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I am honored to be back in 2024, once again highlighting the incredible accomplishments of advanced practice registered nurse (APRN) advocates in their pursuit to remove statutory and regulatory barriers to patients' full access to APRN care, based on an ever-growing body of evidence demonstrating high-quality, cost-effective care.

Adding to this body of evidence and knowledge, Dr. Joanne M. Pohl and colleagues published “A Decade of Data: An Update on the Primary Care and Mental Health Nurse Practitioner and Physician Workforce” this year.1 In this report, the authors add to their existing data on primary care workforce numbers, comparing primary care NP graduates to US medical school primary care residency matches; they also expand on previous reports by including and comparing psychiatric mental health NP graduates and US medical school psychiatry residency matches.1,2 Not surprisingly, the report shows that NPs continue to be the fastest-growing primary care provider type in the US.1 Numerous policy recommendations are proposed by the authors, including the removal of restrictive statutes in the 23 states that do not authorize full practice authority (FPA) as defined by the American Association of Nurse Practitioners (AANP).3 (See Summary of practice authority for NPs in the US for a visual depiction of the variation in practice authority across the 50 US states and Washington, D.C.)

Of the 86% of the US state boards of nursing (BONs) or NP/nursing organizations that completed The Nurse Practitioner survey on the status of APRN practice within their areas this year in preparation for this report, 60% reported improvements in practice alignment and prescriptive authority, along with improving reimbursement rates and achievement of pay parity for APRNs across roles. Themes include full/independent practice and scope of practice, transition to practice (TTP) periods and challenges to implementation, licensure and titling, prescriptive authority, and miscellaneous practice authority changes. Although this introductory article focuses mainly on the NP role, statutory or regulatory updates are included for CRNAs, CNSs, and CNMs in the following individual state summaries when reported by survey respondents. Readers are encouraged to review relevant legislation and regulatory changes for more information.

As reported in past APRN legislative updates in The Nurse Practitioner, an overview of the approximate total number of APRNs in each US state and Washington, D.C. is provided in Total number of active clear licensed/certified APRNs in 2023.

Updates to practice authority Scope of practice

In January 2023, the California Board of Registered Nursing (BRN) implemented provisions of Assembly Bill 890 (2020) pertaining to NP scope of practice (SOP).4 § 1481, § 1482.3, and § 1482.4 within Title 16, Division 14, Article 8 of the California Code of Regulations authorize NPs to practice without standardized procedures, define categories of NPs and BRN certification requirements including national certification in a population focus, and define California's TTP period and attestation requirements, among other details.

The New Jersey BON reports that APRNs continue to practice under Executive Order (EO) 112, established April 1, 2020 and renewed in EO 281 on January 11, 2022, waiving the requirement for collaborating agreements between APRNs, including CRNAs, and physicians until the EO is rescinded.5,6 Effective April 9, 2024, New York Educ L § 6902(3)(b) authorizes NPs with more than 3,600 hours of practice experience to 1) practice and have collaborative relationships with one or more qualified physicians or a New York State Department of Health-licensed hospital, long-term-care facility, or clinic (without a written practice agreement or written practice protocols) or 2) practice in accordance with a written practice agreement with a collaborating physician.7

In West Virginia, regulatory standards for APRN scope of practice were adopted in § 19-7-15, which requires APRNs to perform nursing acts and provide services commensurate with their education, training, and experience.8

Challenges to implementation of TTP periods

Four states responded to the survey question regarding implementation of TTP period statutes. Although there is no evidence supporting improved quality and safety of NP practice in states requiring a TTP period, in those states where they are required, regulatory challenges remain. In one midwestern rural state, inconsistent application of rules pertaining to APRN mentorship hours and lack of detailed expectations of the application review process have complicated or delayed the process to obtain full prescriptive authority, according to a local advanced practice nursing association.

Three states reported challenges to physician willingness to sign attestations of completed TTP period hours. This seems to be a growing concern, given that many states require APRNs to practice under supervision of or in collaboration with physicians prior to applying for and/or obtaining FPA. One state reported that there are not enough collaborating physicians to make APRN TTP period requirements reasonable, thereby limiting APRN-owned practices from hiring new providers. Several states have enacted laws and adopted rules allowing for allocation of collaboration hours obtained in another state; however, experienced independent NPs coming from a state which does not require a TTP period are still prohibited from practicing in that state without first completing a TTP period.

Figure:

Summary of practice authority for NPs in the US

Another state reported that employers hesitate to hire NPs during the TTP period. Because oversight is required for practice and/or prescriptive authority, this NP association believes that physician willingness to work with NPs during the TTP period is impeded, adding to the burden of lack of access to care.

- Total number of active clear licensed/certified APRNs in 2023 State Total APRNs NPs CNSs CNMs CRNAs Alabama 10,079 7,005 55 29 2,975 Alaska 2,037 1,869 41 175 258 Arizona 15,599 13,859 123 324 1,293 Arkansas 6,785 5,656 143 45 941 California 44,925 37,317 3,089 1,409 3,110 Colorado 10,328 8,387 513 523 905 Connecticut 8,133 ∗ ∗ 5,44! ∗ Delaware 3,693 3,103 130 60 400 Florida 47,458 ∗ ∗ ∗ ∗ Georgia 19,233 16,457 155 645 1,976 Hawaii 2,455 ∗ ∗ ∗ ∗ Idaho 4,480 3,641 47 91 629 Illinois 26,450 14,981 827 468 2,360 Indiana 9,431 7,804 284 143 451 Iowa 8,131 7,114 74 157 786 Kansas 8,878 7,131 363 102 1,282 Kentucky 14,030 12,033 133 158 1,706 Louisiana 9,622 7,727 127 85 1,683 Maine 4,145 3,384 58 126 577 Maryland 14,310 10,270 115 321 928 Massachusetts 16,580 13,865 627 561 1,527 Michigan¥ 11,635 8,600 235 200 2,600 Minnesota 11,081 9,075 451 440 2,255 Mississippi 7,938 6,900 ! 28 1,010 Missouri 15,084 12,398 270 177 2,239 Montana 3,371 2,962 33 94 282 Nebraska 3,901 3,012 84 61 744 Nevada 5,518 5,414 27 6 323 New Hampshire¥ 2,656 2,103 19@ 123 411 New Jersey 16,598 ∗ ∗ ! (BOM) ∗ New Mexico 6,060 5,184 79 165 632 New York 39,767 39,767 ! ! ! North Carolina 17,915 13,286 277 431 3,921 North Dakota 2,647 2,126 30 30 448 Ohio 28,108 22,905 1,007 520 3,699 Oklahoma 6,691 5,434 293 88 876 Oregon 8,772 7,358 131 434 849 Pennsylvania 18,955~ 18,955 277 ! ! Rhode Island 2,923 2,582 120 ! 221 South Carolina 9,557 7,466 80 134 1,877 South Dakota 2,870 2,232 45 55 538 Tennessee 17,684 14,528 125 234 2,797 Texas 46,242 38,744 624 974 5,900 Utah 6,195 5,493 12 225 465 Vermont 2,015 1,752 22@ 98 137 Virginia 16,956 13,654 386 471 2,445 Washington 14,044 12,050 98 615 1,281 Washington, D.C.¥ 1,162 1,375 44 96 147 West Virginia 4,979 4,002 24 67 886 Wisconsin 8,783 + + 261 + Wyoming 1,958 1,695 18 39 206

The numbers reported in this chart were shared with The Nurse Practitioner by state BONs and/or state nursing associations between August and September 2023.

¥BON did not provide updated information to The Nurse Practitioner, and numbers were not available on BON website. Numbers included in this table reflect the most recently available data, as reported in past legislative updates.

∗Combined with total number of APRNs for that state

~“APRN” term not defined in statute or regulation

!Not recognized as an APRN or equivalent by the BON and not included in state's “Total APRNs” column

@Psychiatric clinical nurse specialists recognized as APRNs only

+Certified as Advanced Practice Nurse Prescribers (APNPs)

Licensure and titling

The state of Connecticut enacted Public Act No. 23-97, amending § 20-94d of the Connecticut General Statutes and authorizing licensure to an APRN by endorsement if they present evidence that they have acquired 3 years of experience as an APRN in another state with requirements for practicing that are substantially similar to, or more stringent than, those of Connecticut.9 In Missouri, House Bill 402 was passed by the legislature and approved by the governor amending § 335.016 (2) of the Revised Statutes of Missouri, requiring licensure as an APRN in addition to holding a registered professional nursing license.10

In March 2023, Chapter 183 of the Virginia Assembly was approved by the governor, replacing all references to “licensed nurse practitioner” throughout the Code of Virginia with “advanced practice registered nurse,” effective July 1, 2023.11 This change brings Virginia in alignment with titling according to the APRN Consensus Model.12

Prescriptive authority

Several states reported improvements to APRN prescriptive authority in 2023, thereby improving access to timely care and treatment. Arizona improved access to care by amending ARS Sect. 32-3248.03, authorizing healthcare providers to dispense up to a 12-hour supply of an opioid medication upon discharge from an ED if there is no 24-hour pharmacy within 50 miles of the hospital, effective October 2023.13 The state of Utah amended Utah Code Section 58-31b-803, eliminating the TTP period requirement for Schedule II controlled substance (CS) prescribing in March 2023.14 Utah is the 28th state (including Washington, D.C.) to authorize FPA as defined by the AANP.

Effective January 1, 2024, Illinois Public Act 103-0060 removes a barrier to timely care by authorizing APRNs with FPA to prescribe up to a 120-day supply of benzodiazepines without a consultation relationship with a physician.15 Thereafter, a continued prescription for benzodiazepines requires a consultation with a physician. In Kentucky, the governor approved Chapter 73 of the Kentucky Revised Statutes, which amended Section 314.042 and thereby improved CS prescriptive authority for APRNs.16 Following 4 years of practice under a Collaborative Agreement for the Advanced Practice Registered Nurse's Prescriptive Authority for Controlled Substances (CAPA-CS) and approval by the BON, an APRN may be exempt from the requirement for a CAPA-CS when they have maintained registrations with the DEA and the state prescription drug monitoring program (PDMP).

Missouri improved timely access to care through amendment of § 195.070 of the Revised Statutes, effective August 2023.17 APRNs holding a certificate of CS prescriptive authority from the BON with delegated authority to prescribe CSs may prescribe Schedule III-V CSs and Schedule II CSs containing hydrocodone; they may also now prescribe Schedule II CSs for patients receiving hospice care pursuant to the provisions of § 334.104. Schedule III narcotic CS and Schedule II - hydrocodone prescriptions are limited to a 120-hour supply without refill. In Ohio, the Ohio Revised Code Section 4723.481 (C)(2)(n) was amended to authorize CNSs, CNMs, and CNPs to prescribe Schedule II CSs, under certain conditions, if the prescriptions are issued at the site of a behavioral health practice that does not otherwise qualify under continuing law as a site where APRNs may prescribe those drugs.18 This provision went into effect October 3, 2023.

West Virginia's BON adopted regulatory changes to Title 19, Series 8 of the Legislative Rule pertaining to W. Va. Code § 30-7-15a, 15b, and 15c.19 These changes update prescriptive authority for APRNs by removing the excluded drug list and authorizing Schedule II CS prescriptive authority as provided in § 16-54-1 et seq. of the code.

Miscellaneous practice authority

Several additional states reported improvements in practice authority, including signature authority (Alaska, Louisiana), access to virtual care and behavioral evaluation (Idaho, Arizona), removal of physician geographic proximity limitations (Missouri), referral privileges (Tennessee), and provider-neutral language (Washington).20-26

Reimbursement

This year, Nevada reported updates to reimbursement authority. Senate Bill 504 was approved by the governor and became effective July 2023.27 This legislation provides for parity of reimbursement between physicians and APRNs in Nevada's Medicaid program.

Conclusion

The author would like to thank all BONs and NP or nursing associations for their contributions to the 36th Annual APRN Legislative Update. All actions reported were confirmed and summarized by the author, and every effort was made to ensure that the information was factual and current as of the time the article went to press. Please see individual state summaries for more detailed information.

Alabama

www.abn.alabama.gov

www.npalliancealabama.org

www.campaignforaction.org/state/alabama

Practice authority

The Alabama state BON has sole regulatory authority to establish qualifications of and certification requirements for APRNs; however, Alabama remains a collaborative practice state, and the BOME retains regulatory authority over physicians engaged in collaborative practice with CRNPs or CNMs. APRNs are defined as “APNs” in Alabama statute and include the CNP (“CRNP” in statute), CNS, CNM, and CRNA roles. CRNPs and CNMs practice within BON- and BOME-approved written CPA protocols; however, collaboration does not require direct, on-site supervision by the collaborating physician. Professional oversight and direction are required as outlined in Alabama Board of Nursing Administrative Code Chapter 610-X-5-.09 and Chapter 610-X-5-.20 and include a requirement for on-site physician attendance (a minimum of 10% of the CNP/CNM's scheduled hours) when the CRNP or CNM has fewer than 2 years of collaborative practice experience.

Alabama meets the AANP's criteria for a reduced practice state. APRN SOP is defined in regulation and in accordance with national standards and functions identified by the appropriate specialty-certifying agency, congruent with Alabama law.

CRNPs and CNMs must hold a master's or higher degree in advanced practice nursing and must hold and maintain national board certification, with a few exceptions, pursuant to Alabama Board of Nursing Administrative Code Chapter 610-X-5-.03 and Chapter 610-X-5-.14. No TTP is required for APRNs in the state of Alabama.

AANP American Association of Nurse Practitioners

APN Advanced Practice Nurse

APNP Advanced Practice Nurse Prescriber

APRN Advanced Practice Registered Nurse

ARNP Advanced Registered Nurse Practitioner

BC/BS Blue Cross/Blue Shield

BOM Board of Medicine

BOME Board of Medical Examiners

BON Board of Nursing

BOP Board of Pharmacy

CARES Act Coronavirus Aid, Relief, and EconomicSecurity Act

CE Continuing Education

CHAMPUS Civilian Health and Medical Program of the Uniformed Services

CME Continuing Medical Education

CNM Certified Nurse Midwife

CNP Certified Nurse Practitioner

CNS Clinical Nurse Specialist

CPA Collaborative Practice Agreement

CPNP Certified Pediatric Nurse Practitioner

CRNA Certified Registered Nurse Anesthetist

CRNP Certified Registered Nurse Practitioner

CS Controlled Substance

DEA Drug Enforcement Administration

DME Durable Medical Equipment

DO Doctor of Osteopathic Medicine

FNP Family Nurse Practitioner

FPA Full Practice Authority

HMO Health Maintenance Organization

MAT Medication-Assisted Treatment

MCO Managed Care Organization

MD Doctor of Medicine

NPA Nurse Practice Act

NPI National Provider Identifier

OTC Over the Counter

PA Physician Assistant/Associate

PCP Primary Care Provider

PCNS Psychiatric Clinical Nurse Specialist

PDMP Prescription Drug Monitoring Program

PMHNP Psychiatric-Mental Health Nurse Practitioner

PNP Pediatric Nurse Practitioner

RNP Registered Nurse Practitioner

R&R Rules and Regulations

SOP Scope of Practice

TTP Transition to Practice

WHNP Women's Health Nurse Practitioner

CRNPs and CNMs may prescribe, administer, and provide therapeutic tests and drugs within a BON- and BOME-approved protocol and formulary. In collaborative practice with a physician, CRNPs and CNMs may prescribe Schedules III, IV, and V CSs and, under limited circumstances, may prescribe Schedule II CSs, pursuant to rules of the Alabama Administrative Code for the BOME: Chapter 540-X-18-.07. In addition to DEA registration, a Qualified Alabama Controlled Substances Registration Certificate is required for qualified CRNPs and CNMs to prescribe these drugs.

Under current regulation for Schedules III-V authority, CRNPs and CNMs are required to complete 12 CME contact hours in advanced pharmacology and prescribing trends, and they must complete 4 additional contact hours every 2 years for renewal of the Qualified Alabama Controlled Substances Certificate. All CRNPs and CNMs are required to access the Alabama PDMP.

Reimbursement

There are no legislative restrictions for APNs on managed care panels. The Alabama Medicaid program enrolls and reimburses CRNPs independently pursuant to supervision rules; however, a CRNP who is employed and reimbursed by a facility that receives reimbursement from the Alabama Medicaid program for services provided by the CRNP may not enroll. BC/BS will reimburse CRNPs and CNMs working in collaboration with a preferred physician provider at 70% of the physician rate.

Alaska

www.commerce.alaska.gov/web/cbpl/professionallicensing/boardofnursing.aspxhttps://anpa.enpnetwork.com

https://www.aprnalliance.org/

www.campaignforaction.org/state/alaska

Practice authority

The Alaska state BON regulates the APRN role, which statute defines as including the CNP, CNS, CNM, and CRNA functions. APRNs are further defined as RNs who, due to specialized education and experience, are certified to perform the acts of medical diagnosis and prescription as well as to dispense medical, therapeutic, or corrective measures under regulations adopted by the BON. Alaska meets the AANP's definition of FPA.

APRN SOP is defined under 12 AAC 44.430 in Alaska Administrative Code. Regulations require that an APRN have a plan for patient consultation and referral, but a physician relationship is not required. APRNs in Alaska are statutorily recognized as PCPs. Nothing in the law precludes admitting privileges for APRNs. Entry into APRN practice requires a graduate degree in nursing and national board certification. There is no TTP requirement in the state. APRNs are authorized to issue do-not-resuscitate (DNR) orders and death certificates.

Authorized APRNs have independent prescriptive authority, including for Schedule II-V CSs. APRNs are legally required to review the PDMP database prior to prescribing CSs and must complete 2 CE hours in pain management, opioid use, and addiction each 2-year license renewal cycle. APRNs are legally authorized to request, receive, and dispense pharmaceutical samples in Alaska. To renew prescriptive authority, APRNs must maintain national certification and complete the opioid CE requirement. Opioid prescribing limitations restrict the number of therapy days that can be prescribed by an APRN.

Reimbursement

All healthcare in Alaska is provided on a fee-for-service basis. FNPs, PNPs, PMHNPs, CNMs, and CRNAs are authorized by law to receive Medicaid reimbursement; NPs receive 85% of the physician payment. A nondiscriminatory clause in the insurance law allows for third-party reimbursement to NPs; Alaska legally requires insurance companies to credential, empanel, and/or recognize APRNs.

Arizona

www.azbn.gov

https://aapnn.enpnetwork.com

www.campaignforaction.org/state/arizona

Practice authority

The Arizona State Legislature grants APRNs authority, and the BON alone regulates their practice. In Arizona, APRNs include CNPs (“RNPs” in statute), CNSs, CNMs, and CRNAs. According to Arizona Revised Statutes (ARS) section 32-1601, RNPs and CNMs in the state are registered nurses who have an expanded SOP, which includes “recognizing the limits of [their] knowledge and experience by consulting with or referring patients to other appropriate healthcare professionals if a situation or condition occurs that is beyond the knowledge and experience of the nurse or if the referral will protect the health and welfare of the patient.”

No formal CPA is required. Arizona meets the AANP's criteria for a full practice state. RNP SOP standards are defined in Arizona Administrative Code R4-19-508, which indicates that RNPs are authorized to admit patients to healthcare facilities, manage the care of admitted patients, and discharge patients. However, Arizona Department of Health regulations require an attending physician for patients admitted to an acute care facility. Acute care facilities apply this citation as the basis for denying independent admitting and hospital privileges to RNPs