Restricted Practice for Advanced Practice Nurses (APNs)

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Virginia regulations for advanced practice nurses (APNs) involve restricted practice for nurse practitioners (NP), midwives, nurse anesthetists, and clinical nurse specialists (CNS). The restriction to full practice is a barrier to all APNs as they cannot practice at the highest level of education and training received. In addition, regulations governing advanced nurse practice roles involve the Board of Medicine and the Board of Nursing (Virginia Board of Nursing & Virginia Board of Medicine, 2022). Additional oversight by the Board of Medicine has undeniably added to the continued burden of practicing with physician supervision and delaying increased access to care in rural and impoverished communities that full practice would allow.


NPs must have an active practice agreement with a physician for five years before applying for autonomous practice, while CNS must continue to practice with ongoing supervision. (Virginia Board of Nursing & Virginia Board of Medicine, 2022). Certified nurse midwives (CNM) must have documented 1,000 hours of clinical practice and a practice agreement with another medical provider before applying for autonomous practice (Virginia Board of Nursing & Virginia Board of Medicine, 2022). In addition, nurse anesthetists must continue to render care under the supervision of a medical doctor (Virginia Board of Nursing & Virginia Board of Medicine, 2022). Applying for autonomous practice and prescriptive authority for nurse practitioners requires an additional payment of 135 dollars and the ongoing cost of renewing licensure biennially and maintaining national certification. The burden of maintaining licensure, applying for autonomous practice, and prescriptive authority while navigating the rapidly changing healthcare environment has created more obstacles for advanced practice nurses on a state and national level.


Physician organizations are one of the largest competitors on the state and national level that interfere with an APN's ability to practice independently. Organizations like the American Medical Association (AMA) actively fight against the scope-of-practice expansion for all non-physician practitioners. In May 2023, the AMA proudly announced the defeat of eleven scope-of-practice laws in Mississippi, four bills in Indiana, one in Georgia, and one in South Dakota (American Medical Association, 2023). In addition, the AMA is challenging proposed federal bills to expand scope-of-practice for NPs, physician assistants (PAs), and pharmacists (American Medical Association, 2023). Organizations such as the AMA have vast resources and lobby against APNs' ability to practice independently, firmly believing that reducing practice restrictions puts patients in harm's way.


Conversely, the American Association of Nurse Practitioners (AANP)is advocating for the expansion to full practice across the United States on a national and federal level. In direct opposition to the AMA, there is a call for the Improving Care and Access Act (ICAN) which would allow NPs to have the authority to independently manage care in long-term facilities and have the rights to admit Medicare and Medicaid recipients into any hospital (American Association of Nurse Practitioners, 2023). This is significant as NPs, and PAs comprise one-third of primary care providers in the United States and provide up to 40% of billable services for Medicare patients (American Association of Nurse Practitioners, 2023).


In Virginia, the General Assembly is the legislative branch of representatives or delegates from districts across the state (Virginia State Government, n.d.). The legislative branch consists of the House and Senate. The House of Delegates is presided over by the House speaker, Todd Gilbert, while the Senate is presided over by the Lieutenant Governor, Winsome Earle-Sears (Virginia State Government, n.d.). The lieutenant governor has no current term limits, but the Governor may not run for two consecutive terms (Virginia State Government, n.d.). The current Governor of Virginia is Glenn Youngkin. The executive branch of the state of Virginia is a combination of the Governor, Lieutenant Governor, and Attorney General- Jason Miyares (Virginia State Government, n.d.).



Physician groups, Nurse Practitioner groups, insurance companies, and other health groups spend excessive money each year to hire lobbyists at the state and local levels to influence politics. According to a recent analysis, 713.6 million dollars was spent in 2020 in the United States to lobby state and federal groups (Schpero et al., 2022). Lobbyists are hired to influence the legislative process in favor of the organizations that hire them. Another practice that borders on bribery is actively contributing to the campaign of a member of Congress to favor a proposed bill. Sponsors are needed to support legislation, yet doing so involves money, power, and influence to pass legislation (Buppert, 2018).



References



American Association of Nurse Practitioners. (2023). The Improving Care and Access to Nurses (ICAN) Act. https://www(dot)aanp(dot)org/advocacy/federal/federal-issue-briefs/ican-actLinks to an external site.



American Medical Association. (2023, May 15). Ama successfully fights scope of practice expansions that threaten patient safety. https://www(dot)ama-assn(dot)org/practice-management/scope-practice/ama-successfully-fights-scope-practice-expansions-threatenLinks to an external site.



Buppert, C. (2017). Nurse practitioner's business practice & legal guide (6th ed.). Jones & Bartlett.



Schpero, W. L., Wiener, T., Carter, S., & Chatterjee, P. (2022). Lobbying expenditures in the us health care sector, 2000-2020. JAMA Health Forum, 3(10), e223801. https://doi(dot)org/10.1001/jamahealthforum.2022.3801Links to an external site.



Virginia Board of Nursing & Virginia Board of Medicine. (February 2, 2022). Regulations Governing the Licensure of Nurse Practitioners (18 VAC 90-30-10) [Title of Regulations]. Commonwealth of Virginia. http://www(dot)dhp(dot)virginia(dot)gov/media/dhpweb/docs/nursing/leg/NursePract.pdfLinks to an external site.



Virginia State Government. (n.d.). Virginia government. https://www(dot)virginia(dot)gov/state-government/Links to an external site.