Monday May 30th 2016

Transition to full practice authority for APRNs

Andrea Brassard

The American Nurses Association (ANA) supports its constituent and state nurses associations (C/SNAs) as they seek removal of legislative and regulatory barriers to advanced practice registered nurses (APRNs) services. The ANA staff participates in weekly “SWAT” team conference calls with other national APRN organizations to discuss current and proposed legislation and strategies to implement the APRN Consensus Model.

One strategy that has been proposed in several states to mitigate physician opposition to full practice authority is to require a transition period before APRNs can practice independently.  Of the 17 states and the District of Columbia that have full practice authority for nurse practitioners (NPs), four states — Colorado, Maine, Nevada and Vermont — currently 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.

This year, three states — Connecticut, Minnesota and New York — removed requirements for physician oversight after a transition period.

• Connecticut’s new law removes the collaborative agreement after three years.

• Minnesota removes the collaborative agreement after 2,080 hours.

• The recently enacted budget in New York state includes a provision that will substitute an attestation statement for the written collaborative agreement for NPs with more than 3,600 practice hours.

And in Nebraska, the governor vetoed a bill that would have removed the collaborative agreement for experienced NPs — defined as 2,000 hours. The governor’s veto was accompanied by a statement that said he would support legislation that mandated 4,000 hours.

As you can see from the state examples, there is much variation in proposed clinical practice hours.  Some suggest that these transition-to-practice models mirror physician residencies, which typically range from three to five years of 80-hour work weeks.  When legislation to remove APRN barriers is proposed in states without full practice authority, physicians often cite the many hours of physician training as an opposition tactic.  In contrast, APRNs are required to have a minimum of 500 clinical practice hours to qualify for national certification exams, although many graduate programs require additional hours.

The arguments for practice hours do not consider that APRNs, like all other health care professionals, do not practice in a vacuum.  In fact, most APRNs are employed by physicians or hospitals.  The very small percentage of APRNs who open their own practices typically do so only after many years of experience.  There is no evidence that requiring post-graduate training for NPs or other APRNs affects patient safety or quality care.  ANA recently endorsed 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 to the provider workforce.”

At the 2014 ANA Membership Assembly, a dialogue forum on scope of practice engendered a lively discussion of transition to APRN practice as a legislative tactic in states that do not yet have full practice authority. After the discussion, ANA’s Reference Committee recommended that ANA:

• Support elimination of the requirements for APRNs to have practice agreements with physicians.

• Encourage nursing research to compare full practice APRN authority states, transition to APRN practice states, and restricted APRN states.

For more information about these recommendations, contact Andrea Brassard, ANA’s director of health policy at  Together, we can continue to remove barriers to APRN practice and care.

— Andrea Brassard is the director of health policy at ANA.


NP Roundtable statement “Nurse Practitioner Perspective on Education and Post-Graduate Training”:

APRN Consensus Model:

Practice Transition Accreditation Program™:

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