Why expanding APRN scope of practice is bad idea

Expanding the scope of practice for advanced practice registered nurses (APRNs) leads to higher costs and reduced safety for patients who are better served by an integrated care team led by a physician whose education and training requirements far exceeds those of other health professionals.

“Patients are better served when all members of the health care team share information, and decision-making based on their unique skills—all with the common goal of improving the health of the patient,” AMA President Susan R. Bailey, MD, told the Nebraska APRN Technical Review Committee.

The committee is tasked with reviewing a proposal to create a single set of regulations for certified nurse practitioners (CNPs/NPs), certified clinical nurse specialists (CNSs), and certified nurse midwives (CNMs). It would also align state law with a national consensus model for APRN regulation and the newly revised APRN licensure compact.

The APRN compact differs significantly from other interstate licensure agreements. While such compacts for physicians and psychologists ensure license portability to different jurisdictions, the APRN compact would supersede state scope-of-practice laws “by removing any physician supervision or collaboration requirements and allowing APRNs to prescribe non-controlled medications and devices.” Dr. Bailey, an allergist and immunologist in Fort Worth, Texas, told the committee.

Dr. Bailey described research showing that independently practicing APRNs raise health care costs by ordering more diagnostic images and prescribing more antibiotics and opioids than physicians.

“Expanding the scope of practice of APRNs to allow independent practice and prescriptive privileges will increase utilization of diagnostic services, antibiotic prescribing and opioid prescribing—all of which can take a real toll on health care costs as well as threaten the health and safety of patients,” Dr. Bailey said. “We implore you to put patients first and reject this proposal. These added costs and patient safety concerns will place a strain on the health care system, on our patients and on their families.”

As defined by the Nebraska Board of Nursing, full practice and prescriptive authority includes the ability to prescribe pharmacologic and nonpharmacologic interventions and to develop and implement care plans.

Dr. Bailey warned that granting this authority could lead to siloed care and that team-based care is the better alternative.

“All health care professionals play an important role in providing care to patients, including nurse practitioners, nurse midwives, clinical nurse specialists, physician assistants, pharmacists, the list goes on,” Dr. Bailey said. “It really does take a whole team to care for patients.”

Dr. Bailey noted how physicians complete four years of medical school and then gain 10,000 to 16,000 hours of clinical experience during three to seven years of residency training. In comparison, NPs complete two to three years of graduate-level education and 500 to 720 hours of clinical training.

The AMA Health Workforce Mapper shows that nonphysician providers, such as NPs, are more likely to practice in the same geographic locations as physicians—even in states that allow NPs to practice independently.

Dr. Bailey noted that, “while often promised,” increased access to care in underserved areas “simply does not happen” after NP scope of practice expansion. The committee will decide soon whether to give a positive or negative recommendation to Nebraska’s unicameral state legislature regarding the scope of practice expansion proposal.

AMA Center For Health Equity
Andis Robeznieks
October 30, 2020