HomeFeaturesAsk a Professor: How Florida’s NPs Are Fighting for Full Practice Authority

Ask a Professor: How Florida’s NPs Are Fighting for Full Practice Authority

“The biggest thing we can do is educate the public and our legislators on what we, as NPs, do. Patients love NPs because we spend time with them. We talk with them. We provide a different level of engagement. That’s the story we need to tell. That’s where our power comes from.”

Rene Love, Associate Dean For Academic Affairs-Graduate Clinical Education & Clinical Professor at the University of Florida College of Nursing

America does not have enough primary care physicians to serve its population’s needs, and the gap increases further as the Baby Boomer generation ages. The problem is particularly acute in Florida, which has the second-largest elderly population in the nation (USA Today 2024). And the patients aren’t the only ones aging: as Florida’s physicians age towards retirement, more providers are needed to replace them.

Floridians have a complex set of healthcare needs that include and extend beyond primary care. Chronic disease management, mental health services, and preventative care are in high demand, particularly in rural and underserved areas. More providers in more places is a critical part of the answer, and Florida’s expertly trained and educated nurse practitioners (NPs) are ready to help.

Meet the Experts

Stacia M. Hays, DNP, APRN, CPNP, CCTC, CNE

Dr. Stacia M. Hays is a board-certified Pediatric Nurse Practitioner (PNP). She earned her MSN from the University of Texas at Austin and her DNP from the University of Florida. Dr. Hays previously served as Coordinator for the Pediatric Primary Care Nurse Practitioner track at the University of Florida. Her scholarship areas focus on nursing quality and advocacy, as well as improving resilience in children who have suffered trauma, disasters, and other high-risk conditions.

Dr. Hays serves as Treasurer on the Executive Board of the National Association of Pediatric Nurse Practitioners (NAPNAP) and is the Florida (north) representative for the American Association of Nurse Practitioners (AANP). Dr. Hays has been the regional lead for the Florida Action Coalition and the Florida Center for Nursing. She has also served as a faculty advisor to the UF Health Patient Safety and Nursing Quality Council. She is the recipient of state, national, and international leadership and advocacy awards.

Dr. Hays was interviewed for this article in the summer of 2020.

Rene Love, PhD, DNP, PMHNP-BC, FNAP, FAANP, FAAN

Dr. Rene Love is associate dean For academic affairs-graduate clinical education and a clinical professor at the University of Florida College of Nursing. She earned her DNP from Vanderbilt University and her PhD from the University of Arizona.

Dr. Love’s research interests and scholarship are in vulnerable populations. In particular, she is interested in resilience within this population. She is also interested in supporting students to have opportunities to build knowledge and training in vulnerable populations. Dr. Love has led national groups working with competencies, curriculum, and scope and standards setting for AACN. She is past president of the International Society of Psychiatric Mental Health Nursing and served as a member at large on the board of the National Organization for Nurse Practitioner Faculty.

Dr. Love was interviewed for an update to this article in the summer of 2024.

Strides to Improve Florida’s NP Practice Authority Laws

Florida has over 32,000 nurse practitioners. These are highly trained healthcare providers who are adept at diagnosing illnesses, prescribing medicines, and treating diseases in both acute and primary care settings. Studies have repeatedly shown that qualified NPs provide safe and effective care that’s equal to that of physicians.

“Many people still don’t understand what we do,” Dr. Hays says. “But for more than 50 years, nurse practitioners have been taking care of patients, demonstrating excellent outcomes, and achieving high levels of patient satisfaction.”

Florida is one of several states that still restricts an NP’s ability to practice to the full extent of their education and training. This manifests mainly in supervisory requirements necessitating a physician’s approval for certain procedures and prescriptions. Rarely is a physician on-site to validate individual decisions, thus creating an extra level of bureaucracy that hampers the quick and effective treatment of an NP’s patients.

“The states that have restricted practice authority for NPs, those are the states that have the worst health outcomes—and those are the states that are spending the most money,” Dr. Hays says. “Those numbers don’t lie.”

NPs have been fighting to get those numbers in front of legislators for a long time. Finally, after seven years of false starts, HB 607 passed the Florida Legislature in 2020, allowing qualified nurse practitioners to independently care for patients in primary care settings without physician supervision. During the legislative session, Dr. Hays was in Tallahassee almost every week, establishing important relationships with legislators, making calls, and talking to the Board of Nursing.

Passing the bill meant a bitter and protracted fight with the Florida Medical Association, who had endorsed Florida’s governor, Rick DeSantis, in his election primary. But Dr. Hays, Florida’s NPs, and the Florida Coalition for Advanced Practice Nurses (FCAPN) continued to push for the removal of barriers to NPs providing quality, patient-centered care to their fellow Floridians.

The Importance of Passing HB 607

“We didn’t do this on our own,” Dr. Hays says. “We partnered with business and healthcare organizations who support access to high-quality care, and did a lot of the legwork, but we had so many supporters out there.”

Some of those supporters included Speaker of the House Jose Oliva, who made healthcare access a priority for Floridians, and Representative Cary Pigman, an emergency medicine physician who supported independent practice for the past eight years. Other partners included the National Council of State Boards of Nursing (NCSBN), Floridians United for Health Care, the Associated Industries of Florida (AIF), the Florida Chamber of Commerce, Florida Blue, the American Association of Retired Persons (AARP), the American Association of Nurse Practitioners (AANP), and the Florida Nurse Practitioner Network (FNPN).

“We couldn’t have done it without them,” Dr. Hays says.

The result of that multi-stakeholder effort is that, as of July 1, 2020, Florida’s NPs became a little freer to deliver the services they’ve been extensively educated and trained to give. Floridian NPs who have at least 3,000 hours of supervised experience, and who have completed a graduate-level education in differential diagnosis and pharmacology in the last five years, can now provide independent services in areas such as family medicine, general pediatrics, and general internal medicine.

Limitations of the New Bill

“This bill was a great step forward,” Dr. Hays says. “However, there are still a lot of limitations.”

The biggest limitation was in the bill’s scope being narrowed to primary care NPs, with primary care being a somewhat ambiguous term. Definitions of primary care vary between government reimbursement models and the NP consensus model, and primary care often overlaps with other facets of healthcare. Further clarification is needed to include as many NPs as possible.

“Some of the barriers we’re having are in changing old language,” Dr. Hays says. “As bills have been updated over the last 20 years, some of that language is left and is now outdated and obsolete. The word ‘physician’ is in there because that is where the focus was in times past, but NPs have been left out.”

A second limitation was the language of the educational requirements. For most medical doctors, nurse practitioners, and pharmacists, schools utilize a concept-based approach, wherein things like differential diagnosis are taught within the context of diagnostic practices. There isn’t necessarily a class on differential diagnosis alone. The five-year requirement is a factor, too: under HB 607, veteran NPs may be required to leave their rural and low-cost clinics in order to educate themselves in areas in which they’re already competent.

“I’ve been an NP since 2003 and I teach pharmacology and differential diagnoses,” Dr. Hays says. “But now I may have to take a graduate-level course in pharmacology, or take forty-five credits of continuing education, in order to meet the criteria of this bill.”

Looking Forward: Continued Advocacy For Florida’s Nurse Practitioners

The fight remains to push for full practice authority. Florida’s NPs are still struggling to get authorization to run rural care buses to improve access to care in outlying communities. Others are faced with the cost burden of paying supervising physicians. And board-certified Pediatric Nurse Practitioners like Dr. Hays are frustrated by regulatory barriers to treating common mental health issues like ADHD, anxiety, and depression, and forced to refer long-term patients to far-off providers that they don’t have any prior relationship with.

“The care is so fragmented,” Dr. Hays says.

The remaining restrictions aren’t just limiting the services that Florida’s NPs can provide; they’re also potentially incentivizing healthcare professionals to move out of the state. Graduating NPs in Florida find that their reimbursement is less than it is in other states, and that the fees they must pay to a supervising physician cut into the feasibility of opening their own practice. NPs from other states are also less likely to practice in Florida, where they’ll have less autonomy than they’re used to. Until full practice authority is realized in the state, brain drain is a legitimate concern.

“It’s definitely a stepwise approach,” Dr. Hays says. “You can pass these bills, but it’s the culture that needs to change. Once we achieve full practice authority, the doors are wide open. Instead of focusing on removing barriers to practice, we can focus on getting care to the people who need it.”

Update 2024: Pushing for Progress

The effects of HB 607 have been indisputably positive: more NPs are able to practice to the full extent of their training and education, increasing access to care for many Floridians. Primary care NPs, under the bill’s allowances, have been able to open their own practices in rural underserved areas. But the limitations of the bill are as pronounced as ever.

“Under HB 607, psychiatric-mental health nurse practitioners (PMHNPs) do not have the ability to apply for full practice authority,” Dr. Love says. “And that’s a real shame, because mental health is such a serious issue in our state.”

Full practice authority remains either impossible or unrealistic for many NPs in Florida. However, the Council on APRN Autonomous Practice, which is overseen by the Board of Nursing and the Board of Medicine together, is working to develop and recommend standards that further reinforce Florida’s commitment to enhancing the role of NP. There’s still a long way to go.

“Prior to coming to Florida, I worked in Arizona, which has full practice authority,” Dr. Love says. “I was able to go into a practice setting where there were no mental health providers, and I was able to get credentialed and begin providing services as part of a larger team. We opened up access to a lot of people there, and it was truly an underserved population. Here in Florida, I have to go back and get a collaborating physician, and I have to go through a series of steps as if I’m a brand-new provider, even though I’ve been practicing since 1998. There are so many restrictions and limitations. It can be frustrating.”

In Florida, as in all other states, NPs were relied upon during the public health emergency brought on by Covid-19, with governmental waivers allowing them to temporarily practice to the full extent of their training and education. However, once the public health emergency ended, the waivers were repealed. Similarly, during Covid-19, the nation came to a collective understanding about the importance of mental health—but that understanding hasn’t yet translated into meaningful changes at the legislative level in Florida.

“Florida could open up and do a lot more,” Dr. Love says.

Within the last year, there was an advocacy effort to push for PMHNPs in Florida to be able to apply for full practice authority. But it was led by out-of-state entities, and not coordinated with Florida’s major NP advocacy groups. In the legislative world, where so much comes down to timing and unity, a failed attempt can be worse than no attempt—and this attempt failed. Florida’s NPs are now regrouping and planning the path forward.

“The biggest thing we can do is educate the public and our legislators on what we, as NPs, do,” Dr. Love says. “Patients love NPs because we spend time with them. We talk with them. We provide a different level of engagement. That’s the story we need to tell. That’s where our power comes from.”

The direction of travel, both in Florida and across the nation, is towards full practice authority for all NPs. Facing a shortage of providers, the US does not have the luxury of limiting the abilities of expertly trained, able-bodied providers. States like Florida will inevitably wake up to that fact.

“We’re making progress,” Dr. Love says. “It’s not going to happen tomorrow, but we’re all dedicated to, and passionate about, the future.”

Matt Zbrog

Writer

Matt Zbrog is a writer and researcher from Southern California, and he believes nurse practitioners (NP) are an indispensable component of America’s current and future healthcare workforce. Since 2018, he’s written extensively about the work and advocacy of NPs, with a particular focus on the rapid growth of specialization programs, residencies, fellowships, and professional organizations. As part of an ongoing series on state practice authority, he’s worked with NP leaders, educators, and advocates from across the country to elevate policy discussions that empower NPs. His articles have featured interviews with the leadership of the American Association of Nurse Practitioners (AANP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and many other professional nursing associations.