Nursing & Healthcare News

Nurse Practitioner Autonomy in California?

COVID-19 could be the catalyst

Could the COVID-19 crisis provide the push that finally brings about full practice authority for nurse practitioners? An NP autonomy bill is again before the California State Senate.  While the bill would provide a path to independent practice for NPs, other states’ experience with similar bills offers some important caveats nurses should understand.

Physician Resistance

In January, the California State Assembly approved A.B.890, which would create an autonomous practice certification process for certain qualified nurse practitioners. (The bill doesn’t include other types of APRNs.)

Previous attempts to pass NP autonomy bills in California have all failed due to strenuous physician resistance. Although A.B.890 passed the Assembly by an overwhelming 66–1 margin, the bill is currently stalled in the Senate.

However, the COVID-19 crisis could give NP autonomy a much-needed push. The pandemic is exacerbating existing provider shortages while forcing healthcare organizations to reduce their care costs. Allowing independent practice for NPs could be a solution for both problems.

Former HHS Secretary Donna Shalala recently told STAT News, “Frankly, 70 percent of primary care could be handled by advanced practice nurses.” Shalala’s home state of Florida passed a comparable NP autonomy bill in March.

Uphill Climb to Autonomy

Like the Florida bill and a similar law passed in Virginia two years ago, A.B.890 would not automatically allow NPs to practice autonomously. Rather, it would provide a path to autonomy.

Nursing Education

To practice without physician supervision, California NPs would first have to apply for autonomous practice certification and demonstrate that they have met certain minimum requirements for education, certification and experience. There would also be additional prerequisites to practice outside of typical acute care settings.

Autonomous NPs would be required to inform new patients that a nurse practitioner is not a physician. NPs who meet these requirements would be permitted to assess, diagnose and treat illness; order tests; prescribe medication; certify disability; and even delegate tasks to medical assistants without Regulatory Bottlenecks.

As with other path-to-autonomy bills, A.B.890 would establish certain statutory minimum standards for autonomous NPs while leaving the precise details to be determined by the appropriate regulatory body after the law is enacted.

In Florida and Virginia, that approach has created significant delays and bottlenecks. Although the Florida law goes into effect July 1, Florida NPs still don’t know what will be required to apply for their state’s new independent practice licenses.

Establishing Virginia’s minimum standards for independent practice licensure involved months of contentious lobbying and debate. Virginia’s final regulations are so cumbersome — requiring 9,000 clinical practice hours and attestation forms signed by each supervising physician — that only about 800 NPs have received independent practice licenses since the law took effect in January 2019.

Hiring Now

The bottleneck could be even worse in California. While Virginia’s requirements are based on prior experience, A.B.890 would require California NPs who wish to practice independently to first complete a transition-to-autonomous-practice program providing at least 4,600 clinical hours (three fulltime-equivalent years) of “additional clinical experience and mentorship … to prepare a nurse practitioner to practice without the routine presence of a physician and surgeon.”

No such programs currently exist, and the body that would be responsible for setting minimum standards for them (and other independent practice prerequisites) doesn’t exist yet either. That means that even if A.B.890 passes in the near future, it could be 2024 or later before any California NPs are certified to practice independently!

Board vs. Board

Unlike the Florida law, which gives that state’s nursing board authority to determine standards for independent practice licensure, A.B.890 would assign that responsibility to a new nine-member advanced practice registered nursing board within California’s Department of Consumer Affairs.

The new APRN board would consist of four nurse practitioners, two members of the public and three physicians. This means NPs seeking autonomous practice certification would be subject to two different regulatory boards: the BRN and the APRN board. Over time, this dual-board approach could risk eroding the position of the BRN, ceding more control over California nursing practice to the APRN board’s physician members — a potentially bitter price for NP autonomy.

Read the full text of A.B.890 and track its progress at leginfo.legislature.ca.gov.

Editor’s Note: A revised version of the bill was signed by Gov. Newsom on Sep. 29.

 


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