Nursing Leader Illuminates Strategies to Expedite Independence for Nurse Practitioners
In September 2020, California governor Gavin Newsom and the state legislature opened the pathway for nurse practitioners to treat patients without physician supervision when they enacted AB 890 (Asm. Wood). This is a critical change that has the potential to increase access to health care for many state residents, particularly those most affected by provider shortages. Advocates of the legislation celebrated the milestone, which came after three previously unsuccessful attempts to pass similar legislation. But for health policy experts like Susanne Phillips, DNP, a family nurse practitioner and associate dean at the University of California Irvine’s Sue & Bill Gross School of Nursing, the victory comes with the knowledge that important work needs to be done on the regulatory side to achieve full implementation of the bill so that patients can fully benefit from the law.
Her perspective is informed by her previous leadership roles within the California Association for Nurse Practitioners and the state Board of Registered Nursing (BRN). She has also closely followed how the same transition played out in 28 states and the District of Columbia, where nurse practitioners (NPs) already have the right to practice without physician oversight after licensure or after a transition period.
Phillips got her bachelor’s and master’s degrees in nursing at California State University, Long Beach, and earned her doctorate at Yale University in 2015. I recently interviewed Phillips on Zoom and asked her how California can maintain momentum as the Board of Registered Nursing works to implement AB 890. This transcript has been edited for length and clarity.
Q: What needs to happen to accomplish implementation of AB 890?
A: One of the first items the BRN has to address is whether the national nurse practitioner certification exams cover everything listed in the NP’s scope of practice. The law states that they have until January 1, 2023. The BRN and the California Department of Consumer Affairs’s Office of Professional Examination Services began working to answer this question earlier this year. Simultaneously, the BRN has established the Nurse Practitioner Advisory Committee, which has held extensive stakeholder discussions prior to the BRN beginning to draft regulations. For example, the law states that nurses can transition to practice independently after three years of supervision, but we need to articulate how nurses will prove they have done this. These are some of the important implementation details that still need to be hashed out.
Q: What have you learned from other states that went through this process?
A: The feedback that we’ve gotten from other states is that the regulatory process is not the only thing that takes time. It’s not uncommon for a state to grant NPs full practice authority while still denying them the right to sign certain forms like a sports physical for medical clearance. To change these kinds of restrictions, nurses must return to their state legislature with what we call “clean-up bills.” One of the things that needs to be tackled in the next clean-up bill for AB 890 is allowing nurses who have already practiced under supervision for years to work independently. AB 890 addresses nurses who are new graduates via the transition to practice requirement, but there is nothing in the law now that says Susie Phillips, who has practiced for 23 years under supervision, can practice independently.
Q: What does California need to do to smooth the path for full practice authority for nurse practitioners?
We certainly need organizations that hire NPs to embrace this law change to ensure timely access to high-quality, cost-effective care. Health care institutions of all sizes provided great support for AB 890. Now we need partners from more than 80 health care institutions, agencies, councils, and clinics to work with nurse practitioner leaders to create a standardized process of implementing the transition to independent practice. At the University of California, for example, advanced practice provider leaders from UC Health hospitals and their respective administrators are working on internal processes to determine who is eligible to practice independently and how to share this information with the BRN.
Q: What is at stake for nurse practitioners?
A: About 29,500 nurse practitioners are currently licensed in California, and allowing them to practice to the full extent of their education and training can improve access to care, reduce inefficiencies, lower costs, and guarantee the patient’s right to decide who they want as a provider. Broad recognition of this important role that NPs can play in improving health care outcomes will support the NPs practicing throughout the state as they work to support the health care needs of California’s residents. Right now, a patient on Medi-Cal has to find a primary care physician before they can select a nurse practitioner because we are not listed in the provider directory. Those are regulatory barriers that we still need to address. Over time, it is important to reduce the barriers making it harder for people to choose an NP as their primary care provider.
Q: From your experience as an academic and a provider, how do you think AB 890 can transform practice in California?
A: I hope the bill will allow more NPs to start their own businesses and attract other health care providers to their teams. Nurses have always been accustomed to practicing in a team-based model, regardless of what the law says, because that’s how we’re trained. I imagine that we’ll see more nurse practitioner–owned corporations, and they will hire nurse midwives, clinical nurse specialists, registered nurses, physical therapists, and other allied health professionals. As AB 890 implementation moves ahead, I hope we can identify the regulatory barriers early, address them simultaneously rather than one after the other, and decrease the time it takes NPs to get out there and treat patients without physician supervision.