Transition to Practice
Contributed by Health Policy Committee member Sarah B. Green, DNP, CPNP-AC
The number of states introducing and passing advanced practice registered nurse (APRN) practice legislation continues to grow, representing upwards of 28 states as of 2022, although the actual level of practice authority varies from state to state. Over time the United States (U.S.) public has become increasingly more familiar with the role of the nurse practitioner (NP) and simultaneously there is an ever-growing need for access to healthcare. Public trust and the need for providers has given rise to conversations regarding the ability of NPs to practice to the fullest extent of their education and training in order to provide high-quality patient care. The COVID-19 pandemic has further highlighted the gaps in access to care across the country, particularly in underserved communities.
Although decades of evidence demonstrate the high-quality care that NPs deliver, barriers continue to exist with the patchwork of state-based advanced practice legislation. What was intended in the APRN Consensus Model to align licensure, accreditation, certification, and education (LACE), to seek uniformity for NPs to practice to the full extent of their education and licensure and ease mobility across state lines, has very rarely been fully implemented in state practice regulations across the U.S.
Although not often seen as a partisan political issue, challenges to NP scope of practice legislation often exist between state medical and nursing bodies with disagreement over issues that range from clinical hour requirements for NPs to practice without a collaborating physician, to settings in which an NP can practice without supervision, and who will have regulatory oversight of NP licensure. The vision of the Consensus Model being utilized as originally intended has become murky and clouded with regulations and lengthy and expensive campaigns both supporting and opposing practice legislation across the country.
It is important to note that APRN Full Practice Authority (FPA) does not equal independent practice. The term FPA refers to authorization for NPs to evaluate, diagnose, order and interpret diagnostic tests, and initiate and manage treatments, including prescribing medications. This authorization is codified in state statute and granted under the licensure authority of individual state boards of nursing. An NP is eligible to apply for this licensure by meeting the requirements for APRN education, graduating from a nationally accredited NP program that has met the standards for didactic and clinical education, and passing a national NP board certification exam. Maintaining that licensure carries additional continuing education and recertification requirements. Licensed NPs must consult and refer to other health care providers as appropriate to meet the needs of patients and be accountable to the state board of nursing to provide the nationally set standard of care.
Transition to practice requirements have been implemented as part of some practice legislation in states across the country, resulting in variable degrees of practice autonomy. Transition to practice legislation requires that newly graduated NPs practice under the supervision or mentorship of an experienced clinician. Hour requirements are widely variable across states, from 1,000 hours up to five years of supervised practice and are often used as precedents by opponents to unobstructed NP practice in other states. Despite a lack of evidence to support utilization of transition to practice models, often described by proponents of this legislation as providing a “medical residency level education” transition to practice models have become more common in APRN practice legislation across the country in recent years.
Extensive research has demonstrated that NPs provide safe and effective care at the time of graduation and these transition requirements are not consistent with the Consensus Model. Transition to practice restrictions have not shown to increase the value or safety to patient care and to adversely impact to the cost of care and decrease or limit access to patient care. Additionally, transition to practice restrictions have the potential to negatively impact the number of NPs seeking to practice in states with restricted or reduced practice.
As the conversation regarding APRN practice legislation and transition to practice requirements continues across the U.S., it is essential that we as pediatric-focused NPs have a comprehensive understanding of existing and pending legislation in the states where we practice. We must have a seat at the table in the crafting of legislation and the subsequent board of nursing regulations to advocate for NPs practicing to the fullest extent of our education and training and to seek the fewest restrictions to patient access to care for children and their families.
NAPNAP’s Executive Board recently approved our 2022 Health Policy Agenda. Read more about the goals and strategies that guide our health policy efforts, including collaborations/partnerships, positions and statements, outreach to legislatures and regulatory agencies, and much more.
Senate Committees Focus on Mental Health Initiatives
At a hearing focusing on policies to protect youth mental health, Senate Finance Committee leaders said Feb. 8 that they intend to draft a bipartisan legislative package this summer broadly addressing behavioral health needs. Chair Ron Wyden (D-OR) said the panel will establish bipartisan workgroups of members focusing on five areas including strengthening the workforce; increasing coordination and access to care; ensuring parity between behavioral and physical health care; furthering the use of telehealth; and improving access to mental health care for children and young people.
Testifying before the panel, Surgeon General Vivek Murthy, MD, said the coronavirus pandemic has had a “devastating” effect on the mental health of young people. “I’m deeply concerned as a parent and as a doctor that the obstacles this generation of young people face are unprecedented and uniquely hard to navigate and the impact that’s having on their mental health is devastating,” Murthy said, adding, “Our obligation to act is not just medical, it’s moral.”
On Feb. 3 NAPNAP President Andrea Kline-Tilford, PhD, CPNP-AC/PC, FCCM, FAAN participated in a virtual meeting called by Sen. Debbie Stabenow (D-MI), who is co-chairing the Finance Committee group addressing workforce issues, to talk about the youth mental health crisis and the role of Certified Community Behavioral Health Clinics in providing comprehensive mental health care.
At an earlier Feb. 1 hearing, Senate Health, Education, Labor, and Pensions Committee Chair Patty Murray (D-WA) also expressed alarm over the sharp uptick in mental illness since the start of the pandemic, including among children. Murray called on Democrats and Republicans to work together to craft legislation to address the problem, noting that part of the problem is that the nation’s mental health workforce is stretched too thin to meet children’s growing needs and “something is going to break.”
Regulators Delay Review of COVID Vaccine for Infants and Toddlers
After scheduling a meeting of its expert advisory panel to review data submitted by drug makers Pfizer and BioNTech on a coronavirus vaccine for children 6 months-5 years, the Food and Drug Administration canceled the meeting on Feb. 11 and said it will not make a decision on whether to authorize the vaccine until data on a third dose becomes available. The delay means it could be mid-April at the earliest before shots are available for younger children. The agency decided not to move forward in considering a two-dose regimen of the vaccine after data from an ongoing trial showed the shots didn’t generate strong protection. The agency said, “We believe additional information regarding the ongoing evaluation of a third dose should be considered as part of our decision-making for potential authorization.”
Congress Skirts Shutdown As Talks Near Funding Deal
The Senate is set to approve another short-term extension before funding for government agencies runs out Feb. 18 as Senate and House negotiations move closer to agreement on omnibus appropriations deal to fund federal program through the rest of fiscal year 2022. The House on Feb. 8 passed a third stopgap to extend current agency funding through March 11, buying appropriators time to work out the details of a $1.5 trillion agreement that will include money for nursing education, workforce, and research programs.
A day later, congressional leaders reached an overarching agreement Feb. 9 to increase military and non-defense budgets, a crucial breakthrough for appropriators to work out funding for individual agencies and programs. Negotiators wouldn’t divulge the funding totals and contentious policy debates could still upend negotiations on final bill text, but leaders in both parties applauded the framework agreement. The standoff has blocked a host of spending increases and policy changes including significant boosts for nursing priorities. The House passed legislation last summer increasing funding for Title VIII nursing workforce development programs by $50 million, while Senate Democrats proposed an increase of $16.5 million.
Senators Release Pandemic Readiness Bill
Senate Health, Education, Labor, and Pensions Committee Chair Patty Murray (D-WA) and top-ranking Republican Sen. Richard Burr (NC) on Jan. 25 released a draft of sweeping legislation to overhaul of the nation’s public health programs and how the government monitors disease outbreaks, stockpiles supplies, and responds to future pandemic threats. The “Prepare for and Respond to Existing Viruses, Emerging New Threats, and Pandemics Act (PREVENT Pandemics Act)” would refocus the mission of the Centers for Disease Control and Prevention and the Food and Drug Administration, requiring Senate confirmation of the director of the CDC and calling for regulators to improve clinical trials through digital strategies and using real-world evidence. The bill would also create a task force appointed by bipartisan congressional leadership to assess the country’s preparedness for pandemics and making recommendations to the President and Congress on improvements.
Plans for advancing the legislation are unclear, but it could be combined with mental health measures or the “Cures 2.0 Act” (H.R. 6000), a broad proposal introduced last November by Reps. Diana DeGette (D-CO) and Fred Upton (R-MI) to boost biomedical research and streamline access to new treatments. That measure would also authorize $6.5 billion to realize President Biden’s plan for a new federal research agency, overhaul telehealth policy for government programs and order agencies to implement a range of programs to speed consumers’ access to new treatments.
Senate Panel Cracks Down On Online Child Sex Content
Legislation to rein in the blanket immunity that shields online platforms from liability for child sexual abuse material posted by third parties was endorsed Feb. 10 by the Senate Judiciary Committee, clearing the way for a full Senate vote. The “Eliminating Abusive and Rampant Neglect of Interactive Technologies (EARN IT) Act” (S. 3538), introduced by Sens. Lindsey Graham (R-SC) and Richard Blumenthal (D-CT), would limit tech companies’ liability shield protections under Section 230 of the Communications Decency Act for child sexual abuse content on their platforms. The bill would enable state attorneys general and survivors to sue tech companies under federal and state civil law and state criminal laws for the posting of child sexual abuse content, and it would create a commission to establish best practices and guidance for law enforcement and policy makers. The committee approved similar legislation two years ago, but the full Senate never took it up.
In Other News…
Democrats Struggle to Revive “Build Back Better”
President Joe Biden’s broad social and climate spending plan, as passed by the House last year, is dead – rejected by West Virginia Sen. Joe Manchin, one of the 50 Democratic votes essential for the passage of the bill under Senate budget rules that prevent Republicans from blocking it. Senate leaders have moved on to other issues, leaving the fate of “Build Back Better” nursing priorities in limbo as Democrats try to find a way to revive at least some parts of the earlier proposal. A legislative calendar crowded with appropriations for two fiscal years, a Supreme Court nomination, and possible action on voting rights, pandemic preparedness, and mental health legislation leaves a very narrow opening for party leaders to draft a bill that Manchin will support.
In addition to talking with staff for Senate leaders and Sen. Manchin, NAPNAP and other nursing and children’s health groups are also exploring other possible options for advancing key policies including closing the Medicaid coverage gap, extending continuous Medicaid coverage for children, permanently authorizing the Children’s Health Insurance Program, and providing funding for nursing education enhancement grants and scholarship and loan repayment programs.
Supreme Court Nomination Crowds Senate Agenda
The Jan. 26 announcement that Justice Stephen Breyer will retire at the end of the Supreme Court’s current term gives President Joe Biden a chance to reinforce the court’s liberal minority and deliver on his campaign pledge to make history by nominating the first African American female justice. But it also adds a potentially politically divisive and time-consuming debate to an already-crowded Senate legislative calendar shortened by the approaching midterm elections.
At a White House event honoring Breyer Jan. 27, Biden restated his vow to nominate a Black woman to the Supreme Court by the end of February, saying “it’s long overdue.” The appointment could have an important impact on the court’s consideration of a wide range of health care issues including possible landmark rulings on reproductive rights, vaccine mandates, environmental regulations, “public charge” immigration policies, and affirmative action.