Peer Response

Response 1

Hello,

This is a great post. You have presented important points about the restrictions APRNs face in Texas due to the state’s limited practice model. Your discussion of how the COVID-19 pandemic brought the need for APRN autonomy into the spotlight is timely and relevant. One aspect worth exploring further is how telehealth can help advance APRN autonomy. During the pandemic, telehealth was widely adopted to fill healthcare gaps, allowing APRNs to serve more patients, particularly in rural and underserved areas. Studies suggest that telehealth may be a vital component in expanding APRN roles and increasing their independence in states like Texas, where legislative hurdles remain (Gajarawala & Pelkowski, 2021). Could advocating for the permanent expansion of telehealth policies help create a path toward full practice authority?

Additionally, as you mentioned, many physician groups work against APRN autonomy. This factor, based largely on patient protection issues, still poses a major challenge to the enactment of FPA statutes. However, from the available studies of states that allowed FPA, it has been found that clinical outcomes of primary care treated by APRNs are non-inferior to or superior to that by the physicians, particularly in the shortage areas (Kleinpell et al., 2023). Extending training and knowledge dissemination of these positive results could change the tone of the legislative debate regarding Texas.

Notably, APRNs have specific experience and can contribute to solving the problem of staff shortages in healthcare. Texas should exert pressure on APRN autonomy to help boost the quality of healthcare and fill essential gaps in the staffing of healthcare professionals. Having a single vision makes it easy to work together, and therefore, the strategy can include joining advocacy groups like Texas Nurse Practitioners. Do you consider promoting the use of spearheading efforts to advocate for and fight for telehealth and APRN-led care to be part of fighting for FPA?

References

Gajarawala, S., & Pelkowski, J. (2021). Telehealth benefits and barriers. The Journal for Nurse Practitioners, 17(2), 218–221. https://doi.org/10.1016/j.nurpra.2020.09.013

Kleinpell, R., Myers, C. R., & Schorn, M. N. (2023). Addressing Barriers to APRN Practice: Policy and Regulatory Implications During COVID-19. Journal of Nursing Regulation, 14(1), 13–20. https://doi.org/10.1016/s2155-8256(23)00064-9

Response 2

Hello

This is a very insightful post. Your analysis of APRN practice in Florida provides valuable insight into the regulatory challenges APRNs face. Your mention of the 2020 changes allowing for autonomous practice in specific settings is a significant development. However, there is more to explore regarding how APRNs in Florida could further expand their autonomy, especially in specialized areas such as mental health, where the need for APRNs is critical. The introduction of bills like HB 771, aimed at expanding autonomous practice for psychiatric nurses, is crucial in addressing the mental health care shortage. Do you think more advocacy for psychiatric APRNs could pave the way for broader changes across other specialties?

Another point to consider is the role that evidence-based outcomes could play in influencing policymakers. In States with full practice authority (FPA) APRNs, studies have presented evidence of continued improved patient care outcomes at par with or even superior to physician-managed settings (Kleinpell et al., 2023). Cohort to this avail could assist in transforming the political system in Florida, whereby medical associations remain a staunch detractor. Were these research-based outcomes able to be utilized to instigate legislative shifts in Florida as has been done in other states?

Additionally, Florida APRNs stand a chance of proving to the stakeholders within the healthcare facilities that they are in a position to deliver independent, quality care. As such, they could build up much better evidence as to the desirability of the increased level of autonomous practice (Toney-Butler & Martin, 2023). Are you willing to collaborate with these types of organizations to promote FPA in Florida?

It is also worth exploring how Florida’s APRNs can work within existing frameworks to improve patient care while advocating for broader practice changes. How might APRNs navigate these regulatory challenges to deliver comprehensive care to underserved populations?

References

Kleinpell, R., Myers, C. R., & Schorn, M. N. (2023). Addressing Barriers to APRN Practice: Policy and Regulatory Implications During COVID-19. Journal of Nursing Regulation, 14(1), 13–20. https://doi.org/10.1016/s2155-8256(23)00064-9

Toney-Butler, T. J., & Martin, R. L. (2023, January 2). Florida nursing laws and rules. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532859/

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PEER RESPONSE 1:

BY: Aldo Gonzalez posted Oct 1, 2024 7:31 PM

In Texas, Advanced Practice Registered Nurses (APRNs) operate under a restricted practice model, meaning they are not granted full practice authority (FPA). According to the Texas Board of Nursing (BON), APRNs are required to collaborate with a physician to provide patient care, particularly when it comes to diagnosing and prescribing medications. This mandates a formal collaborative agreement and physician oversight, limiting the autonomy of APRNs (Texas Board of Nursing, n.d.). Unlike states with full-practice authority, APRNs in Texas face these restrictions, which can create barriers to independent practice.

The conversation surrounding FPA in Texas has gained momentum, especially due to the COVID-19 pandemic, which exposed gaps in the healthcare workforce. Temporary measures were implemented during the pandemic, allowing APRNs greater freedom to practice independently to address increased healthcare needs (National Council of State Boards of Nursing, 2022). While these temporary changes have sparked discussions about permanently expanding APRN autonomy, no lasting legislation has been enacted. A major obstacle to achieving FPA in Texas is opposition from physician groups who argue that maintaining physician oversight is crucial to ensuring quality care (Buppert, 2018). Nonetheless, organizations like Texas Nurse Practitioners (TNP) continue advocating for legislative changes to remove these restrictions.

As a nurse licensed in Texas, I plan to support the push for FPA by becoming involved in advocacy through professional organizations like TNP. By staying engaged in these efforts, I hope to contribute to improving access to healthcare and supporting APRNs’ autonomy in the state.

Peer Response

PEER RESPONSE 2:

BY: Miguel Sierra Garcia

In Florida, the level of practice for advanced-practice registered nurses is restricted. Buppert (2023) identified that an APRN in Florida is a professional licensed to practice nursing and authorized to perform advanced practices, including certified midwifery, certified practical nursing, certified registered anesthesia, clinical skilled nursing, and psychiatric nursing. APRNs in Florida are regulated by the Board of Nursing and perform advanced-level nursing based on their training and experience, usually under the supervision of a physician (Autonomous Practice for Certified Psychiatric Nurses, 2024). This same bill noted that since 2020, a type of autonomous practice that does not require medical supervision in specific settings was authorized. It also specifies that in Florida there are approximately 62,545 APRNs, of which 11,201 practice autonomously (Autonomous Practice for Certified Psychiatric Nurses, 2024).

In Florida, the autonomous practice of advanced practice registered nurses (APRNs) is regulated by Chapter 464, which states that APRNs can only autonomously perform primary care activities such as family medicine, pediatrics, and internal medicine (Online Sunshine, 2024). In the case of certified nurse-midwives, can provide midwifery services as long as they follow a transfer policy and have coordinated care with a doctor. Additionally, this statute states that a minimum of 3,000 hours of clinical experience, continuing education, and financial responsibility are required to practice autonomously in the state. Although autonomous practice is permitted, a joint council of physicians and APRNs recommends practice standards to the Board of Nursing. This advice is evidence of a political context where the full autonomy of APRNs remains subject to oversight and regulation (Online Sunshine, 2024).

To reverse restricted practice in the state, several bills have been proposed that seek to remove barriers to APRNs’ free exercise of practice. An example is the bill HB 771. This bill seeks to authorize psychiatric nurses to practice autonomously in mental health since these nurses can only perform primary care functions (Autonomous Practice for Certified Psychiatric Nurses, 2024). Amid the COVID-19 pandemic, a major step forward was the passage of HB 607 (Florida Board of Nursing, 2021). Clay Pigman sponsored this bill to eliminate mandatory collaborative practice requirements with a physician (Bachtel et al., 2020).

Obtaining full practice authority for APRNs in Florida has faced numerous barriers. According to Stone-Gale (2023), one of the main barriers is the opposition of various medical associations, which has created a negative climate for expanding the practice of APRNs. The author also points out that the legislators who approved the bill HB 607 are no longer active in the legislative ranks and the current state representatives are reluctant to favor the change. Kleinpell et al. (2021) noted that one of the primary barriers APRNs face is transition-to-practice requirements that require APRNs to practice under medical supervision. These same authors added that these barriers raise the costs of care, increase health disparities, and increase staffing shortages. Because of these barriers and the difficulties created in healthcare, I plan to advocate for changes to current policies in my state. I intend to meet with colleagues and other stakeholders to raise awareness of the need for change. Nurses have an important role in advocacy and in the formulation and implementation of policies that improve health outcomes and our working conditions. I hope to be able to advocate for new bills that favor full practice authority.