southwest region of the state. In Virginia, NPs historically provide care to underserved populations to offset the increasing primary care provider shortage in the state.15
NP FPA advocates can use these data to inform decision-making for next steps in legislation to further expand practice in the state. These data along with the existing spirit of compromise between organizations will facilitate the success of future FPA legislative efforts.
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8. American Medical Association. Physician-led team-based care. Resource materials to support legislative and regulatory campaigns [Powerpoint slides]. 2018. http://www.ama-assn.org/practice-management/payment-delivery-models/physician-led-team-based-care
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12. Cohen S, Rodgers B. A primer on political philosophy. In: Mason DJ, Gardner DB, Outlaw FH, O'Grady ET, eds. Policy and Politics in Nursing and Health Care
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13. Smith S. Nurse Practitioners: Scope of Practice
(Policy brief HB793). 2017. https://oppo.vcu.edu/faculty-training/research-fellowship/
14. @VACNP. As of Oct. 1, there were 556 NPs with autonomous practice licensure in Virginia. Whether employees or volunteers, these NPs are increasing access to care by treating patients without the need for a collaborating physician. If you haven't applied yet, what are you waiting for?!! https://twitter.com/VACNP/status/1186708104093863936
. Posted October 22, 2019.
16. Health Resources & Services Administration. Health Professional Shortage Area (HPSA) Find tool. 2019. https://data.hrsa.gov/tools/shortage-area/hpsa-find