The California Nursing Agency has approved rules that will allow nurse practitioners to treat patients without the supervision of a physician. It’s a move that aims to expand access to care in the Golden State at a time when labor shortages plague just about every corner of health care.
The vote earlier this month is one of the last big steps needed to fully implement a 2020 law that will allow nurse practitioners to practice more freely. Nurse practitioners, who have advanced degrees and training, currently must enter into a written agreement with a doctor who oversees their work with patients.
Despite some earlier concerns about potential delays, nurse practitioners say they are now confident applications to start the certification process will go live early in the new year as planned.
“I hope we don’t crash the website, but we’re very excited,” said Cynthia Jovanov, president of the California Association of Nurse Practitioners. “It means that if I want to do a mobile clinic in Skid Row, I don’t have to be held hostage by paperwork to find a partner doctor who may not have the same desire.”
Nurse practitioners are a cost-effective way to bring more primary care providers to communities that need them, especially in rural areas, said Glenn Melnick, a health economist at the University of Southern California.
“And that can benefit the consumer as long as the quality of care is acceptable,” he said. However, there are a limited number.
California nurse practitioners have been fighting for years to free themselves from the scrutiny of doctors. The biggest refusal came from the doctors. During the legislative debate, the California Medical Association said nurse practitioners had less training than doctors, so allowing them to practice independently could reduce the quality of care and even pose a risk to patients.
The law is not “carte blanche”
In 2020, Governor Gavin Newsom signed into law Assembly Bill 890, which was drafted by Assemblyman Jim Wood, a Democrat from Santa Rosa. To take full effect, the Board of Registered Nursing first had to work out the details, including how nurse practitioners would transition to their more independent role and what type of additional training or testing, if any, would be required. to get certified.
The act essentially created two new categories of nurse practitioners. Starting in January, nurse practitioners who have completed 4,600 hours or three years of full-time clinical practice in California can apply for the first category. This first step will allow them to work without contractual medical supervision, but only in certain establishments where at least one doctor or surgeon also practices. The idea is that nurse practitioners could always see a doctor when needed.
“So it doesn’t give them (nurse practitioners) the carte blanche that I think some people were afraid of,” said Loretta Melby, executive director of the state’s Board of Registered Nursing. “And then when they’re there for three years in that group setting with a doctor or a surgeon, only then can they move on to the (second category).”
This second designation will grant nurse practitioners full practice authority, with no restrictions of setting. And in theory, nurse practitioners could open their own medical practices. Given the phased approach, eligible nurse practitioners will likely achieve full independence around January 2026.
California’s requirements for nurse practitioners to transition to full independence will be among the strictest in the country, according to an analysis by the California Health Care Foundation.
Nurse practitioners can perform physical exams, order lab tests, diagnose illnesses and prescribe medications, but in California this had to be under the supervision of a physician. Of the 31,000 nurse practitioners in California, an estimated 20,000 will be eligible to apply for expanded authority in 2023, according to the California Association of Nurse Practitioners.
Kenny Chen, a family nurse practitioner in South-Central Los Angeles, exemplifies the kind of clinicians that researchers say California needs more of: he’s interested in primary care; he speaks several languages, including Spanish and his native Mandarin; and he enjoys working with underserved populations.
Chen said while he doesn’t expect major changes to his current role at the Martin Luther King, Jr. Outpatient Center, the new law would allow his clinic to hire more nurse practitioners without having to comply. physician-nurse practitioner ratios.
“It can be very difficult to recruit doctors to come and work in South Central Los Angeles,” Chen said.
Giving more authority to nurse practitioners, he said, may also attract more of them to California. All other western states, for example, already allow nurse practitioners greater independence. California’s restrictions could be a deterrent, he said.
Ahead of the vote, the California Medical Association sent a letter to the Board of Registered Nursing stating that the nursing board’s rules for transitioning nurse practitioners to their independent roles lacked clarity and did not provide more meaningful guidance than what was already indicated in the text of the law.
Melby, the nursing council’s chief executive, said she had also heard concerns that the law would broaden the scope of services that nurse practitioners can provide, but clarified that the law did not actually change the type of work nurse practitioners would do.
“What has been updated is the supervision requirement,” Melby said. “And so it’s not like the nurse practitioner is now going to have the freedom to go out and perform surgery; this has never been the scope of practice for a nurse practitioner.
New rules could increase access to healthcare
According to workforce researchers, allowing nurse practitioners more flexibility is a small but essential piece of the puzzle in easing California’s provider shortage.
Even before the pandemic, California was experiencing a shortage of medical providers. A 2019 report by a commission of health care experts estimated that by 2030 the state would need 4,100 additional primary care clinicians. According to the report, about 7 million Californians already live in areas with shortages of providers in need of primary, mental and dental care.
Rural counties tend to have the greatest shortages – in counties like Glenn, Trinity, San Benito and Imperial, more than 80% of people live without sufficient access to care. And when patients find care, they often rely on nurse practitioners. Some studies have shown that although physicians still make up the largest proportion of primary care providers in rural areas, nurse practitioners choose to work in rural settings at a faster pace.
Alexa Curtis, a family mental health and psychiatric nurse practitioner at a substance use disorder treatment center in Nevada County, said need in rural communities has driven most of her career. Curtis, who is also associate dean at the University of San Francisco’s School of Nursing, plans to develop a rural street medicine program focused on homeless people with mental health needs and addictions. substance use.
Once she gains greater authority, “I will be able to pursue this goal without the barrier and expense of having to find a supervising physician,” she said.
But working with other types of providers, including doctors, will always be part of his practice. “That’s how we are trained and how we operate as nurse practitioners,” she said.
Earlier this year, Newsom also signed into law Senate Bill 1375, which allows nurse practitioners to provide reproductive care and first-trimester abortions without a doctor’s supervision.
Both of these wins were huge for nurse practitioners, said Jovanov, chair of the nurse practitioner lobby. “I can tell you that this will lead to many more bills for regulations that need to change. We are on this momentum and it is really exciting.
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