Ask a Professor: The Practice Environment in Indiana
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“Honestly, NPs are amazing. We are great at what we do. We establish a rapport with patients. We look at things holistically. But the current laws don’t allow us to practice independently.”
Marne Juestel, DNP, APRN, FNP-BC, Clinical Assistant Professor of Nursing at the Indiana University Northwest School of Nursing
The US is experiencing a primary care crunch, and Indiana is not immune. According to the Kaiser Family Foundation (KFF), Indiana has 117 Primary Care Health Professional Shortage Areas (HPSAs) that are collectively home to more than two million people. Those numbers have been growing and will continue to grow rapidly as Baby Boomers retire. Like many other states, Indiana desperately needs an influx of capable and cost-efficient primary care providers. But medical schools can’t graduate enough physicians to meet the need, and fewer physicians are going into primary care than ever before.
NPs could be a significant part of the solution to Indiana’s healthcare shortages. The increasing professionalization and maturation of NP education, training, and clinical practice has expertly equipped NPs to provide primary care, acute, and specialty health services. And most HPSAs are in rural and underserved areas, where NPs are statistically more likely to practice than their physician counterparts.
Unfortunately, the laws in Indiana have not kept pace with the evolution of the NP profession. While supervisory requirements may have been necessary when they were formed several decades ago, back before NPs had graduate degrees, residencies, fellowships, preceptorships, and hundreds of hours of clinical experience, today they’re outdated. Over half the states in the US have instituted some form of full practice authority: laws that allow NPs to practice to the full extent of their education and training.
Indiana is not yet one of them, but there’s hope on the horizon from an unlikely source.
Meet the Expert: Marne Juestel DNP, APRN, FNP-BC
Marne Juestel, DNP, APRN, FNP-BC, is a Clinical Assistant Professor of Nursing at the Indiana University Northwest School of Nursing in Gary, Indiana. She received her BSN from Valparaiso University, and her DNP from Rush University.
Over a 25-year nursing career, Dr. Juestel has practiced as an emergency medicine NP and as a family NP, working in both rural and non-rural settings. Prior to joining the faculty at IU Northwest, Dr. Juestel served as an assistant professor at Purdue University Northwest. She currently splits her time between academic and clinical settings.
The Challenges of NP Practice in Indiana
“Honestly, NPs are amazing,” Dr. Juestel says, with a laugh. “We are great at what we do. We establish a rapport with patients. We look at things holistically. Many of us work in Federally Qualified Health Centers (FQHCs) or rural health clinics. We try to have our students do clinicals in those types of sites for the underserved, and then that can flow into a job for them. But the current laws don’t allow us to practice independently.”
Over 50 years of research have shown that NPs provide high-quality primary, acute, and specialty healthcare services in a wide variety of settings. But Indiana is a restricted practice state, meaning that NPs still face barriers in practicing to the full extent of their education and training.
In Indiana, NPs are not explicitly recognized in state policy as primary care providers. In order to practice with prescriptive authority, they’re required to enter into a collaborative agreement with a supervising physician. The supervising physician must review 5 percent of an NP’s charts where medicine has been prescribed.
These restrictions, many of which were designed before improvements were made to the education and training of NPs, undercut the ability of NPs to cover the increasing health shortages in Indiana.
And the restrictions are even more of an impediment in rural and underserved areas, which is precisely where the need is greatest, and where there are the fewest physicians potentially able to supervise an NP.
“My first job was in a rural health clinic,” Dr. Juestel says. “I got an HRSA loan repayment for $50,000 of tuition at Rush University, and I learned a lot. You see all walks of life in a rural health clinic. There is a gap there in terms of available primary care.”
Restricted practice sometimes asserts itself in other unpleasant ways, primarily through its establishment of a direct hierarchy: the supervising physician has final authority. While that might be ideal in some specialty practice settings, many of the health services rendered in primary care and family practice are not highly complex issues.
Under the current restrictions, an NP with a long history of working with a particular rural patient population may encounter conflicting opinions from a younger supervising physician who has just moved to the area; or an NP attempting to prescribe clinically safe contraceptives to a patient may meet resistance from an ideologically-opposed rural physician. Dr. Juestel has encountered both situations in her NP career.
Corner cases aside, the most burdensome feature of the restricted practice environment in Indiana is that expertly trained, long-serving, highly experienced NPs cannot run their own independent practice. As more primary care physicians retire and move away from rural clinics, the NPs most able and willing to take their place are prevented from doing so.
“I’ve been working in a family practice for ten years,” Dr. Juestel says. “My collaborating physician is going to retire eventually, and then he’ll turn over this practice to someone else. But right now, because of the laws, that can’t be me. Why should another doctor, who doesn’t know the patients, come in and run the place? It doesn’t make sense. We’re both hoping something changes, and I can take over when he’s ready to leave.”
Making a Measured Transition to Independent Practice
The available research suggests that most NPs in Indiana are ready for independent practice. A 2017 Rand report found that full practice authority for Indiana’s NPs might contribute to improvements in provider supply, access, utilization, and patient experience with care. This dovetails with preliminary data from the other 28 states which have adopted more progressive legislation aimed at allowing NPs to practice to the full extent of their training and education. But uncertainty remains around how that legislation should look in Indiana.
In 2019, Indiana Senate Bill 394 proposed the removal of the collaborative agreement requirement for NPs, but it died in chamber. One of the narratives in opposition to the bill revolved around the perceived inexperience of new NPs and the lack of standardization across NP programs.
But in many states, full practice authority for NPs is dependent upon the NP obtaining several years of hands-on, semi-supervised experience post-graduation. Residencies, fellowships, and preceptorships are all rising in popularity for recent graduates of NP programs, facilitating the transition from education to practice.
“I’ve been doing this for 20 years, and I absolutely would not want NPs practicing independently straight out of school,” Dr. Juestel says. “And there is a difference between online programs and the type of program where I went to school and that I teach at IU Northwest; they’re just not the same. We need to standardize our education and make it so NPs are coming out respected and qualified. The programs need to be rigorous. Then NPs should have three years of full-time experience under a good NP or physician mentor, as in a residency program. After that, it should be open for independent practice.”
In 2020, a crisis even more insistent than the state’s looming primary care shortages forced the hand of Indiana’s decision-makers. As part of Governor Eric J. Holcomb’s Executive Order 20-05, all restrictions which impeded the delivery of NP services were waived, temporarily. Several other restricted practice states followed suit, resulting in an unprecedented opportunity for progressively-minded NPs to prove their point: when empowered to the full extent of their training, NPs can make a huge difference, especially in a full-scale crisis.
And, despite the biggest fears of the fans of restricted practice for NPs, lifting restrictions appeared to have helped. Dr. Juestel and her colleagues will be sifting through new data sets and looking for new research about this period of temporary full practice authority.
“We absolutely need more quantitative research studies, which we never have the time to do,” Dr. Juestel says. “We’re all so busy. Many of us are women raising families, balancing different tasks. I teach NP students. I work three days a week as an NP. I have five kids. So how do you find time to get involved, to go down to Indianapolis and advocate? But we have to be involved and be there. We have to.”
Matt Zbrog is a writer and researcher from Southern California, and he believes a strong society demands a stronger healthcare system. Since early 2018, he’s written extensively about emerging topics in healthcare administration, healthcare research, and healthcare education. Drawing upon interviews with hospital CEOs, nurse practitioners, nursing professors, and advocacy groups, his writing and research are focused on learning from those who know the subject best.