Monday December 18th 2017

Update: Transition to full practice authority for APRNs

Lisa Summers

In 2014, this column addressed a disturbing trend: legal and regulatory requirements for a transition to practice period before advanced practice registered nurses can practice autonomously. As the American Nurses Association worked to support its constituent and state nurses associations seeking removal of legislative and regulatory barriers to practice, we found ourselves debating these requirements as a strategy to mitigate physician opposition to full practice authority.

In that year, three states — Connecticut, Minnesota and New York — removed requirements for physician oversight after a transition period. In the same year, the Nebraska governor vetoed a bill that would have removed the collaborative agreement for experienced nurse practitioners — defined as 2,000 hours, saying that he would support legislation that mandated 4,000 hours. In 2015, however, the new governor signed an FPA bill that included a transition to practice period of 2,000 hours.

At the 2014 ANA Membership Assembly, a dialogue forum on scope of practice engendered a lively discussion of transition to practice as a legislative tactic in states that do not yet have full practice authority and ANA developed a set of “Principles for Full Practice Authority” (see www.nursingworld.org/principles) that reflected the Reference Committee’s recommendation that ANA support elimination of the requirements for APRNs to have practice agreements with physicians.

Of the 19 states and the District of Columbia that have full practice authority for NPs, 11 states (up from four in 2014) now require a transition period before independent practice or prescriptive authority. The transition period details in hours or years a period of supervised practice under physician or experienced APRN oversight.

ANA is indebted to Susanne J. Phillips, DNP, APRN, FNP-BC, whose DNP project contributed heavily to the ANA principles document. As Phillips’ ongoing work demonstrates, “The regulatory trend of post-licensure practice periods for APRN full practice authority has been documented for several years. Setting policy without evidence to support these new regulatory mandates increases the variability of practice requirements from state to state.”

As is evident in the table included in the “principles” document, there is much variation in how this plan is implemented: Not all APRN roles are affected; requirements stipulate a time-period in months or years, ranging from 18 months to three years, or hours (2,000 to 3,600); and the oversight can be by an experienced APRN and/or a physician.

The principles document provides a framework for states addressing this issue, citing among many resources ANA’s endorsement of the NP Roundtable statement, “Nurse Practitioner Perspective on Education and Post-Graduate Training,” which cautions that requiring additional clinical hours for NPs after graduation “would create new, costly bottlenecks to building the provider workforce.”

That said, many health care professionals — particularly those working in high-volume settings with patients whose care is particularly complex or acute — may benefit from an extended period of orientation or onboarding, or from a formal fellowship. Although the term “residency” has been used to describe such programs for RNs, the term “fellowship” is generally preferred for APRNs. It is important to stress that while these programs are beneficial in some settings, APRNs are prepared at the graduate level and deemed competent clinicians upon graduation and passage of national certification; there is no need for legal or regulatory mandates for transition to practice. Organizations seeking to create APRN fellowships should use standards based on the evidence such as the ANCC Practice Transition Accreditation Program. Fellowship programs provide time and support to APRNs seeking to specialize in a practice area such as critical care or cardiology.

For more information, contact Lisa Summers at lisa.summers@ana.org. Together, we can continue to remove barriers to APRN practice and care.

— Lisa Summers is the senior policy advisor, APRN issues, in Health Policy at ANA.

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