State responses to COVID-19: Potential benefits of continuing full practice authority for primary care nurse practitioners.

BACKGROUND: During the COVID-19 pandemic, federal and state governments removed the scope of practice restrictions on nurse practitioners (NPs), allowing them to deliver care to patients without restrictions. PURPOSE: To support policy makers' efforts to grant full practice authority to NPs beyond the COVID-19 pandemic, this manuscript summarizes the existing evidence on the benefits of permanently removing state-level scope of practice barriers and outline recommendations for policy, practice, and research. METHODS: We have conducted a thorough review of the existing literature. FINDINGS: NP full scope of practice improves access and quality of care and leads to better patient outcomes. It also has the potential to reduce health care cost. DISCUSSION: The changes to support full practice authority enacted to address COVID-19 are temporary. NP full practice authority could be part of a longer-term plan to address healthcare inequities and deficiencies rather than merely a crisis measure.

Dual-eligible beneficiaries and inadequate access to primary care.

OBJECTIVES: To determine whether enough primary care providers are in close proximity to where dual-eligible beneficiaries live to provide the capacity needed for integrated care models. STUDY DESIGN: Secondary data analysis using dual-eligible enrollment data and health care workforce data. METHODS: We determined the density of dual-eligible beneficiaries per 1000 population in 2017 for each of 3142 US counties. County-level supply of primary care physicians (PCPs), primary care nurse practitioners, and physician assistants was determined. RESULTS: One-third of the 791 counties with the highest density of dual-eligible beneficiaries had PCP shortages. Counties with the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type were concentrated in Southeastern states. These areas also had some of the highest coronavirus disease 2019 outbreaks within their states. CONCLUSIONS: States in the Southeastern region of the United States with some of the most restrictive scope-of-practice laws have an inadequate supply of primary care providers to serve a high concentration of dual-eligible beneficiaries. The fragmented care of the dually eligible population leads to extremely high costs, prompting policy makers to consider integrated delivery models that emphasize primary care. However, primary care workforce shortages will be an enduring challenge without scope-of-practice reforms.

State policy change and organizational response: Expansion of nurse practitioner scope of practice regulations in New York State.

BACKGROUND: In January of 2015, New York (NY) implemented a new policy, Nurse Practitioners Modernization Act, which removed the required written practice agreement between physicians and experienced nurse practitioners (NPs). PURPOSE: We examined NP work environment in NY before (2012) and after (2018) the implementation of the new policy. METHODS: Cross-sectional survey data on work environments were collected from NPs in NY in 2012 and 2018. Work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire. In 2012, 278 and in 2018, 348 NPs completed the tool. Regression analyses were used to examine the relationship between the study year and work environment. FINDINGS: Controlling for individual and organizational characteristics, NPs reported significantly better work environments in 2018. Positive changes were observed both for experienced and less experienced NPs. DISCUSSION: Removing state-level policy restrictions on NPs may promote a better work environment within health care organizations.

"The Future of Nursing: Accelerating gains made to address the continuum of substance use".

PURPOSE: Guided by four key messages from the decade-old Institute of Medicine (IOM) report, "The Future of Nursing," this paper highlights the progress made by the nursing profession in addressing substance use and its related disorders and offers recommendations to sustain and advance efforts to enhance care for persons who use substances, one of the most stigmatized and vulnerable populations. RESULTS: Patterns of substance use have shifted over the past 10 years, but the associated harms remain consequential. As awareness of the continuum of substance use has expanded, the care of persons with substance use has also expanded, from the domains of psychiatric-mental health and addictions nursing specialties to the mainstream of nursing. Now, greater efforts are being undertaken to identify and intervene with persons at risk for and experiencing substance use disorders. Nurses have advanced the knowledge and skills necessary for substance-related nursing care including education and training, leadership, care innovations, and workforce expansion and can drive efforts to increase public knowledge about the health risks associated with substance use. Recommendations aligned with each of the four IOM key messages are offered. CONCLUSIONS: As a profession, nursing has a responsibility to expand the progress made in addressing substance use - from prevention and early intervention to tertiary care. Nurses at all levels of education and practice are in key positions to carry out the recommendations herein to accelerate the changes needed to provide high quality care for persons impacted by substance use.

Psychiatric-mental health nursing workforce in 2018: Implications for the future.

The workforce was examined using the 2018 National Sample Survey of Registered Nurses to determine supply characteristics and perspectives of psychiatric-mental health nurses. The study looked at the success in achieving some of the workforce related recommendations of the Future of Nursing. A strong foundation exists for increasing the contributions of psychiatric-mental health nursing to overcoming shortages of mental health professionals and to improving access to mental health care. More work needs to be done to remove regulatory barriers to promote practicing to the extent of knowledge, education and training. Overall, the psychiatric-mental health nursing workforce is primed for the future.

Effect of state regulatory environments on advanced psychiatric nursing practice.

The first key message in the landmark Future of Nursing report is that "Nurses should practice to the full extent of their education and training" (Institute of Medicine, 2011). Although there has been significant progress across states to remove or diminish barriers to the exercise of full scope of practice by advanced practice registered nurses (APRN), state regulations continue to unnecessarily restrict APRN practice in most of the United States. This article integrates data from studies that examine how state and local regulation affects psychiatric mental health APRN practice with the literature on how state scope of practice regulation affects the size and distribution of the broader APRN workforce, access to care, health care costs and prices, and innovation in health care service delivery. Common themes include confusion about regulatory requirements and mixed experiences of mandated physician supervision.

Where are we now? Practice-level utilization of nurse practitioners in comparison with state-level regulations.

BACKGROUND AND PURPOSE: Full practice authority for nurse practitioners (NPs) is optimal for high-quality, cost-effective health care. However, a complete picture of utilization after states have adopted full practice authority needs to be determined. The purpose of this examination was to review the evidence regarding practice-level utilization (PLU) of NP PLU in comparison to state-level regulations (SLRs). METHODS: Studies published in English and based on US populations were identified through PubMed, CINAHL, and Scopus (January 1, 1989-December 31, 2018), and bibliographies of retrieved articles. Of the 419 articles identified with these limits, 19 (5%) met all inclusion and exclusion criteria. CONCLUSIONS: Four categories of PLU were identified: billing practices, level of supervision, privileges, and prescriptive authority. Significant differences were seen between urban versus rural NPs and primary care versus specialty NPs. Thirteen of the 19 studies did not specifically address the SLR of the included sample. IMPLICATIONS FOR PRACTICE: No studies described the type of NP certification, practice specialty, and utilization, and compared all to the SLR. There is a need for more evidence concerning PLU of NPs across the tiers of SLR. Only then can health care organizations, political leaders, and other stakeholders have the information needed to proceed with beneficial practice-model changes.

The Distribution of Advanced Practice Nurses Within the Psychiatric Workforce.

OBJECTIVE: To examine the size and distribution of the advanced practice psychiatric nurse workforce relative to the total psychiatry workforce to determine whether nurses are predominantly working in areas with higher or lower levels of behavioral health specialists. METHODS: State-level data for psychiatric nurses were obtained from the American Nurses Credentialing Center, and included mental health psychiatric nurse practitioners, adult psychiatric nurse practitioners, child psychiatric clinical nurse specialists, and adult psychiatric clinical nurse specialists. Supply estimates of the full psychiatry workforce were calculated for comparison purposes. State population estimates were obtained from U.S. Census Bureau data. State workforce estimates were converted to a 1:100,000 provider-to-population ratio to analyze the density of providers across states. RESULTS: In 2018, the psychiatric workforce supply was estimated to be composed of 66,740 providers, including psychiatrists (n = 47,046; 71%), psychiatric nurses (n = 17,534; 26%), physician assistants (n = 1,164; 2%), and psychiatric pharmacists (n = 966; 1%). Overall, psychiatric providers appeared to be most densely concentrated in the northeast region of the United States. A dearth of providers was most pronounced within areas in the 12-state Midwest region, southern states, California, and Nevada. The average concentration of psychiatric workers was 22.61 per 100,000 population. CONCLUSIONS: The findings of this study find inconsistent pattern of how psychiatric nurses are distributed relative to the rest of the workforce, but reinforce the idea that they are essential in addressing care needs in areas with low concentrations of psychiatry specialists-especially if they are authorized to work to the full extent of their training/education.

In Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven By Nurse Practitioners And Physician Assistants.

Few patients with opioid use disorder receive medication for addiction treatment. In 2017 the Comprehensive Addiction and Recovery Act enabled nurse practitioners (NPs) and physician assistants (PAs) to obtain federal waivers allowing them to prescribe buprenorphine, a key medication for opioid use disorder. The waiver expansion was intended to increase patients' access to opioid use treatment, which was particularly important for rural areas with few physicians. However, little is known about the adoption of these waivers by NPs or PAs in rural areas. Using federal data, we examined waiver adoption in rural areas and its association with scope-of-practice regulations, which set the extent to which NPs or PAs can prescribe medication. From 2016 to 2019 the number of waivered clinicians per 100,000 population in rural areas increased by 111 percent. NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents. In rural areas, broad scope-of-practice regulations were associated with twice as many waivered NPs per 100,000 population as restricted scopes of practice were. The rapid growth in the numbers of NPs and PAs with buprenorphine waivers is a promising development in improving access to addiction treatment in rural areas.

Nurse practitioner's independent prescriptive authority and opioids abuse.

This paper investigates the impact of legislative changes allowing nurse practitioners to prescribe schedule II controlled substances independently. We find that this legal environment is associated with an increase in treatment admissions for opioid misuse and a decrease in opioid related mortality only when Mandatory Prescription Drugs Monitoring Programs are in place.