Time for Full Practice Authority

Opinion | By Sarah Endicott DNP ’13

Portrait of Sarah Endicott
Sarah Endicott DNP ’13

Wisconsin residents are concerned about access to high quality health care. This is especially true in rural areas like the community where I live and worked as a geriatric nurse practitioner. Waits for appointments and drives to clinics can be long. Coverage can be limited or non-existent, as can provider and patient awareness of available options and services.

While there is no single solution to the problem, there are answers. One is to allow advanced practice registered nurses to practice to the full extent of their education, training and experience.

Currently, Wisconsin state law limits APRNs to what the American Academy of Nurse Practitioners refers to as “reduced practice.” Practically speaking, this means that APRNs in Wisconsin practice with less freedom and more restrictions than comparably educated and licensed peers in some states, including bordering states Minnesota and Iowa. Reduced practice results in decreased access to quality health care, poorer health outcomes and the flight of providers.

Currently, advanced practice registered nurses in 22 states and two U.S. territories have full practice authority. An additional 11 states do not allow APRNs full practice authority but impose fewer restrictions than Wisconsin. The Academy of Medicine and the National Council of State Boards of Nursing recommend the full-practice model.

In Wisconsin, one restriction is that APRNs must have a documented collaborative practice agreement with a physician.

The APRNs carry the responsibility of securing the collaborative agreement.

A legislated collaborative agreement is not the same as collaboration. All health care professionals collaborate. It is an ethical imperative in practice, and nursing has long been a champion for collaboration and an innovator of team-based care. The required collaborative practice agreement is simply a restrictive document that burdens APRNs and restricts their ability to practice in underserved areas where they lack access to a physician to sign the agreement.

Under the current law, APRNs practice under their own licenses and assume full responsibility for patient care. The law does not require the physician to provide education or training to the APRN or to see any of the patients under the care of the APRN in collaboration or consultation. However, the physician is able, and likely will, take a percentage of the APRN’s billing as part of the agreement.

I collaborated with nurses, physicians, physical therapists, speech therapists, occupational therapists and dieticians every day of my practice. Each of us brings expertise, experience, and a unique view to patient problems. Together we provide excellent care. Yet APRNs are the only health care professionals legislated to collaborate. Required collaboration that subordinates one profession to another is not true collaboration and it is not the way I work with my colleagues from other disciplines. And if collaboration is legislated for nurses, it should be for all health care professionals.

Legislative collaborative agreements also create arbitrary barriers to care. In a brief released in October 2018, the Wisconsin Policy Forum reported that 20 of Wisconsin’s 72 counties do not have a practicing psychiatrist. Several other counties share a single psychiatrist. In order to practice in these under-served counties, psychiatric advanced practice nurses—who are educated, trained and licensed to provide psychiatric mental health care—would need to enter into a collaborative practice agreement with a physician who has less education and training in behavioral health. The other option is to enter a collaborative practice agreement with a physician who does not practice in that county and who does not know the population or the local behavioral health resources.

There are better ways to meet the mental health needs of Wisconsin.

Ultimately, legislated collaborative practice agreements prevent APRNs from taking care of the patients who need them most. They do not improve care; they only limit access to it. We need to allow full practice authority for APRNs so that the people of Wisconsin can access the health care they need and deserve.

The opinions expressed here are those of the individual faculty member and are not intended to represent the UW–Madison or the School of Nursing.