When nurses in Virginia decided to lobby for fewer restrictions on nurse practitioners (NP), they knew any changes to the existing law would require a hard-fought battle with physician groups and legislators opposed to expanding nursing practice authority.

Home to one of the oldest legislatures in the western hemisphere, the state leaned more conservative. The Medical Society of Virginia had a significant influence in the political arena and would resist changes to the current law, which required NPs to have collaborative agreements with physicians to practice.

Cynthia Fagan, DNP, RN, FNP-BC

Cynthia Fagan, DNP, RN, FNP-BC

In 2018, the Virginia Council of Nurse Practitioners worked with lawmakers to introduce a bill that would allow NPs to practice independently after 1,040 hours — the equivalent of six months — of collaboration with a physician.

The council expected to negotiate with physician lobbyists, and nurse practitioners were willing to increase the number to 3,000 hours of collaboration. But in the eleventh hour a subcommittee chair introduced a substitute bill with a requirement for 9,000 hours — or five years — of collaboration.

"I think the medical association thought we would reject this bill, but the change would still allow about 50% of the nurses in the state to become autonomous because they had been practicing for more than five years," said Cynthia Fagan, DNP, RN, FNP-BC, government relations chair for the Virginia Council of Nurse Practitioners. "We decided to support the bill."

Although Virginia is the only state that requires nurse practitioners to collaborate with a physician for 9,000 hours before working independently, Fagan considers the new law a victory for two reasons.

  1.  NPs can eventually transition to practice independently.
  2. Legislators struck a stipulation on the substitute bill dictating only NPs certified in the area of the collaborating physician specialty could transition to obtain autonomous practice. The change would have discounted hours for many nurses, Fagan said.

National progress on practice authority

Virginia is now one of 22 states where nurse practitioners can practice independently, and one of 10 states that have removed restrictions on NPs in the past 10 years. DC, Guam and American Samoa also have full practice authority.

Expanding NP practice authority became a high priority nationally in 2010 when the Institute of Medicine issued a report with eight recommendations to improve healthcare in the United States. One of the recommendations focused on increasing access to care by allowing nurses to practice to the full extent of their education and training.

In states that have lifted restrictions on nurse practitioners, nurses have learned from both successes and failures about how to influence policy decisions.

In Virginia, one of the keys to success was finding a legislator who could champion the changes. Roxann Robinson, a Republican in the Virginia House of Delegates, was ideal for this role because she was an optometrist who had faced similar challenges with ophthalmologists, Fagan said.

Volunteer leaders like Fagan also realized juggling advocacy work with full-time jobs was limiting their effectiveness, and the Virginia Council of Nurse Practitioners hired a full-time executive director in 2017 who could dedicate more time to the effort.

The organization also started offering webinars and other forms of training to teach members how to get involved in advocacy efforts. Nurses started learning how to interact with legislators and write letters to these influencers, and 200,000 nurses wrote letters to the governor describing the drawbacks of the medical association's proposed restrictions on who could qualify as a physician collaborator.

Fagan believes these letters helped influence the governor's decision to reject these restrictions.

Gaining public support for full practice authority

In 2016, nurse practitioners in West Virginia gained the right to full practice authority after three years of collaboration with a physician, and NPs worked with the legislature for years to achieve this change.

"Even though nurse practitioners had accurate data and evidence to support the change, for a long time this did not seem to matter," said Aila Accad, MSN, RN, executive director of the Future of Nursing West Virginia Action Coalition. "The physicians had more political support."

full practice authority

Aila Accad, MSN, RN

Then AARP agreed to work with West Virginia nurses to lobby for the proposed bill, and the organization turned to the public to garner support. Organizations like West Virginians for Affordable Healthcare, the West Virginia Council of Churches and the West Virginia National Association of Social Workers joined a bipartisan collaborative to advocate for the bill.

"Once it was evident to legislators that the bill had wide support, they passed it," Accad said.

In Pennsylvania, the state's Senate recently backed a bill allowing nurse practitioners to practice independently after serving a three-year, 3,600-hour collaboration agreement with a physician.

But the bill has stalled in the Professional Licensure Committee for the last two years, which prevents the legislation from moving to the House of Representatives, said Cheryl Fattibene, DNP, MSN, MPH, CRNP, chief nurse practitioner officer for the National Nurse-Led Care Consortium.

"We already know we have the votes we need to pass the bill in the House, but it's never moved beyond the committee," Fattibene said.

She knows there are political forces at work that may be preventing the bill from moving forward, but there is reason for hope — a new legislator will lead the Professional Licensure Committee next year, she said.

For nurses who are working in states that have not passed practice authority legislation, joining a national organization such as the American Association of Nurse Practitioners is an important first step for advancing change, Fattibene said.

"Nurses can learn what is going on in other states and access people who can be sources of support for this work," she said.

Although it's tempting to stay busy with the daily work of treating patients, she urges nurses to take the time to educate both physicians and lawmakers about the issues involved. When she testified before a House committee two years ago about the benefits of full practice authority, the questions from legislators were revealing.

"I was amazed by their lack of knowledge about our scope of practice," Fattibene said. "Laws are often being made by people who are uninformed about what we do, and nurses need to use their voices to teach people about the difference they can make in healthcare."

Take these courses related to full practice authority:

Protect Yourself: Know Your Nurse Practice Act
(1 contact hr)
Nurses have an obligation to keep abreast of current issues related to the regulation of the practice of nursing not only in their respective states but also across the nation, especially when their nursing practice crosses state borders. Because the practice of nursing is a right granted by a state to protect those who need nursing care, nurses have a duty to patients to practice in a safe, competent, and responsible manner. This requires nurse licensees to practice in conformity with their state statutes and regulations. This course outlines information about nurse practice acts and how they affect nursing practice.

Advanced Practice Nurse Pharmacology
 (25 contact hrs)
This course will help advanced practice nurses meet the new ANCC 25-contact hour pharmacology requirement for re-certification beginning Jan. 1, 2014. Written and rigorously peer reviewed by pharmacists and advanced practice nurses, this course features a wide range of medical conditions and the medications associated with them. Chapter topics include hypertension, diuretics, GI, critical care, sexually transmitted diseases, asthma, oncology, non-opioid analgesics, diabetes, weight loss, mental health conditions such as anxiety, bipolar disorder, depression and much more. The chapters highlight clinical uses, dosing, interactions and adverse effects for the common medications used in your practice. APN tips are featured throughout the chapters to help you in your prescribing practices.

Team-Based Healthcare: Helping to Improve Patient Outcomes
 (1 contact hr)
Use of the interprofessional team approach has led to improved outcomes in some patient populations and disease states. Many different models exist and all can be adapted to fit specific population needs. As healthcare reimbursement continues to evolve, team-based approaches may be warranted to optimize patient care.

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