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ANALYSIS FOR TRANSITIONING TO FPA 1

An Analysis of the Process of Nurse Practitioners Moving to Full Practice Authority and

Developmental Summary of Practice Implications to Assist Others in the Future

By

Lisa Woodley

A capstone project submitted to the faculty of

East Carolina University College of Nursing

In partial fulfillment of the requirements for the degree of

Doctor of Nursing Practice with concentration in

Adult Gerontology Primary Care Nurse Practitioner

Greenville, North Carolina, United States

2017


East Carolina University

College of Nursing

Doctor of Nursing Practice

Final Project Approval

Student Name: Lisa Woodley

Project Title: An Analysis of the Process of Nurse Practitioners Moving to Full Practice Authority and Developmental Summary of Practice Implications to Assist Others in the Future

Private Review Completed on: April 22, 2017

Public Presentation Completed on: April 13, 2017

Final Project/Final Paper Approval: April 27, 2017

As the Chair of this student’s Doctor of Nursing Practice Project Committee, I have reviewed and approved this student’s project and final paper and agree that he/she has met the project expectations, including the DNP Essentials, and has completed the project.

DNP Committee Chair Signature:

__Carol Ann King, DNP, MSN, FNP-BC, Clinical Associate Professor, ECU CONDate___4/27/2017___________________Dr. Carol Ann King, DNP, FNP-BC


Abstract

Nurse Practitioners (NPs) have assumed a progressively important role as primary care providers

for millions of Americans. Full practice authority (FPA) is the collection of state practice and

licensure laws that allow NPs to use their training to the fullest extent. The purpose of this

scholarly project is to explore the positives, barriers, or issues the preceding states and

Washington District of Columbia (DC) faced transitioning from restrictive or reduced practice to

FPA. An analysis, including key findings to assist with future transitioning will be provided. An

extensive search of white papers, reports, newspapers, blogs, and websites to gain information

for this subject was conducted. Personal interviews and communications with each of the FPA

states was sought through their advanced nurse practitioner association or their advanced practice

nursing council for more descriptive insight to each states experience. The results of this project

provide an effective model for transition for the remaining states without FPA.

Keywords: full practice authority, restrictive or reduced practice, transitioning


DEDICATION

This project is the culmination of a long journey that would not have been possible without the

love and support of my wonderful husband and loving family. Their sacrifices and

encouragement over the past few years and especially while working on this project has keep me

going.


ACKNOWLEDGEMENTS

I am grateful to many individuals of the nursing community from all across the nation who

shared their memories and experiences. My appreciation to the wonderful Advanced Practice

Nursing organizations that help to support and expanded my work by giving very generously

their time, hospitality, and wisdom. I must recognize as well the colleagues, preceptors, faculty,

librarians, and family for their support. I would like to express my gratitude to Dr. Nanette

Lavoie-Vaughan, Dr. Carol Ann King, and Dr. Sara Hubbell for their expert advice and

encouragement.


TABLE OF CONTENTS

CHAPTER1: Introduction 8

Introduction to the problem 8

Purpose 9

Background 9

Significance of the problem 10

Barriers to Full Practice Authority Transition 15

CHAPTER 2: Research Based Evidence 19

Theoretical Framework 19

Definition of Terms 19

CHAPTER 3: Methodology 20

Review of related literature 21

Project Design 21

Summary 22

CHAPTER 4: Results 22

Positives of Full Practice Authority 22

Hospital Privileges 23

Barriers 26

Common Themes 27


Other Considerations 32

Practice Implications/Key Findings 33

CHAPTER 5: Discussion 33

Recommendations for practice 33

Relate project results to theoretical/conceptual framework 35

Significance of results to healthcare and/or nursing 36

Special Interest 37

Overall Strengths and Limitations 38

Benefit of Project to Practice 39

Conclusion 40

REFERENCES 41

APPENDICES 48

Tools 49

Practice Implications 52


An Analysis of the Process of Nurse Practitioners Moving to Full Practice Authority and

Developmental Summary of Practice Implications to Assist Others in the Future

Chapter 1: Introduction

Introduction to the problem

The role of the nurse practitioner (NP) is providing major contributions to improving

healthcare in the United States (US). NPs are playing a progressively more important role as high

quality providers in primary care for millions of Americans. Evidence from multiple studies

supports the contributions of NPs to improving primary care health outcomes and reducing

costly health resource use nationwide (Spetz, Skillman, Holly, & Andrilla, 2016).

All states license nurse practitioners (NPs), and their official designation depends on the

state. Titles include: Advanced Registered Nurse Practitioner (ARNP), Advanced Practice

Registered Nurse (APRN), Advanced Practice Nurse (APN), Certified Nurse Practitioner (CNP),

Certified Registered Nurse Practitioner (CRNP), and Licensed Nurse Practitioner (LNP). Since

there are many different ways each state listed NPs in their decades-old laws and regulations, the

language can appear confusing. The Consensus Model provides guidance for states to adopt

uniformity in the regulation of APRN roles. The National Council of State Board of Nursing

(NCSBN) created a Campaign for Consensus, an initiative to assist aligning APRN regulation

(National Council of State Board of Nursing, n.d.).

Currently, almost half of the US has changed from restrictive or reduced practice to full

practice authority (FPA). NPs who operate in FPA states are free to “start and operate their own

independent practices in the same way physicians do, and have a substantial impact on

improving healthcare access, quality, and costs (Spetz, Skillman, Holly, & Andrilla, 2016).” At

this time we have twenty-two states and District of Columbia (DC) that have approved FPA


status for NPs allowing them to “assess, diagnose, interpret diagnostic tests, and prescribe

medications independently (Simmons School of Nursing and Health Sciences, 2016).”

The states with FPA are: Alaska, Arizona, Colorado, Connecticut, District of Columbia,

Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Montana, Nebraska, Nevada, New

Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, South Dakota, Vermont,

Washington, and Wyoming (Vestal, 2013). There are also eight areas considered U.S. territories:

American Samoa, Guam, Commonwealth of the Northern Mariana Islands, Commonwealth of

Puerto Rico, Republic of Palau, Federated States of Micronesia, Republic of the Marshall Islands

and U.S. Virgin Islands. Two have FPA: Commonwealth of the Northern Mariana Islands and

Commonwealth of Puerto Rico. The Veterans Affairs (VA) and The American Indian

Reservations (AIR) are considered separate entities that utilize NPs and therefore have

regulations related to FPA, bringing the total to twenty-seven distinct states, territories, or

organizations with FPA.

Purpose

The purpose of this scholarly project was to examine the published information about the

FPA process and complete interviews from the twenty-seven states, territories, or organizations

with FPA, then explore the positives, barriers, and issues they faced transitioning from a

restrictive or reduced practice to FPA. The final product is an analysis summary to assist with

transitioning to FPA that addresses common events and solutions from the preceding transitions.

The results of this project would have effective practice implications for transitioning for the

remaining states without FPA.

Background

According to the American Association of Nurse Practitioners (AANP) FPA is:


The collection of state practice and licensure laws that allow for APRNs to evaluate

patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—

including prescribe medications—under the exclusive licensure authority of the state

board of nursing. Under a FPA model, APRNs are still required to meet educational and

practice requirements for licensure, maintain national certification and remain

accountable to the public and the state board of nursing to meet the standards of care in

practice and professional conduct. APRNs will continue to consult and refer patients to

other healthcare providers according to patient needs (American Association of Nurse

Practitioners, 2013).

All but two of the current FPA states, (Montana and Oregon) have transitioned from

reduced or restrictive practice to FPA. Montana and Oregon never mandated any collaborative

agreement requirements with physicians in their state history of regulations. Another note of

exception, “Maine has never had any legislation on collaborative agreements, but a rule change

in 1997 allowed NPs to practice independently (H.R. Doc. No. 08-286, 2008).”.

The trend of NPs as primary care providers began with Washington State and Arizona in

the 1970’s. The trend continued to Alaska, Iowa, Colorado, and Washington DC in the 1980’s,

which led to four more states (New Hampshire, New Mexico, Wyoming, and Maine) in the

1990’s, with FPA evolving each time. Since the year 2000, another 11 states (Idaho, Vermont,

Hawaii, North Dakota, Nevada, Rhode Island, Minnesota, Connecticut, Nebraska, Maryland, and

South Dakota) have followed to a FPA model.

Significance of problem

As the nation awaits Congress’s plans of repealing and replacing our current healthcare

system, questions linger for providers, policymakers, and customers on how this will affect


healthcare insurance and provision of care. Since 1965, when then President Lyndon B. Johnson

signed American healthcare into law with the creation of Medicare and Medicaid, up until the

latest reform with the Patient Protection and Affordable Care Act (ACA) in 2010 legislation has

worked to improve health outcomes with preventative healthcare and primary care services

(Center for Medicare and Medicaid Services, 2017). The ACA provided an increase in coverage

but also created a demand for more providers to meet the needs of those newly insured. The

Kaiser Family Foundation reported that in 2016 the U.S. had 441,735 primary care physicians

and 484,384 specialist physicians for a total of 926,119 physicians. Yet today, we do not have

acceptable access to primary healthcare in many communities due to a shortage of primary care

providers. Presently in the U.S. 57 million individuals do not have acceptable access to primary

healthcare (Opportunity Nation, 2014)

Currently, there are more than 222,000 NPs licensed in the United States (U.S.), with

83.4% of those NPs certified in a capacity of primary care providers (AANP, 2016). Evidence

supports the high quality and cost effectiveness of NP care and the continued interest of the

discipline to contribute to solving the primary care dilemma in the US (AANP, n.d.).

Recognizing that NPs play a large and significant role in the American healthcare delivery

system has brought progress, with states modernizing outdated rules and regulations. The result

has been decreased costs and increased quality care to the neediest rural and underserved areas of

the country. The American Nurses Association put together a list of fifteen top organizations,

each with their personal reports from independent studies with extensive research, documenting

the same themes: improve access to care, improve patient outcomes, and reduce health

disparities, all while promoting a more efficient and cost-effective primary care system by easing

the restrictions on NPs (Summers, 2016). With the national shortage of primary care physicians,


both physicians and NPs in primary care should work together to meet the needs of this nation

(Summers, 2016).

Concerns expressed by the opposition to the removal of barriers to APRNs need to be

addressed. Some physician groups including the American Medical Association (AMA),

American Academy of Family Physicians, and other physician groups are opposed to removal of

barriers, claiming patients' health are at risk (Health Policy Brief: Nurse practitioners and

primary care updated, 2013) Another claim is the difference in education, and that the use of

‘Doctor’ by NPs who have completed doctoral programs to obtain the Doctor of Nursing Practice

(DNP) degree, could lead to confusion and misconceptions by patients. For more than fifty

years, NPs have shown evidence, through extensive research by other organizations that patient

health is not at risk.

There is compelling evidence documenting NPs ability to provide high quality care with

improved or equal outcomes and patient satisfaction. The same holds true comparing education.

The Association of Family Medicine Residency Directors (2012) discusses the “vast difference

in clinical training”. This article states the typical hours of training for family medicine

physician is 21,000 total hours, where a NP is 2,300 to 5,300 hours depending on the advanced

nursing schools program (Schaffer et. al. 2012). Although this article equates the skill sets of

both groups as complementary to each other, it boldly states the groups are not equal. It

emphasizes that without physician oversight, FPA would lead to lowering the standard of

primary care and form a 2-tiered system of access to care (Schaffer et. al. 2012).

In an Issue Brief created by the Primary Care Coalition (n.d.) they firmly state that NPs

“lack the broader and deeper expertise needed to recognize cases in which multiple symptoms

suggest more serious conditions.” This brief explains that the study of medical science by


physicians is thousands of hours of clinical study prior to independent practice. The last point

stated is the difference between the physician’s highly structured educational paths which is

consistent across the U.S. for all physicians. The NPs do not have this same standard because

they differ from state to state and school program to school program (Primary Care Coalition,

n.d.)

Another issue preventing the primary care providers from being able to reach the

populace and provide access is the Standard of Practice (SOP) issues surrounding the NPs. The

AMA believes, “medical doctors should lead these teams in a hierarchical structure” which

includes collaboration with and over the NPs and physician assistants (PAs) (Iglehart, 2013). In

this publication, Iglehart (2013) promotes physician-led teams function successfully with

integrated systems like Geisinger Health System, Kaiser Permanente, and the Department of

Veterans Affairs (Iglehart, 2013). Physicians believe expanding the SOP of NPs would be

risking patients’ lives by creating a 2 tier healthcare system, taking the position that physicians

care cannot be matched (Iglehart, 2013).

In 2006, the AMA formed its Scope of Practice Partnership to battle against expansions

into its turf (i.e. sole claim of their title of “doctor”)from a huge array of fields, including nurses,

optometrists and psychologists, as well as licensed DCs (Chiropractic Physician), MDs

(allopathic physicians) and LACs(Acupuncture Physicians) (Weeks, 2010). In previous

situations like this, the U.S. Court of Appeals ruled that the AMA’s presentations violated the

Sherman Antitrust Act, stating physicians do not own the title “doctor.” The claims of concerns

from physicians about patient safety are completely unsubstantiated. What truly needs

differentiating is whether these concerns have any validity or primarily represent a concern about

competition. It is not about patient outcomes but physician incomes (Iowa, 2016).


Christopher Glazek (2015), explains that in some situations, NPs must pay their

"supervising physician" between $1,000 and $2,000 monthly. A common practice in all states is

having required fees tied to the collaboration agreements to allow an NP to practice and amounts

have been documented as high as $3,000 to $6,000 in some areas. This leads to a financial

burden attached to the practice (Glazek, 2015). The Institute of Medicine (IOM) report of 2010

recommended that the FTC identify state regulations related to advanced-practice nursing that

have an anticompetitive effect without contributing to the health and safety of the public (Health

Briefs: Nurse practitioners and primary care, 2012). NPs need to encourage the FTC to continue

their efforts to protect the public through critical analysis of barriers to fair trade healthcare

practices (Health Briefs: Nurse practitioners and primary care, 2012)

As the massive healthcare system in the U.S. continues to change, so must the model for

a modern innovative healthcare team. Modernizing the SOP for NPs to practice to the full extent

of their training has not been addressed in many decades in many states. State and Federal

lawmakers need to ensure that professions are not targeting anticompetitive conduct in healthcare

which does not protect the public.

Transitioning from a restrictive or reduced practice state to FPA comes with some

positives as well as barriers or issues of varying degrees. According to the AANP Strategic Plan

that was outlined in their State Government Affair statement, APRNs will have plenary authority

to practice in 90% or more of all states and Washington DC by 2020 as their direct goal

(Kopanos, 2011). Plenary authority can best be described as the ability to practice to the level of

education and the scope of training, without restrictions and without physician supervision

(Kopanos, 2011). The benefit of learning from the preceding state’s positives, barriers and issues

will allow for improvement as other states transition to FPA.


Barriers to FPA Transition

Doble and Bonsall (2015) explain the importance for FPA lies in a goal to eliminate

barriers to healthcare access in old, outdated laws and regulatory barriers that prevent NPs from

practicing to the full extent of their degree and providing the full scope of services for which

they are educated. This provides increased access of proven high quality care to geographic

regions where patients have limited access to quality care by expanding the healthcare

workforce. Over the past fifty years we have witnessed twenty-two states and Washington DC

move forward with approval to full practice status for NPs. No state has ever repealed FPA,

once it was brought into law. Yet all states with FPA still have barriers or restrictions due to

imposed mandates by collaborative parties ( Robert Wood Johnson Foundation, 2017).

The Kentucky Coalition of Nurse Practitioners and Nurse Midwives (2011), reported

unnecessary practice barriers that prevent them from using the full scope of their education, thus

reducing patient access to care. Their recommendations focused on removing the barriers that

require some degree of physician involvement or supervision, preventing these healthcare

providers from improving access to care (Midwives, 2011). Six years later they continue to fight

against these unnecessary practice barriers and outdated laws.

Another barrier is regulations that increase costs and duplicate or could delay care for

clients such as home health services. Brassard (2011) states that Medicare laws and regulations

specify only a physician can order home health and hospice services. Currently, an NP can

conduct the interview (commonly referred to as face-to-face encounter) for the physician, report

back to the physician, then the physician can compose a description to justify the need for home

health services, all of which increase costs and delays care (RWJF, 2017).


An additional barrier is insurance companies that do not reimburse NPs for services

equally for the same service provided by physicians. With the passage of House Bill (HB) 2902

in 2013, Oregon became the first state in the nation to require insurance companies to follow

‘equal pay for equal work’ rules on insurance reimbursements for Nurse Practitioners (NPs),

Physician Assistants (PAs) and Physicians in primary care and mental health. HB 2902 also

prohibits insurers from reducing physician rates to comply with the law and creates a task force

to study primary care and mental health reimbursement (Gray, 2013). Christopher Gray (2013),

explains that insurance companies would steeply cut payments to NPs and PAs, mainly those

who practice on their own and lack bargaining power. These providers are usually the ones out

there in rural areas, the only provider for those communities, seeing their payments arbitrarily cut

by insurance companies (Gray, 2013).

Brassard and Smolenski (2011) examined the ability of a primary care provider to care

for a patient who is admitted to an acute care facility. Federal and state laws and regulations, can

block hospitalized patient’ access to their provider of choice, if that provider is an NP. Another

issue is hospital bylaws prohibiting NPs having staff membership, hospital privileges and

providing the continuity of care to admit, manage and discharge their patients from organized

medical facilities. By removing these barriers to care, one can reduce costs, increase customer

choice, and improve healthcare quality. They insist that interprofessional collaboration is

enhanced, hospital administrators benefit, and insurance companies benefit (Brassard &

Smolenski, 2011).

Yee, T., Boukus, E., Cross, D., and Samuel, D., (2013) present barriers to payer policies

and the laws that need to be reformed. They insist that revising state regulation of Medicaid

managed care plans, which cover most Medicaid enrollees, may be a more immediate and


politically feasible way to expand effective utilization of NPs in primary care. In FPA states

where NPs are recognized as primary care providers, managed care plan rates often mirror

traditional Medicaid rates set by the state and vary substantially. Oliver, Pennington, Revelle, &

Rantz (2014) also examined health outcomes of Medicare and Medicaid patients with NP

providers. They examined the relationship between FPA NPs and decreased hospitalization in

Medicare and Medicaid patients. The findings support increasing call for NPs to achieve FPA

(Oliver et al., 2014).

Lack of legislative change at various levels of government was explained as a barrier in

the Kaiser Health News. Christine Vestal (2013) quoted Democratic Assemblywoman Maggie

Carlton, the lead sponsor of Nevada’s SOP law, who said, “It took three legislative sessions and

six years before we could get the right people to talk about the right topics at the right time.”

Vestal’s article goes on to address private physician’s financial gain as their only motivation.

The FTC has weighed in on several state battles over SOP, arguing that physician groups have

no valid reason for blocking such laws, other than to hinder competition (Vestal, 2013). More

than fifty years of legislative battles over SOP laws has slowed progress to FPA due to the

undertone of personal monetary interests.

“Turf wars” and fear of economic repercussions by physicians has been the barrier that

has come to light every time SOP laws for NPs is brought up. Some doctors are resisting the

effort of NPs working independently, and so the AMA pledges to work toward state laws to

maintain physician stronghold (Lowes, 2016). By contrast, Guglielmo (2000) reports after years

of circling the wagons and battling over turf, doctors and APRNs are finding it pays to work

together. Guglielmo interviewed physicians that acknowledged that some doctors are biased

against NPs. One Florida physician adds, "a lot more feel they can't live without them." A


Colorado physician says, “It’s problematic for us to recruit physicians for such a rural setting,

APRNs are extra hands. Economically, it’s neutral, it's a better practice because of them, and all

help run the practice, providing terrific input during committee meetings” Guglielmo closes with

“that's a message organized medicine needs to hear, that practicing doctors are willing to use

already strong working relationships with APRNs and other providers to resolve their political

differences (Guglielmo, 2000).”

Meyers (2016) addressed it by saying “as long as there is ego, fear, and greed, there will

be medical turf wars.” Meyers claims turf wars are just part of the ugly underbelly of medical

practice, and will continue, as long as disparate medical interests lay claim to dwindling

resources and profits. Some argue turf wars are the free market at work. Others claim they are

applying higher standards to protect the public interest. By creating care models delivered by

non-MD provider substitutes with supervision, they are serving a market need without losing

quality of care. Some see it as a cartel just trying to protect their wallets and those of their

participants. To resolve these conflicts depends on compromise in many regulatory and

legislative settings. However they play out, turf wars are a part of medical practice for the

foreseeable future.

FPA would remove barriers but most likely not all barriers or issues relating to the

environment within NPs practice. The remaining twenty-eight states with reduced or restricted

practice are the intended beneficiaries. These states are Alabama, Arkansas, California,

Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts,

Michigan, Mississippi, Missouri, New Jersey, New York, North Carolina, Ohio, Oklahoma,

Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, and Wisconsin.

Chapter 2: Research Based Evidence


Theoretical Framework

Everett Rogers Diffusion of Innovation Theory was chosen to assist in implementing this

scholarly project because his theory highlights the use of early adaptors, which mirrors the

process of transitioning to FPA. Simard and Rice (2013) explain how best practices are not

always implemented. Using Rogers’s theory of diffusion, the innovators can implement and

successfully apply best practices into healthcare setting. Realizing the best practice to

implement and using diffusion theory of early adaptors, will also require obtaining buy in. The

same thing applies with FPA. A United Kingdom editorial examines how to encourage nurses to

have buy in to innovation. Get them to believe the “greatest source of energy and motivation for

bringing innovation in healthcare practices for the improvement of health outcomes” is through

the process of Rogers’s theory (Diffusion of Innovation Challenge for Nurses Nursing Essay,

2013). Though diffusion theory will explain the process of change, it does not provide direction

on how to use the change process or information to increase the response to the change process.

Definition of Terms

Nurse Practitioner (NP) - Advanced practice nursing/nurse, APN, family nurse

practitioner, FNP ("US NLM," 2014).

DNP- Doctor of nursing practice, practice doctorate, advanced practice (Chism, 2009).

Scope of Practice- SOP, a nurse practitioner’s SOP focuses largely on health

maintenance, disease prevention, counseling, and patient education in a variety of settings

(Pratt & Katz, 2001, p. 7)

Barrier- Challenges, restrictive, obstacle that prevents movement or access, prevents

communication or progress ("Barrier," 2016)

AANP- American Association of Nurse Practitioner ("AANP," 2016).


Full Practice Authority- FPA is the collection of state practice and licensure laws that

allow for nurse practitioners to evaluate patients, diagnose, order and interpret

diagnostic tests, initiate and manage treatments; including prescribe medications, under

the exclusive licensure authority of the state board of nursing ("AANP FPA," 2013).

Legislation- Having the power to make laws ("Legislative," 2016).

MD/DO- Medical Doctor/ Doctor of Osteopathic ("MD / DO," 2015).

AMA- American Medical Association ("MD / DO," 2015).

Consensus Model- initiative to assist aligning APRN regulation by adopting uniformity

among the states. NCBON outlines APRN practice, “describes the APRN regulatory

model, identifies the titles to be used, defines specialty, describes the emergence of new

roles and population foci, and presents strategies for implementation” (APRN Consensus

Model, 2017).

IOM- Institute of Medicine is a nonprofit organization established in 1970 as a

component of the US National Academy of Sciences that works outside the framework of

government to provide evidence-based research and recommendations for public health

and science policy ("IOM," 2012).

CMS- Centers for Medicare-Medicaid Services ("CMS," n.d.).

Chapter 3: Methodology

The purpose of this project is to explore the positives, barriers, or issues NPs providers

could experience transitioning to FPA. The goal was to seek out what occurred, what the

outcome was and could things have been different based on the data obtained from other sources.

This chapter will discuss sample setting, project design for implementation, and procedure for

data collection, data analysis and practice implications development.


An institutional review board (IRB) approval was sought for this project. The IRB

deemed this DNP scholarly project exempt. Which requires no further review by IRB.

Review of the Related Literature

A literature review using the key words: nurse practitioner, full practice authority,

transitioning. ("nurse practitioners"[MeSH Terms] OR ("nurse"[All Fields] AND

"practitioners"[All Fields]) OR "nurse practitioners"[All Fields] OR ("nurse"[All Fields] AND

"practitioner"[All Fields]) OR "nurse practitioner"[All Fields]) AND full [All Fields] AND

("Practice (Birm)"[Journal] OR "practice"[All Fields]) AND authority[All Fields] was conducted

using the PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and

Google Scholar databases. A total of 23,696 potential relevant articles were obtained. Articles

were removed that were not specific to the US or US territories, the VA or American Indian

Reservation. Articles from other countries were eliminated because they are not relevant.

Articles that were not related to the transitioning after FPA was implemented were also

excluded. Importance was placed on articles that were within the last five years. However, since

this process has been in place since the 1970’s all articles were examined. There were 76 articles

of interest used for this.

Project Design

The project design includes a detailed and extensive search to gain information on this

subject matter through a literature review. This was followed by identifying a contact person at

each state nursing association or board of nursing in the current FPA states. An introductory

email template (See Table 1) explaining the project was developed to open communication

between each state nurse practitioners association to reach the appropriate representative. The

email requested a date and time for a phone interview at their convenience. Before


implementation, an introductory paragraph template was developed (See Table 2) explaining the

project and a standardized set of phone interview questions was included (See Table 3),along

with this author’s email and phone number for further contact or questions. A follow up email

with a reflection of the conversation was sent back for accuracy following the interview. Upon

completion of the interviews, the key findings were organized into practice implications for

transitioning to FPA was developed using the common themes identified.

Summary

A total of twenty-seven distinct separate state, territories or organization responses were

used. These are the twenty-two states with FPA, Washington DC, sixteen U.S. territories of

which eight are insular areas that are inhabited: American Samoa, Guam, Commonwealth of the

Northern Mariana Islands, Commonwealth of Puerto Rico, Republic of Palau, Federated States

of Micronesia, Republic of the Marshall Islands and U.S. Virgin Islands and Department the

Veteran Affairs and The American Indian Reservations. Participation was voluntary, and there

was no penalty for not taking part in the email or interviews. No individuals or their

organization are identified by name. The only identification is by state in which participants are

located.

Chapter 4: Results

Positives of FPA

Positives identified included the ability to own and operate independent practice. This

ranged from Minnesota, with a large land mass but a rarity for NPs to have private practices by

choice, to places like Nevada who struggle to have the preferred private practice because of

mandated collaborative agreements with physicians to be Lab directors for Point of Care testing

with high stipends such as $2,000.00 a month (L. Woodley, personal communication, November


1, 2016). Many FPA states continue cultural change as they head into regulatory and legislative

sessions to clean up language and update laws and regulations. Rhode Island (RI) may be new to

FPA, just transitioning in 2013 but they have the same real positives with choice to practice

independently. One practice in RI has been around for years and has been instrumental in

training and teaching NPs their role in primary care. (Woodley, L. (2016, November 8). Phone

interview.

The greatest positive was stated many times and that was “what a difference this meant

for the people.” Vermont boasts of the positives since FPA: NPs are being invited to join

committees, holding a seat on boards where they had not in the past, having global signature

authority, and allowed voting privileges on teams that they had not been invited before FPA.

Vermont is working with insurances to change NP coverage privileges for inclusion. (L.

Woodley, personal communication, October 12, 2016).

Grassroots was brought out with nursing coming together as a group to advance their

cause. For example, North Dakota’s group was called the Center of Nursing. Many states felt

they had a new relationship and new understanding with legislation. It was more than respect, a

different kind of collegial feeling because they are valued members who are now invited to

provide insight and input. Connecticut felt it was the respect of public official for the NPs, and

among our colleagues as we come together unified through this process of transitioning to FPA.

(L. Woodley, personal communication, October 26, 2016).

Hospital Privileges

Only one state, Iowa, has regulations specifically for hospitals, stating they shall not

deny clinical privileges to APRNs solely based on their license or the accredited school in which

they received their training (IA ADC 481-51.5(135B)). Currently, on a hospital-by-hospital basis


there are boards, credentialing committees, and bylaws of the hospitals that continue to deny

admitting, managing and discharge privileges to NPs unless they agree to have a collaborative

contract. No autonomous NP has admitting privileges. University affiliated medical private

practices also require NPs to have collaborative practice agreements (even though this is a FPA

state) for employment. Within the past five years the state NP group has worked to get NPs on

hospital boards and still working to obtain voting privileges with those hospital board seats. This

same group continues to educate hospitals across the state with a tool kit designed to have

continuity among the NPs so community leaders and Legislative members have the same

consistent information and everyone is talking the same language, a very effective grassroots

effort on their behalf. By using this uniformity when it comes time to update laws or change

outdated bylaws everyone has the same understanding, and this will aid in moving the process

forward. (L. Woodley, personal communication, November 2, 2016).

Connecticut’s take on hospitals requiring collaborative agreements for NPs is that it is a

hardship for the physicians, as well as a liability issue. APRNs are independent thinkers and have

autonomous practice, they should have seats on hospital boards with voting rights. This is the

business side of it is the way APRNs are approaching the issue. Insurance companies can hold

APRNs back by extending times for them to get credentialing. “But in the end it is not what is

best for the physician or the APRN. What makes a difference for the patient is what counts” (L.


You have to have a collaborating physician to allow an NP to manage, or discharge

patients in hospitals of Nevada. At this time NPs are never invited to sit on hospital boards.

That would also mean they do not have voting rights. Only NPs of hospital groups or medical


groups with hospital privileges are allowed to work at hospitals in Nevada with collaborating

agreements. (L. Woodley, personal communication, November 1, 2016).

In Nebraska, most hospitals have required NPs to have a supervising MD to have privileges.

Some medical centers are still mandating as terms of employment that NPs have collaborative

practice. Some medical practices groups are still mandating as terms of employment that NPs

have a collaborative supervising physician assigned. There has been a change to consider more

NPs for board positions. Most boards may have a position for a nurse, but do not define whether

the seat is designated for advanced practice. (L. Woodley, personal communication, October 25,

2016).

In Idaho there is nothing in the nurse practice act that restricts NPs from admitting,

managing, and discharging patients. However, hospitals have a right to restrict and govern

within their own institution and they can have collaborative practice agreements for NPs.

Occasionally practices of medical groups do require collaborative practice but this is rare. Private

organizations can require additional items but most do not. Idaho has several NPs on state

boards, depending on the board and they have voting rights. Hospital boards were not

specifically addressed. (L. Woodley, personal communication, October 25, 2016).

Montana has unique hospital practice issues. The issue of hospitals giving full admitting

privileges is more complicated. While NPs have FPA, employers are allowed to stipulate

requirements for membership and privileges. Most hospitals require a "supervising" physician

relationship for NPs. How rigid the "supervision", is variable from site to site. This arrangement

is not a "collaborative" agreement as required by many states. (L. Woodley, personal

communication, October 31, 2016).


New Mexico faces hospital practice issues like the rest of the country, as hospitals have

their own by-laws, which can limit NP admitting privileges. The New Mexico Nurse Practice

Council plans to introduce legislation in the 2017 Legislative Session to mandate that hospitals

allow NPs to practice to their full scope which means admitting and discharging their patients.

(L. Woodley, personal communication, November 6, 2016).

Most positions in Minnesota are tied to healthcare systems and unfortunately like other

states that means still require collaborative agreements. Some health systems have changed

policies but their smaller hospitals have not updated their policies to reflect FPA. There are

practice groups still mandating collaborative agreements. It was not clear that medical boards

have APRNs as board members or that they would have voting rights. (L. Woodley, personal

communication, November 8, 2016).

Barriers

The list of barriers for NPs to obtain FPA is long but one of the most important should be

to amend the current regulations and laws which are outdated and do not reflect modern

healthcare practices. The Campaign for Action from the NCBON to unify the regulations and

laws for APRNs will help move the nation in that direction. Elimination of these restrictive,

obsolete regulations would improve access of care, removes delays in providing care, decreases

costs to healthcare and most of all allows consumers the choice to acquire the primary care

provider of their choosing.

Currently in the U.S. where NPs have FPA, some public and private insurance payers

delay access to healthcare by obstructing NPs from practicing independently by not paying them

directly or reimbursing at a significantly lower rate. These steps financially burden a primary

care provider like NPs, making it difficult to sustain a primary care practice. Reimbursement


varies from state to state with Medicaid and Medicare. Throughout the country, numerous

insurance companies will not reimburse APRN’s for their services. Often NPs are required to

use incident to billing. This “incident to billing’ model is liable for potential fraud and possible

abuse. Equitable reimbursement for NPs providing the same service deserves the same pay. Two

organizations have also supported the NPs reimbursement equity (Institute of Medicine [IOM]

and Federal Trade Commission [FTC]) and identify anticompetitive regulations to support this

measure of equality (Charting nursing future: The case for removing barriers to APRN practice,

2017).

Obtaining FPA does not necessarily mean NPs have regulations or laws to practice freely.

FPA is supposed to be about practicing to the full extent of your training. However, some see it

as independent practice and many hospitals have bylaws that do not recognize FPA.

Collaboration is supposed to be equal among professions especially in places with FPA.

Unfortunately, these hospitals, or university tied groups and practices still require collaboration

under the direction of a physician. So even with FPA there are still barriers to practicing to the

full extent of your training.

Common Themes

Big Picture. It is hard for some to realize that there is an enormous picture to consider

obtaining FPA. It is not just the fact that we want FPA but the why, where, when, what and how

(Today's Healthcare) needs to be discussed as this puts things into perspective and places the

same perception in everyone’s mind (Focus). (L. Woodley, personal communication, October 12,

2016).

Modernizing Legislation is about updating out of date legislation that has not changed

since being put into place, for some, back in the 1970’s. APRNs have been delivering high


quality, cost effective healthcare in the United States for over half a century, with low

malpractice & litigation. (L. Woodley, personal communication, October 12, 2016).

Verbiage. The single most important lesson that must be done first! Words have different

meaning when spoken out of context which happens ALL the time. Listing words that have

concern and that are often misused are: doctor and physician (not all doctors are physicians),

physician and provider (not all providers are physicians), nurse and nurse practitioner (not all

nurse are nurse practitioners). Watch your words very closely in publications, teaching, and

speaking. Many times words are transposed. One word can change the meaning completely. For

example, primary care physician shortage is different from primary care provider shortage. (L.


Lobbying. An important part of the process. Always monitor the legislative process and

keep track of bills being slipped into other legislation (happens ALL the time). There is always

something going on in legislation. (L. Woodley, personal communication, November 1, 2016).

Involvement. This is more than showing up when really needed or begged to be involved.

Locally, state, or nationally, this has to be a priority in every NPs career. Figure out what you

can do and do it. If you’re not aware of your surroundings then you cannot have input or change

for the better. (L. Woodley, personal communication, November 2, 2016).

Grassroots Building. This was interesting because different states had very different

opinions on this subject. Relationships strengthen a partnership. Some states wanted all of

nursing to help with the transitioning because numbers count, while others felt this is an advance

practice issue and should be handled by themselves. Some wanted physician assistant input,


others did not. There will always be a need in the future to help and to be helped. (L. Woodley,

personal communication, November 6, 2016).

APRNs. Deciding who wants to be included and who wants to do things separately is a

hard choice. Building together as a team or separating, do all APRNs want to be on the team?

Buy in is a necessity. Often getting all four teams of APRNs (nurse practitioners, clinical nurse

specialists, nurse-midwives, and nurse anesthetists) together to move forward with legislation

action is a process. Keep the doors open and make educated choices why to move forward

together or not. (L. Woodley, personal communication, October 26, 2016).

Public Perception of APRNs. Not all in the public (general or professional) know or

understand what an APRN is exactly. Educate in a uniform manner. Using the same teaching

and wording builds a strong foundation. APRNs are trusted. (L. Woodley, personal

communication, October 12, 2016).

Time. The process for transitioning to FPA for some can be very quick and for others a

very long time. Time can be a friend and a foe. That may seem hard to accept but sometimes the

time spent revealed something not seen before and things finally fall into place. Persevere. This

has been in the making for over fifty years, in the grand scheme of things. (L. Woodley, personal


Just the beginning of a journey for APRNs in your area. Realizing that obtaining FPA is

just the start, there are many more hurdles to tackle. For example, changing the hundreds of

thousands of legislative wordings that state only “physician” and not “provider”, can have an

impact. Strategic planning will help plan out what to tackle and when to move forward. (L.

Woodley, personal communication, November 2, 2016).


Look to be included. As APRNs, this is not limited to legislation but to serving on boards

and in hospitals. There are many opportunities. If physicians are included, then you as a

provider should be as well. So, if a legislative action needs physician input they probably need

provider input as well. APRNs are also providers. Organizations want leaders in the community,

boards of companies need fresh perspectives, and hospitals deserve APRNs viewpoints. (L.


Legislators do not want to pick sides. That is not how policymakers operate. Picking a

side would cost them votes. They want you to step up and show them an answer. Show them

with evidence why you’re right, building trust as a professional. Legislators hold physicians

with the highest regard. Hold your opinion with value, support with evidence and shape honest,

open communication with legislators. (L. Woodley, personal communication, November 8,

2016).

You cannot ask for everything. Decide on what you need to open the doors. The

legislative process is not a shopping checklist of wants. This is not a one shop stop, choices will

need to be made. The whole process of obtaining FPA is a work of compromise. Prioritize,

because there will be things that will not move forward. (L. Woodley, personal communication,

November 6, 2016).

Purposefully misleading is a reality in the legislation process. Opposition will mislead by

interchanging words like nurse practitioner and nurse. Don’t be defensive, this is a tactic to

confuse the policymakers. Use the power of knowledge and professionalism to show the truth.

(L. Woodley, personal communication, October 31, 2016).


Rogue APRNs are unfortunately a reality. There is always this possibility. Be prepared

on how to handle this tactic. Be professional. APRNs can have their opinion but that does not

represent the opinion of the 10,000 licensed APRNs in the state. (L. Woodley, personal


Clarity on matters is a powerful tool. Staying connected with policymakers to explain

opposition misleading information professionally lays a foundation of honesty. By using

evidence, this clarifies and builds trust and strengthens APRNs credibility. (L. Woodley,

personal communication, October 25, 2016).

Education comparison is the number one argument for the opposition. Comparing

educational schooling of a physician and NP is not as easy as black and white, because we have

no similar standard for comparison. Physicians and NPs are alike in that both providers diagnose,

write orders, interpret labs and diagnostic tests, prescribe medications, and treat patients

including management of acute and chronic disease processes. Physician and NP care and

knowledge similarities are complementary, but each has a fundamental capability that is unique

and completely distinctive. (L. Woodley, personal communication, October 26, 2016).

Collaboration has been the word of discussion for transitioning to FPA because it has

different meanings in different states or the interpretation is different, requiring legislative

clarification. All providers collaborate with other providers, always have and always will. (L.


Fostering Innovation to the modern healthcare of the 21st century. Currently 27 states,

organizations and territories have transitioned to FPA utilizing APRNs to ensure healthcare

access to all. The "medical hierarchy perceptions" that once existed where physicians were


captains of the ship does not foster teamwork. It instead promotes a physician supremacy over

the healthcare team and will not survive in modern medicine. A collaborative model of working

with healthcare professionals is the acceptable current and future of healthcare. Accomplishing

this goal of placing value in each team member for an engaged workforce fosters modern

innovation. (L. Woodley, personal communication, October 31, 2016).

There is no checklist to obtain FPA, this practice implications was developed to assist

those trying to transition to FPA. Develop strategies from the lessons learned that fit your needs

and will make FPA a reality. Benefit from those who have already obtained FPA, you may not

have to face some of the problems because you profited from lessons they learned. (L. Woodley,

personal communication, October 31, 2016).

Keep goal in hand, as the battle for transitioning to FPA is not easy. Always focus on

providing, “Improve access to care.” With the application of improving access to healthcare

through FPA. (L. Woodley, personal communication, November 2, 2016).

Other Considerations

Other important advice gleaned from the interviews conducted includes

Develop strategies from the lessons learned that fit your needs and will make

FPA a reality.

Benefit from those who have already obtained FPA, you may not have to face

some of the problems because you profited from lessons they learned.

Keep goal in hand, as the battle for transitioning to FPA is not easy. Always

focus on providing, “Improved access to care.”

Visual Summary


The outcome of this project included a summary of findings (See Figure 1) to help assist

with the transition to FPA for the remaining twenty-eight states. The practice implications figure

has three columns, the first being the concept. The concept is the idea some states consider

important in helping with transitioning. The second column provides emphasis on the value,

detailing the significance of the concept. The last column explores why the concept significance

affects the future. Each state may view the individual concepts differently but these

interventions impacted the preceding states in some fashion that they wanted to share. The goal

was to provide practice implications to assist in the transitioning to FPA for the remaining states

as an application translation of research into practice (See Figure 1).

The product of the project was a white paper and analysis to include key findings. The

key findings include the factors each state felt had some influence on their ability to transition to

FPA. The key findings is a guide for each state to use and customize to their own individual

need. There are three separate columns for each intervention. The first column describes the

intervention, the second column was the factor or influence reason it made a difference, the last

and final column is what future value the intervention needed. These are only key findings, there

is no magic formula that will obtain FPA for any state. As APRNs, the choices each state takes

towards FPA needs to be deeply-rooted with models that work for them. Each state will struggle

through the creative process, through the change process, and the choices they make will guide

them. The world of APRNs is exciting, complex and intriguing. As APRNs, we need to be more

comfortable being involved and contributing to influences that change our future. With the work

that has been prepared by this project, the difference may start here.

Chapter 5: Discussion

Summary


Recommendations for Practice

Improving primary healthcare by ensuring healthcare access to all is the goal of FPA.

The recommendations listed are some of the solutions to move forward with providing primary

care access to the population. Listed here are recommendations that guarantee improvement to

primary care access with minimal to no financial implications. Throughout this paper options

were presented but financial concerns and ongoing pursuit for funding excluded them from the

list below. IOM recommendations (Institute of Medicine, 2010):

Modernization of Scope-of-Practice for APRNs

Removal of outdated regulations and language

Support of APRNs for payment equality

Implementing and upholding any willing provider laws

Incentives to Lure Professionals to Medically Underserved Areas

Prior to education funding, negotiated packages

Preparing Students and Encouraging Careers in Primary Care

Pathways to support mentoring and education

When these Recommendations are Implemented, the benefits to

Transforming Healthcare into the 21st century meeting the demands of the U.S.

population with innovative modern medicine

Collaboration with all providers

Increases NPs’ Accountability

Including admitting privileges to manage their population

Team work, interdependent roles of providers, and the recognition of independent professionals

Collaboration


Easing Professional Tension

Interprofessional Education

Improving health and well-being of patients

These key findings or practice implications were developed to let the remaining states see

what has happened in the past with a goal to help them in the future as they seek transitioning to

FPA. Now is the time to embrace the innovative process, to modernize outdated regulations,

reflecting today's modern healthcare environment. Success has been shown from the states who

have already undergone the process and these practice implications can serve as a guideline for

those currently in the process or planning to seek FPA in the near future.

The primary goal of this project is to explore the positives, barriers, or issues APRN

providers could experience while transitioning to FPA. The secondary goal was to seek out what

occurred and what was the outcome. Could things have been different based on the data obtained

from other sources? This chapter defines implications of application of the theoretical

framework by exploring the significance of results to healthcare and nursing, the strengths and

limitations of the project, recommendations, and benefits for nursing practice.

Relate project results to theoretical/conceptual framework

In Everett Rogers Diffusion of Innovations (2003), the theory tries to find and explain

how, why, and at what rate new ideas spread. Rogers’ diffusion of innovations theory is the

most suitable for examining the adoption of innovation in the movement towards FPA

throughout the nation. Rogers (2003) defined the innovation-decision procedure as “an

information-seeking and information-processing activity, where an individual is motivated to

reduce uncertainty about the advantages and disadvantages of an innovation” (p. 172). This


theory provides the foundation to establish buy-in with the remaining twenty-nine states moving

towards FPA.

The expansion of SOP for APRNs is an essential first step in solving the primary care

crisis. Rogers does caution, “getting a new idea adopted, even when is has obvious advantages,

is difficult” (p. 1). As APRNs conceptualize and implement sustainable innovation of FPA, this

will call for action to challenge or campaign for change. Currently the desires are evident with

hundreds of legislative actions filed this past year. Now is the time to identify the barriers,

recognize the issues and devise plans to isolate and eliminate those deterrents. By understanding

the positives, barriers, and issues, the preceding group has endured, this will open the

opportunity to explore the evidence, collect what is relevant to each states unique needs and

disseminate the facts to be used in the application, thereby translation of research into the APRN

professional arena.

Significance of results to healthcare and/or nursing

As NPs have moved to providing primary care, there have been both barriers and

benefits. At this time the ACA has increased Medicaid payments for qualifying physicians

providing primary care service. Non-physician providers, including APRNs, may perhaps in

some areas, qualify for the increased payments but only when working under a qualifying

physician’s supervision. A benefit of the ACA proposals has opportunities for DNP leadership in

healthcare development and restructuring. The future of ACA is on hold as the nation waits to

hear the future of healthcare in America when President Donald Trump reveals his plan to repeal

and replace the ACA.

Some of the progression in legislations for APRNs would include writing prescriptions

that have their names included on prescriptions labels as well as being able to prescribe Schedule


II through V controlled substances. Another progression is being able to write prescriptions for

the disabled handicap placards, perform physical exams for students and drivers, or to be

recognized as primary care providers. Additionally, having the ability to write home health

orders, sign DNR orders, or death certificates, global signature authority, referral to physical

therapy or Provider Orders for Life Sustaining Treatment. Ideally all states will continue to

change legislation and regulations to hold these same standards.

Barriers would include the ongoing struggle with Boards of Medicine and their

supervision or authority to regulate APRNs and legislative battles to change outdated regulations

and language. One of the most difficult problems for the US is the inconsistency of state

practices for APRNs. In the 1990’s the APRN Consensus Work Group & the National Council

of State Boards of Nursing APRN Advisory Committee worked to develop uniform guidelines

for APRNs that was published in 2008, finally defining a needed national model for all APRNs

in the US and US territories. This national model is called, the Consensus Model for APRN

Regulation: Licensure, Accreditation, Certification, and Education, known as the LACE model

(NCSBN, 2008). This model outlined the four types of APRNs: nurse anesthetists, nurse

midwife, nurse practitioner, and clinical nurse specialist. The APRN using this model now

presents as a unified, organized, cohesive group. In fact, as of 2016, 35 state and US territory

Boards of Nursing have enacted the Consensus Model, while another five states are pending.

Only 11 have yet to propose any legislation concerning the implementation of the model

(Graduate Nursing Edu, 2016).

Special Interest

When you speak of the US, one must also consider the US territories, the US Veterans

Administration and the AIR as an all-inclusive group, not just the 50 states and Washington DC.


Of the sixteen US territories, eight are considered as insular areas, including American Samoa,

Guam, Commonwealth of the Northern Mariana Islands, Commonwealth of Puerto Rico,

Republic of Palau, Federated States of Micronesia, Republic of the Marshall Islands and U.S.

Virgin Islands. All have been contacted but it was the AIR that returned my invitation for insight

to what APRNs and FPA represents to them. American Indian Reservations use APRNs, and

they do have FPA as primary care providers. The AIR does not advertise to have APRNs as

primary care providers, their first intent is to have a physician. However, if that it is not an

option, APRNs are there to provide services to this population. Just as Dr. Loretta Ford and Dr.

Henry Silver developed the first Nurse Practitioner program in the 1960’s, their foresight has

grown and represents the interests of providing care for the people, so does the AIR to provide

services to meet the needs of their patient population. The Veterans Administration on

December 13, 2016 signed FPA for CNS, CNM, and NPs.

Northern Mariana Islands has had FPA since 2009, and their SOP includes primary care

provider status with privileges to order durable medical equipment, devices, nutrition, diagnostic,

supportive services, home health, hospice, physical therapy, occupational therapy and to refer

patients. Hospital privileges are granted if the APRN works for the government hospital.

APRNs are reimbursed 80% of physician reimbursement. CNMI licensed CNP, CRNA and

CNM may prescribe including Schedule II-V.

Overall strengths and limitations of the project

Several strengths exist for this project. First would include the approach to a virtually

untouched subject matter. This strength relied on using the concepts of my DNP education to

seek to enhance the quality improvement for APRNs on a national level. Another

conceptualizing strength was the understanding that the US was more than the original twenty-


two states with FPA. This project included all US territories and organizations in the

examination for a total of twenty-seven. An additional strength is that this project provides a

starting point, with the data and practice implications, for the remaining twenty-eight states to

use to individualize as each state seeks to obtain FPA.

There are several limitations in this project. Not all contacts have responded to emails.

Data has been obtained from all groups but not all groups provided a personal interview. The

insular areas have also not returned information for personal verification. Some of the

information was in Spanish and relied on others to translate and the use of Google to interpret for

accuracy. The major limitation was trying to keep the complexity of the subject to a minimum,

as many barriers led to many other issues or concerns.

Benefit of project to practice

The benefit of gathering experiences from those who have already taken the journey

transitioning to FPA is invaluable. When the time comes, APRNs will use the key findings from

this project to design unique practice implications for their state to transition, then disseminate as

they achieve FPA. The white paper and practice implications will be shared to inform others of

the wealth of information from past transitions to FPA, describing details of the positives,

barriers, and issues experienced.

Another benefit of this project would be future studies can and should tackle the

implications allowing one professions anticompetitive effects to influence another profession.

Should federal regulation intervene after certain limits? Some physician financial concerns about

expansion, state SOP rules for nurses, what about a comparison between groups of providers?

There are numerous future studies that could spin off of this subject matter.

Conclusion


Recognizing primary care as the foundation of the U.S. healthcare system and placing

value in developing it for the 21st century is the first priority. The long-term investments in the

primary care infrastructure will meet the needs of millions of Americans that are not getting the

care that they need now, and not being proactive will worsen the situation. Expansion with

coverage may require more primary care professionals overall, but the most important need is

encouraging more providers to enter primary care in underserved areas. Removing NPs practice

barriers is a step through the door to solving these problems and will substantially improve

accessibility, cost effectiveness and quality healthcare for the population. Once that door is open

a collaborative effort among all providers regardless of education differences can raise the level

of modern healthcare to new heights.


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Appendices


Table 1

Introductory Email

Lisa Woodley, DNP(s)

East Carolina University

College of Nursing

Greenville, North Carolina 27834

[email protected]

Dear Nursing Colleague:

Good morning. My name is Lisa Woodley and I am a student in the Doctor of Nursing Practice

Program at East Carolina University. I am working on my DNP Project, which will provide an

account of the transition experiences of states that have approved full practice authority for nurse

practitioners. I consider your narrative very important for my project and would like the

opportunity to speak with you or your designee. Specifically, I would like to make an

appointment to interview an appropriate representative from your state about problems, issues or

positives experienced in the transitioning phase from supervisory/collaborative practice to

autonomous practice. Once gathering the information from each state and Washington, DC, I

will write an analysis and white paper to inform the remaining states. This will provide valuable

information for the remaining 28 states.

Could we please schedule a phone interview to discuss this project? Time is valuable and I am

committed to honoring your schedule with minimal intrusion. Please respond to this email with a

date and time for this phone interview, as well as a phone number where I can contact you or a

designee.

Thank you in advance for this opportunity. I appreciate your assistance in the compilation of this

comprehensive narrative.

Sincerely,

Lisa Woodley


Table 2

Introductory Paragraph Template

Good morning,

My name is Lisa Woodley, I am a DNPs at East Carolina University in Greenville, North

Carolina. I am working on a scholarly project entitled, Issues or Barriers Nurse Practitioner

Providers Could Experience Moving to Full Practice Authority. This project’s goal is to write a

complete and accurate analysis and white paper of the preceding 21 states and Washington DC

that have transitioned to FPA and their experiences. So first of all I would like to thank you, for

spending these few minutes with me and let you know how truly special this is that you are

willing to do this. I will ask you a few question, for example, I would like to know did you have

buy in or grassroots groups with anyone during your transitions? Then with each question I

would like to see the positive or negative side of each issue or barrier. Do you have any

questions before we start?

End of the Conversation

Please let me thank you again, and let you know everything went extremely well. If you have

any more thoughts or comments you would like to share you can reach me at my email address

([email protected]) and telephone number (919-270-2148) and please feel free to

call or email at any time.


Table 3

Template of Questions

Question 1

I would like to know did you have buy in or grassroots groups with anyone during your transition

to FPA?

Question 2

What was the best thing that came from your transition to FPA?

Question 3

Can you tell the issues that came from your transition to FPA?

Question 4

Were there any barriers that came from your transition to FPA?

Question 5

Is there anything else you would like to share?


Figure 1

Summary for Transitioning to FPA

Big Picture Today's Healthcare Focus

Modernizing Legislation

APRNs have been delivering care in the United States for over

half a century

We deliver high quality, cost effective healthcare with low

malpractice & litigation

Verbiage Watching your words very closely

One word can change the meaning completely

Lobbyist Always monitor legislative process

There is always something going on

in legislation

InvolvementLocally, state,

nationally, this has to be a priority

If you're not aware of your surroundings

then you cannot have input or change for

the better

Grassroots Building

Relationships strengthen a partnership

There will always be a need in the future to help and to be helped


APRNs Building together as a team or separating Buy in is a necessity

Public Perception of APRNs

Educate in a uniformed matter Trusted

Time Can be a friend and a foe

Persevere this has been in the making for over fifty years

Just the begining

Obtaining FPA is just the start, there are

many more hurdles to tackle

Strategic planning will help

Look to be included

If physicians are included then you as a provider should be

as well

APRNs are also providers

Legislators don't want to

pick sides

Show them with evidence why you're right, building trust

Hold your opinion with value


You cannot ask for everything, decide on what

you need to open the doors

This is not a one shop stop, choices will need to be made

Prioritize

Purposeful misleading

Opposition will mislead by

interchanging words like nurse practitioner

and nurse

Tactics to confuse the policymakers

Rogue APRNs

There is always this possibility be

preparedTactics by opposition

ClarityStaying connected

with policymakers to explain opposition

misleading information

professionally

By using evidence this clarifies and

builds trust

Education comparison

Comparing educational schooling

of a physician and NP is not as easy as

black and white

There is no similar structure standard for

comparison

CollaborationHas different

meanings in different states

All providers collaborate with other

providers


Fostering Innovation

27 states, organizations and

territories have transitioned to FPA

Utilizing APRNs to ensure healthcare

access to all

There is no checklist to obtain FPA

Develop strategies from the lessons

learned

Benefit from those who have already

obtained FPA

Keep goal in hand

Improve access to care Through FPA

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