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February 2014



Volume 11, Issue 3




NLN Government Affairs Action Center
NLN Public Policy


The Veterans Health Administration (VHA) is currently considering revisions to its VHA Handbook 1180.03: Nursing Handbook which would allow APRNs to “function as independent licensed professionals regardless of the state in which they are licensed.” The language was first proposed in 2012 by the VHA Office of Nursing Services Annual Report, but has drawn particular attention in the past six months.

Although the VHA language aligns with the first recommendation of the 2011 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, there is active opposition aimed at this change from a number of medical societies. >This opposition has resulted in some members of Congress circulating letters among their colleagues urging secretary of veterans affairs Eric Shinseki to NOT make the change to the handbook.

Email your members of Congress NOW and urge them to reach out to the secretary of veterans affairs Eric Shinseki and express their support for the revised VHA Nursing Handbook. Click here to view an editable, template letter.



The Obama Administration’s FY 2015 budget is scheduled to be released on March 4, 2014.> However, details on specific budgets and line items may not be forthcoming until as late as March 11. The NLN will be monitoring the budget’s effects on Title VIII Nursing Workforce Development Programs. Look for detailed information in the next Nursing Education Policy e-newsletter.


us-map-smConnecticut Proposal Would Allow APRNs to Work Independently

Under a proposal from Governor Dannel P. Malloy’s (D) administration, APRNs would be allowed to treat patients and prescribe medications independently. Connecticut law currently requires APRNs to practice in collaboration with a licensed physician. The Malloy Administration’s proposal would still require APRNs to work in collaboration with a physician for the first three years after becoming licensed. After that, an APRN
would be allowed to practice alone.

Connecticut physicians have opposed previous legislative efforts to allow APRNs to practice independently, saying that lawmakers should not reduce the training and education needed to provide medical care. Some doctors have argued that if APRNs practice independently, patients wouldn’t necessarily have access to a doctor to help address complex issues.

Health care reform puts the debate in a new context. The expansion of insurance coverage to thousands more people is expected to raise the demand for primary care, at a time when Connecticut already faces a shortage of primary care doctors and an aging physician population.

The fact that this year’s bill comes from the governor gives it added weight in the legislative process. A measure last year that would have made similar changes, added as an amendment to another bill, had enough support to pass the House but was never taken up for a vote.

Florida APRNs Win First Round

On February 18, the House Select Committee on Health Care Workforce Innovation approved a proposal (PCB SCHCWI 14-01) that would allow APRNs to provide care without doctor supervision. House Republican leaders have pushed the proposal, at least in part because they say it would help address a shortage of primary-care physicians in the state. Senate leaders have shown less enthusiasm.

Physician groups, such as the Florida Medical Association, are lobbying against the proposal. They point to years of additional training that doctors receive to provide care and raise questions about why students would want to take on huge amounts of debt to attend medical school if they could do much of the same work as nurse practitioners. Representative Cary Pigman (R - Avon Park), a physician who is leading the House’s effort on the bill, rejected arguments about issues such as the proposed changes leading people to forgo becoming primary-care physicians.

Under current Florida law, APRNs work under the supervision of physicians.> The bill still would allow APRNs to work under the supervision of physicians, but it also would free them to meet criteria to work independently and to receive authority to prescribe controlled substances.

APRNs Face Opposition in Kansas

The Kansas Senate Ways and Means Committee currently is reviewing Senate Bill 326 that would provide APRNs with more freedom to perform medical services without the requirement of a collaborative agreement with a physician. The bill would allow APRNs to prescribe drugs, execute a health care plan for patients, provide counseling, serve as a primary care provider, and lead a health care team. Kansas APRNs would still be required to spend 2,000 hours – about one year – under the supervision of a physician before being allowed to transition to their own practice.

Nebraska Legislator Introduces Bill to Bolster NPs

Senator Sue Crawford (Bellevue, Nebraska) has introduced a bill – LB916 – intended to help recruit and retain nurse practitioners. The legislation would remove the integrated practice agreement, which requires a doctor to sign on as someone who is working with the nurse practitioner. Crawford’s bill would still require NPs to work with other providers for cases that are beyond their scope of practice. A nurse practitioner cannot currently practice in Nebraska without the agreement.>

Supporters say APRNs are already providing many of these services under the supervision of a physician, and reducing the restrictions could actually help to alleviate doctor shortages. However, the bill is already facing opposition from the Kansas Medical Society and the Medical Society of Sedgwick County.

Battle in West Virginia over APRN Prescription Authority

A battle may be brewing in West Virginia over APRNs having extended prescription authority. The WV Nurses Association is pushing legislation that would allow APRNs more autonomy to provide care “to the full extent of their education and training.” Currently, APRNs may practice independently, but they must have a collaborative relationship with a doctor. They also have limited authority to write prescriptions.

The debate heated up on January 30 when legislative auditor Aaron Allred released a report that raised concerns about empowering APRNs to write prescriptions for powerful pain medications. Allred told members of the West Virginia House Government Organization Committee that “given the addiction crisis we have in West Virginia, I cannot in good conscience recommend to the Legislature that 2,149 more individuals in West Virginia be allowed to write prescriptions for Class 2 narcotics.” The audit also recommended that APRNs who wish to practice without a collaborative agreement should be licensed by the state board of medicine, a proposal that drew particular objections from APRN representatives.

West Virginia APRNs are already helping to fill a health provider gap in West Virginia; they could do more. > Fifty of the state’s 55 counties are categorized as medically underserved. A report released by WV nurses indicates that “states with similar rural populations, such as Montana, Wyoming, Vermont, Idaho and Maine have removed restrictive APRN barriers to allow their residents improved access to primary care.”> They also cite a RAND Corporation analysis showing that APRNs can provide primary care 20 percent to 35 percent more cheaply than physicians.

Two physicians’ organizations, the American Medical Association and the American Osteopathic Association, oppose expanding the scope of practice of APRNs. The legislative audit says: “The AMA recognizes the value of APRNs within the healthcare delivery system, but expresses concern that the nurse practitioner does not have adequate clinical foundation for independent practice.”