Full practice authority—Effecting change and improving access to care: The Nevada journey Susan S. VanBeuge, DNP, APRN, FNP-BC, CNE, FAANP (Assistant Professor)1 & Tomas Walker, DNP, APRN, BC-ADM, CDE (Vice President)2 1 2

School of Nursing, University of Nevada, Las Vegas, Nevada Nevada Advanced Practice Nurses Association, Desert Endocrinology, Henderson, Nevada

Keywords Policy; legislation; autonomy; health policy; leadership; nurse; practitioners; primary care. Correspondence Susan S. VanBeuge, DNP, APRN, FNP-BC, CNE, FAANP, Assistant Professor, School of Nursing, University of Nevada, 4505 Maryland Parkway, Box 453018, Las Vegas, NV 89154-3018. E-mail: [email protected] Received: August 2013; accepted: January 2014 doi: 10.1002/2327-6924.12116

Abstract Purpose: In 2013, Nevada shifted from a collaborative practice model to full practice authority. Given the challenges many states still face, this article provides an outline of the evolution of the “nurse practitioner” (NP) in Nevada. Reviewing the path Nevada took toward full practice authority, we hope to provide insight including lessons learned and opposition encountered to assist other states working toward full practice authority. Data sources: Literature searches were conducted on PubMed and MEDLINE. Search terms included “autonomous practice,” “nurse practitioner,” and “full practice authority.” Conclusions: Healthcare reform will require nurse practitioners committed to legislative change. Nurse practitioners have the knowledge and ability to affect the legislative process and improve patients’ access to care. With careful planning, full engagement, and team building, making a statute change is possible and should be seriously considered in states still struggling with collaborative relationships. Implications for practice: Nurse practitioners are well situated to provide primary care in the United States. Removing barriers to practice through statute change will empower NPs to effect positive change in our struggling healthcare system.

Success is not final, failure is not fatal: it is the courage to continue that counts. —Winston Churchill

Introduction and background Nurse practitioners (NPs) across the country have struggled down different paths toward full practice authority. There has yet to be a single road to recognition. Most recently, the 2013 Nevada Legislature passed and Governor Sandoval signed Assembly Bill 170 (AB170), granting “nurse practitioners” full practice authority in Nevada. Assembly Bill 170 was the result of more than 4 years of evolution and planning fraught with false starts, changing demographics, and an increasing need for access to healthcare in Nevada. A review of the literature provided the initial groundwork to build a coalition and establish a framework to make this statute change. In 2009, Hawai’i passed

Act 169 to increase access to care, recognizing advanced practice registered nurses (APRN) as primary healthcare providers and removing barriers to full practice authority for APRNs (Mathews, Boland, & Stanton, 2010). Engaging key stakeholders, accessing grassroots coalitions, and addressing community needs were important components of this successful change. Kaplan (2013) describes how grassroots support can make a difference in legislative action when APRNs are involved. Kaplan also recognizes the value of engaged citizen lobbyists as a critical component to achieve success. In 2011, North Dakota became the first state to fully align with the APRN Consensus Model, demonstrating a successful collaborative effort between the North Dakota Board of Nursing and North Dakota Nurse Practitioner Association (Madler, Kalanek, & Rising, 2012). The legislative approach described in their paper provided insight into the importance of identifying a champion in the legislature and building a multifaceted coalition. While

C 2014 The Author(s) Journal of the American Association of Nurse Practitioners 26 (2014) 309–313 

 C 2014 American Association of Nurse Practitioners


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useful information to build upon, Nevada presents unique challenges related to our transient population and our biannual 45-day legislative sessions. Nevada’s State Board of Nursing first recognized NPs in 1979, granting certificates of recognition (Nevada State Board of Nursing, 2013). Shortly after, in 1983, 14 NPs came together as the first NP-focused group, known as the “Special Interest Group (SIG) for Advanced Practitioners of Nursing.” Nevada NPs were members of the SIG for the next 28 years, remaining under the umbrella of the state nursing association. In December 2011, Nevada’s advance practice nurses (APNs) voted to separate from the state nursing organization and create a new NP-focused organization, the Nevada Advanced Practice Nurses Association (NAPNA). One of the many reasons for this change was the belief that the goal of full practice authority needed to be driven by the NPs of Nevada. Currently, NAPNA represents more than 250 NPs across the state with a primary mission of supporting Nevada’s NPs through healthcare policy development, legislative support, and professional education.

Rationale for autonomy in Nevada Nevada’s geography presents challenges in providing healthcare. More than 90% of Nevada’s population is concentrated in and around the urban centers of Las Vegas and Reno—more than 400 miles apart, with the remainder distributed across vast rural areas (USDA Economic Research Service, 2013). Nevada has long suffered a shortage of healthcare providers, ranking 48th in physician–patient ratios and 51st in nursing–patient ratios (Health Care in Nevada, Rankings and Statistics, December 2012). Nevada has 284 identified health professional shortage areas in primary care across both rural and urban areas (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2013). With the full implementation of the Affordable Care Act (ACA) in January 2014, it is predicted more than 20% of Nevada’s 2.7 million person population will require access to primary care, further straining a state where demand has already exceeded supply (U.S. Department of Health and Human Services, 2013). Chronic shortages in primary health care providers often results in an inability to obtain appointments for routine visits, and use of expensive emergency care services for minor problems. This results in an increasing acuity where chronic illnesses are inadequately managed and the opportunity for prevention or early intervention has been missed. This has been particularly problematic in the rural areas of Nevada, where the shortage of primary care providers is more acute. 310

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Prior to the recent statute change, to gain a certificate of recognition to practice, Nevada NPs were required to have a signed collaborative agreement with a physician. This collaborative agreement required the following: 1. A signed statement of competency by a physician. 2. Detailed protocols describing the current practice setting, type of practice, and outline of the practice agreement reflecting the customary standards of the medical specialty. 3. A list of medications, diagnostics, and services that the NP could provide. 4. Statement of an ongoing collaborative relationship between the NP and the physician. Collaborative agreements often required a financial arrangement, with physicians at times charging significant fees for those services. For those NPs living in remote areas, securing physician collaboration was often difficult regardless of the financial arrangement.

The road to full practice authority The road to full practice authority in Nevada encompasses the following areas: 1. Set priorities—keep it simple. 2. Secure a legislative champion. 3. Acquire a representative “on the ground”—hire a lobbyist. 4. Seek external support and guidance with national organizations. 5. Form a working group of NP leadership. Selecting limited targets for the legislative session was a priority before proceeding. Many members had priorities and the list of legislative concerns was extensive. Initially our sole focus was full practice authority, but it soon became evident we would need to include two other important statute changes to bring Nevada into the APRN consensus model (National Council of State Boards of Nursing [NCSBN], 2008). The final drafts of AB170 would include not only full practice authority but also a title change from APN to APRN and a change from “certificate of recognition” to “license to practice.” These additions to AB170 met the goal of bringing Nevada into compliance with the APRN consensus model as sanctioned by the Nevada State Board of Nursing and National Council of State Boards of Nursing. As part of determining initial priorities, the working group set up meetings with the Executive Director of Nevada State Board of Nursing to get feedback on our legislative agenda. Prior to writing proposed language changes, it was important to understand the role of the Board of Nursing (BON), and how proposed changes

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would impact nursing regulation. NAPNA presented formally to the BON at two regularly scheduled meetings prior to the legislative session: first, to formally introduce our new organization, and second, to discuss our intention to seek statute changes effecting advanced practice nursing in Nevada. Our working group maintained regular contact with the executive director who kept the board informed of changes, language proposals, and events as the session evolved. During the session, the positive and collegial relationship formed early on was invaluable as the bill progressed and amendments were made. The BON is a trusted regulatory board in Nevada and their strong alliance with other agencies was key when questions arose from the individual legislators to the governor. Securing champions in both of Nevada’s legislative houses was the single most important task after forming the working group of NP leaders in this campaign. Our legislative sponsors were invaluable as experts in law and statute matters, providing access to research services, and facilitating introductions to other agencies and interested parties that may not have been previously accessible. Recognizing that the outcomes of elections are never certain, a bill draft was submitted by our senate sponsor prior to her heavily contested race. Regrettably our senate representative was not reelected to office, so this became somewhat problematic. While this senate bill was not the one ultimately passed, it served to secure a placeholder in the upcoming legislative session. As the bill was then already securely positioned, the NPs were able to open a dialogue with incoming senators. Meanwhile, our champion in the assembly had a long history of supporting access to care issues and as a senior member was positioned to submit a similar bill simultaneously. Hiring a lobbyist to represent Nevada’s NPs was also part of our success. This seemingly simple task turned out to be quite difficult to accomplish as NP practice issues are frequently politically sensitive, and this representation comes with a heavy load. Our lobbyist is well connected and well regarded, and although Nevada NPs were his first health care client, he worked effectively with our assembly sponsor, who carried the bill to the floor. Benefitting our goal, the lobbyist and legislator knew each other well and had worked together previously. Our job as the NP work group was to educate both parties on the role of the NP, and the needs and goals of Nevada NPs. Working with national organizations, we were able to develop important networking connections with other professionals who had allied interests. Over this legislative journey, we gained the support of the American Association of Nurse Practitioners, American Association of Retired Persons (AARP), the Citizens Advocacy Center, the National Council of State Boards of Nursing, and

Table 1 History of APRN practice in Nevada Date September 28, 1979 June 1991 May 2001 May 2011 June 3, 2013 July 1, 2013

Event First APN certificate issued in Nevada Prescription privileges for APNs in Nevada Drug Enforcement Agency (DEA) prescribing privileges granted National certification required June 1, 2014 Full practice authority, APRN, licensure signed into law AB170 - Full practice authority in effect

the Future of Nursing Campaign, among others. At the state level, we worked with state nursing organizations, the Alzheimer’s Association, various insurance carriers, health care providers in various disciplines, and educators. Each of these relationships added to a cumulative group of stakeholders to see through the changes during the legislative session. To form an effective team, we identified roles and assigned contact targets to each member of the NP working group. The member with the closest physical proximity to the legislature worked most closely with the legislator and lobbyist; other team members divided work among national and local organizations, providing fixed contact points and consistent follow through with rapid turnaround. This proved critical as relationships with the national stakeholders were developed. Two team members did the majority of the writing and research, with assistance by others when necessary. Maintaining communication and assigned roles allowed for rapid turnaround of talking points and information management, critical when the legislative session lasts only 120 days.

The final process The journey to full practice authority began years ago with efforts in securing prescriptive authority (1991), controlled substance privileges (2001), and initial steps in implementing goals of the APRN consensus model (NCSBN, 2008; Table 1). The 2011 legislative session saw the adoption of a national certification requirement for Nevada’s NPs, going into effect June 1, 2014. See the attached timeline (Table 1) for a more complete breakdown. The 2011 legislature did see a bill draft request (BDR) submitted for full practice authority, but this was subsequently withdrawn prior to start of the session. At this point, a small group of NP leaders decided to set sights on the 2013 session, and preparations started. Key leaders began discussions with legislators who had been favorable to nursing and NP issues in previous sessions. In mid2011, small workgroups were assembled to brainstorm 311

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Table 2 Assembly Bill 170 timeline Date December 2011 January 2012 March 2012

June 2012 July 2012 November 2012 December 2012 January 2013 February 2013 April 2013

May 2013

June 2013 July 2013

Event NAPNA established Workgroups established Networking with legislators, government agencies, local and national healthcare organizations Meeting with national AANP leaders Lobbyist hired BDR filed (Senate Bill 69) Weekly workgroup phone conferences begin BDR filed in the assembly (AB170) SB 69 and AB170 heard in committee (same day) AB170 passes in committee with amendments; passes out of assembly (36 yea, 4 nay), moves to senate committee; SB 69 times out of committee and dies AB170 heard in senate committee; passes out of committee with amendments to senate floor; passes in senate (14 yea, 7 nay—constitutional majority); to Governor’s office Signed by Governor on June 3 On July 1, 2013 AB170 enacted into law

and create a coalition of supporters within community, state, and national organizations. A summary timeline of the genesis of AB170 is outlined in Table 2 illustrating the major highlights of this process.

Key lessons learned Stay on message Identify your objective early. Keep it simple, straightforward and use language people can understand. Create the message about the objective, steering conversation back to the message. Allowing extraneous discussion will cloud the issues and dilute the message. Our message was about improving access to care. The importance of this singular message was conveyed to our membership and continually reinforced in e-mail and written literature.

Make yourself memorable Letter writing campaigns proved critical in making our voices heard. Legislators shared they were flooded with letters by NPs. Personal letters sharing stories made the most impact; legislators generally disregard “form” letters. Our membership and community supporters were an amazing resource when we needed them to contact legislators to provide support. Initially calls for support from the membership required great effort by leadership, but as progress was made members became eager to write letters, call legislators, and attend hearings. When time 312

was short and support critical, we did not rely on e-mail as much as personalized telephone calls. While many efforts have focused on e-mail campaigns, it is important to recognize that e-mails can be inappropriately shared and disseminated to unwelcome recipients.

Communication is critical It became evident early on the single most important aspect of this work was managing communication. Rumors could spread quickly, and did at times. Managing communication was essential in maintaining momentum and engagement of the NP community. At times, individual members took up efforts on their own; quick communication was necessary to work with them on our common goals and misinformation addressed before it derailed our efforts.

Keep your eye on the ball The Nevada legislature meets biannually; the session is 120 days in length. There are deadlines for committees, houses, and passage of bills along the continuum of these 120 days. The process is predictable and moves at its own pace, regardless of the energy and momentum a bill might bring. It is easy to lose site of the main objective and get caught in small details. Rumors, fatigue, untruths, and loss of interest are a few of the pitfalls in this legislative marathon. Leaders must keep efforts focused on the end goal, adjusting the path as needed. The importance of being goal-oriented and goal-driven cannot be underscored with enough emphasis. There were many times when a lull in the activity occurred, to be suddenly followed by hours of frenetic work managing rapidly changing situations. Take advantage of the lulls to refocus, refine and redirect, to ensure you are staying on target.

Setbacks, trials, and tribulations In the work leading up to and during the session, unexpected setbacks appeared, and then disappeared just as quickly. One group focused their opposition around the potential of narcotic abuse; this became a topic of discussion throughout the entire session at various times, stating full practice authority for NPs would only exacerbate current prescriptive problems. We addressed this by emphasizing that prescription of scheduled medications has been in the scope of the Nevada NP for over 10 years without incident. Scope of practice was a constant topic of discussion and misinformation; the bill was repeatedly interpreted as an increase or change in scope of practice. Clarification and assurances by the bill sponsor, and

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others, did not always quell the repeated misinterpretation of this topic. At times misinformation would have a life of its own, driven by the opposition even in the face of blatant fiction. During the legislative process, it became evident early on that these changes would be hard fought, and resistance would be maintained to the last minute. Before the last 2 weeks of the session, only nine bills out of the hundreds heard during the session had made it to the governor’s desk for signature. Many ran out of time on the calendar, others were voted down. Assembly Bill 170 survived, moving through the deadlines, stall tactics, and votes. This required stamina and determination by the team leading the effort. The working group shared a constant stream of communication, relying on each other to keep looking forward, fill a gap, address a question, write a talking point, and do what was required to keep moving forward.

Expect the unexpected Among the unexpected events was having an NP colleague testify against herself and her profession on behalf of physicians, at the initial hearings. This single event surprised the majority of NPs and turned the lack of engagement of many members into a tremendous moment of support by engaging them in activities such as letter writing and calls to legislators. We experienced the unexpected assistance of a community organization interested in our bill; they had already made plans to support us by way of testimony at the first hearings. This powerful group’s interest was a win for our bill, providing very credible testimony by a high-profile physician, patients, NPs, and a former legislator. The networking provided many open doors to other potential supporters not necessarily in healthcare, stirring interest in passage of our bill.

The opposition playbook The working group relied on many sources to keep us updated on the opposition’s point of view. Other states that had been down this road were invaluable in providing specific talking points, addressing legislative concerns, and preparing us for testimony. Additionally, local supporters alerted us to opposing talking points and letter writing campaigns that often presented negative and false information about NP practice. They included the usual concerns about NP educational preparation, hours of clinical practicum, scope of practice, and the importance of not disrupting the “physician-led team.”

Scope of practice was frequently used loosely in conversation and can easily confuse a person who is not sure of the definition. The use of clear language and understanding of current scope of practice, which could be easily conveyed, was important in neutralizing negative misinformation. Preparing our legislative allies was of vital importance in hearings as they could also convey the same message in testimony, providing a consistency in correct information.

Implications for NPs Nurse practitioners are on the front line of primary care in the United States. In the changing landscape of implementation of the ACA, NPs are well positioned to provide safe, appropriate care for all patients. The Institute of Medicine (2010) report on the future of nursing stresses the importance of nursing in moving healthcare forward during these turbulent times. Nursing, as the largest profession in healthcare, and NPs stand uniquely positioned to effect change. Empowering states to change outdated practice laws, which serve to reduce access to care, is a necessary part of this change. Nurses are advocates for patients, from the bedside to Congress, and the changes affected by ACA necessitate our involvement. Reforming laws and improving access to care are critical as NPs move to effect positive change in our transitioning healthcare system.

References Institute of Medicine. (2010). The future of nursing: Leading change – Advancing health. Retrieved from Kaplan, L. (2013). Making a difference through grassroots legislative action. Nurse Practitioner, 38(9), 8–9. Madler, B., Kalenek, C. B., & Rising, C. (2012). An incremental regulatory approach to implementing the APRN consensus model. Journal of Nursing Regulation, 3(2), 11–15. Mathews, B. P., Boland, M. G., & Stanton, B. K. (2010). Removing barriers to APRN practice in the state of Hawai’i. Policy, Politics, and Nursing Practice, 11(4), 260–265. National Council of State Boards of Nursing. (2008). Consensus model for APRN regulation: Licensure accreditation, certification & education. Retrieved from Model for APRN Regulation July 2008. pdf Nevada State Board of Nursing. (2013). Nursing facts. Historical perspective of the Nevada State Board of Nursing. Reno, NV: Author. U.S. Department of Health and Human Services. (2013). Facts & features, state by state: How the health care law is making a difference for the people of Nevada. Retrieved from U.S. Department of Health and Human Services, Health Resources and Services Administration. (2013). Health professional shortage areas. Retrieved from USDA Economic Research Service. (2013). State fact sheets: Nevada. Retrieved from


Full practice authority--effecting change and improving access to care: the Nevada journey.

In 2013, Nevada shifted from a collaborative practice model to full practice authority. Given the challenges many states still face, this article prov...
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