Running head: Addressing limited scope of practice

A Call for Action: Addressing Nurse Practitioners Limited Scope of Practice

Alicia Bolduc, Brandy Fischer, Becca Kahrs, Craig Keatley, Vivian Keller, Mishya Otis, Alice
Pearl
Florida State University: College of Nursing

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A Call for Action: Addressing Nurse Practitioners Limited Scope of Practice
Provisions of the Patient Protections and Affordable Care Act have allowed millions of
American citizens who previously were uninsured to access health insurance and health care
services resulting in an increased demand for primary care (Xue, Ye, Brewer, & Spetz, 2016). At
present, physicians, Advanced Practice Registered Nurse Practitioners (APRNs), and physician
assistants provide the majority of primary care services in our nation. The increasing demand for
health care providers and the continuing decline in the primary care physician workforce is
alarming (Poghosyan, Boyd, & Clarke, 2016). In contrast, the APRN workforce has been steadily
increasing and is projected to double within the next fifteen years. If utilized at the full range of
their educational preparation and competencies, APRNs are the key to meeting the increasing
demands for primary care services.
In Florida, APRNs have restricted practice. This obstacle negatively impacts a multitude
of factors including quality of health care. If APRNs are not utilized to the fullest extent of their
education, then higher health care costs, health care shortages, and poor patient outcomes will
ensue (Bartol, 2014). These highly trained nurses will move out of state to lower hospital
readmissions, improve health population outcomes, and decrease annual hospitalizations in other
locations where full scope of practice is embraced (Bartol, 2014). At large, it would be
advantageous to grant APRNs full scope of practice to meet our growing nations population
needs.
Background
The Institute of Medicine (IOM), in 2010, released The Future of Nursing: Leading
Change, Advancing Health report to address the role of nurses in an era of rapidly changing
health care settings and provide a call for action in removing barriers that hinder nurses from

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leading change and advancing health care (IOM, 2015). This report provided eight
recommendations, including the removal of scope of practice barriers (IOM, 2010 a). By
allowing APRNs to practice to the full extent of their education and training, rather than being
dictated by state laws, cost-effective and quality care can be delivered to all populations (IOM,
2015 b). In spite of advances in this area, barriers still exist resulting in state variability and interprofessional tensions. The rapidly evolving health care industry is shifting from acute and
specialty care to primary care, prevention and wellness, and prevention of adverse events. These
new models further push for expanded scopes of practice proving it is not a matter of if but when
all states will unify to grant nurse practitioners full scope of practice.
Stakeholders
In the issue of limited practice for nurse practitioners, there are numerous stakeholders to
be identified. The stakeholders include physicians, nurse practitioners, policy makers, third-party
payers, healthcare facilities, and patients (Buerhaus, DesRoches, Dittus, & Donelan, 2015). All
of the aforementioned stakeholders are directly affected, either positively, negatively, or both, by
the issue of limited practice for nurse practitioners.
With restricted practice, there are noticeable impacts to these stakeholders. Impacts such
as delayed patient care, continued strain on physicians, and increased costs to patients and thirdparty payers. According to Rigolosi and Salmond (2014), underutilizing nurse practitioners cost
the country about nine billion annually due to restricted practice laws because it is keeping the
cost of basic healthcare inflated. Patients are having to make more visits to practitioners offices
because patients are unable to receive all facets of care they may require due to the restricted
practice of nurse practitioners who are attempting to fill the gap in the shortage of primary care
physicians.

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Issue Alternative #1: Full Practice
The pressure to cut costs and the demand for primary care providers are the driving
factors for expanding the scope of practice. Medicare sets APRN payments at eighty-five percent
of the physicians fee schedule to cut costs (Iglehart, 2014). One study found that APRNs were
one and a half times more likely to practice in rural areas in states with full scope of practice
regulations compared to states with restrictive scope of practice (Xue et al., 2016). By
implementing full scope of practice authority, APRNs can improve access to care, especially in
rural areas.
Advance Practice Registered Nurses are key health care providers in addressing the poor
quality of healthcare in the United States. Studies have revealed that significantly improved
outcomes were found in states with full scope of practice APRNs in comparison with states
without full scope of practice (Bartol, 2014). Furthermore, these studies have revealed that states
with full scope of practice are correlated with lower hospital readmissions, lower avoidable
hospitalizations, better health outcomes, and decreased annual hospitalization of nursing home
patients (Bartol, 2014). With the large aging population in Florida and the number of nursing
home residences, expanding the scope of practice for APRNs is a safe and effective solution in
decreasing local annual hospital admissions.
The primary disadvantage of implementing full scope of practice for APRNs is the
concern with revenue for the physicians (Iglehart, 2014). Generally, in states with restricted
scope of practice, APRNs are required to bill under a physician and rendering the services as
incident to the physician (Iglehart, 2014). Physicians, then, receive Medicares full fee as
though they had personally performed the service (Iglehart, 2014). In states with full scope of

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practice, APRNs are not required to bill under a physician rather have the authority to bill
directly for their services (Iglehart, 2014).
Issue Alternative #2: Lifting Physician Based Protocols
In the event that full scope of practice rights for APRNs is not passed by the legislature,
another approach for change is incrementalism. Incrementalism is the changing of existing
policies through small steps to allow for economic and social systems to adjust to change
(Longest, 2016). The removal of physician based protocols for APRNs will allow the path to
open towards a more autonomous and refined practice. The relevancy of Nurse Practitioner's
Business Practice and Legal Guide stays current with the review of how physician based
protocols only cover a minimum level of safe practice (Buppert, 2007). Responsibilities of the
APRN, in physician based protocols, are to collect data from the patient and follow a specific
action plan from the protocol.
Abolishing physician based protocols will refine the scope of practice of the APRNs, by
implementing protocols founded on evidence based practice that will allow for the best
appropriate medical diagnosis and treatment, but also focus on holistic interventions (Archibald
& Fraser, 2013). It will also create a unification among all APRNs, which is a necessity for the
future of maintaining full practice rights. Role identification among APRNs are often
misunderstood related to multi-state conflicting statutes and oppositional views from medical
organizations (Ryan & Ebbert, 2013).
Disadvantages in the incrementalism approach for the relinquishment of physician
protocols are timing with economy stability, budgetary concerns, and modifications to the policy
by lawmakers (Longest, 2016). An APRN is competent to practice medicine without the

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assistance of physician protocols. Approval of this policy change will bring a more holistic
approach to treatment plans and improve patient outcomes.

Issue Alternative #3: Global Signature Authority

Several studies demonstrated APRNs are well-positioned to deliver high-quality, safe and
equal care to patients when compared to primary care physicians (Naylor & Kurtzman, 2010).
However, in many states, APRNs are restricted to delivering efficient care because they are not
legally authorized to sign the paperwork related to the care they have provided (AANP, 2016).
This is also known as global signature authority and can include signing death certificates,
advanced directives, and worker's compensation forms (AANP, 2016). Global signature authority
also gives APRNs the right to sign all health designated forms, including stamp, verification,
certification, affidavit or any endorsement that are necessary to patients care, as long as it is
within their scope of practice.
There are many advantages regarding APRNs having global signature authority. It would
address barriers to an effective and integrated care and reduce healthcare costs. Signature
recognition would allow APRNs to deliver a responsible and transparent patient-centered care.
Patients would receive an efficient, timely and high quality care where their needs, including
necessary paperwork, could be addressed by one provider in one visit. It would also decrease
overall costs, by allowing better utilization of APRNs and potentially freeing up primary care
physicians to care for more complex patients (Yee et al, 2013).
Signature authority for APRNs may be considered a disadvantage by some stakeholders.
According to the National Council of State Board of Nursing (2009), in the process of reaching
full scope of practice, one healthcare profession might view the autonomy gained by APRNs as

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an intrusion or an economic threat into their own area of practice. However, there are numerous
researched evidences that do not support these claims.
Recommendations
For positive patient outcomes with the increasing need for primary health care workers, it
is essential to have Nurse Practitioners be able to utilize their full scope of practice (IOM, 2015
b). Full scope of practice authority would allow nurse practitioners and physicians to spend less
time complying with the state of practice requirements and more time on patient care (Martsolf,
Auerbach, & Arifkhanova, 2015). The physician protocols and restricting the nurse practitioners
full scope of practice hurts productivity, cost, and ultimately the patients seeking care. Studies
have consistently shown retail clinic costs are highest in states with the most restrictive practice
environments (Spetz, Parente, Town, & Bazarko, 2013). Interprofessional collaboration needs to
take place to generate positive patient outcomes, cost effectiveness, and to fulfill a national need
for primary health care services.

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References
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Appendix
Scorecard Analysis