Nurse Practitioners Get Full Practice Authority in Nebraska

Nebraska's move brings to 20 the number of states allowing nurse practitioners full practice authority, puting it "in line with the future of collaborative models of health care," according to one state lawmaker.

Nebraska has enacted a law that scraps the previously required integrated practice agreements for nurse practitioners, becoming in March the twentieth state to grant full practice authority to NPs.

Tay Kopanos, DNP, NP, vice president of state government affairs for the American Association of Nurse Practitioners calls the move "tremendous."

"By retiring the written collaborative agreement, Nebraska has just said, 'We are going to utilize our nursing workforce to their maximum capacity,'" Kopanos says.

Now, 20 states and the District of Columbia allow NPs full practice under the exclusive licensure authority of the state board of nursing. Kopanos says the states where NPs have full practice authority have seen more NPs working in rural and underserved areas and those states are better able to provide earlier preventive healthcare services and access to primary care.

"As states are struggling to address expanding Medicaid populations, an aging population, and increased people living with chronic diseases… states that are utilizing NPs will be ahead of the curve," Kopanos says.

Although that number represents less than half the states in the nation, the trend is moving toward allowing NPs full practice authority. Kopanos says it's "telling" to look at the number of states that have enacted such laws in the just the past few years, as well as the number of states currently introducing legislation to grant full practice authority to NPs. (See AANP's state practice map here).

"In the last four years we have had six states retire the condition of physician involvement," she says, pointing to North Dakota and Vermont in 2011; Nevada in 2013; Minnesota and Connecticut in 2014; and Nebraska so far this year.

Several states have already introduced legislation this year, and there are others that will likely do so later in the legislative session. Maryland, Texas, Illinois, South Carolina, Pennsylvania, and Kansas have all introduced language that would grant full practice authority to NPs. California has placeholder bill waiting for formal language, and a handful of other states are looking act, too. Should all of these states enact laws, the balance would tip toward the majority of states allowing NPs full practice authority.

"States are looking at right-sizing the regulations around nursing practice," Kopanos says.

The notion of "right-sizing" state laws is gaining traction as the NP role marks its 50th anniversary this year. In the decades since it was first established, the NP role has evolved, but in many cases, legislation hasn't evolved with it, creating a disconnect between the high level of care that NPs can provide and the limited care that outdated licensure laws allow. Some laws have been on the books since the 1970s or 80s, Kopanos says.

"Nowhere else in healthcare would it be acceptable to offer the best of what could be offered of the 70s or 80s," she says.

Kopanos points to several organizations, such as the National Governors Association and the AARP, which have supported reexamining scope-of-practice rules to allow for more NPs to practice primary care.

There is opposition, however, from the American Medical Association. In a January 15 letter to Kathy Campbell, chair of the Nebraska Legislature's Health and Human Services Committee, the AMA argued that expanding NP scope-of-practice would "compartmentalize and fragment healthcare delivery. "The AMA said it was "concerned that the changes proposed" by the legislation "may undermine the delivery of patient-centered, team-based care in Nebraska."

In the AMA's view, that team-based care should be led by physicians. In an emailed statement to HealthLeaders, the AMA said:

The American Medical Association encourages physician-led health care teams that utilize the unique knowledge and valuable contributions of nurse practitioners, physician assistants, and other health care clinicians to enhance patient outcomes. Innovative physician-led team models by some of the nation's top health care systems across the country are achieving improved care and patient health, while reducing costs. The AMA looks to these systems as evidence that physician-led, team-based models of care are the future of American healthcare. Patients win when each member of their health care team carries out the role for which they are educated and trained.

But as a recent Supreme Court decision about dental services providers and scope-of-practice laws underscores, the NP scope of practice issue boils down to competition, not patient safety.

"Over four decades of research have consistently demonstrated that there is no safety concern, and quality of care has been high, and in some cases, better than the profession that they have been benchmarked against," Kopanos says.