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The NP Practice Environment in Louisiana

“At the end of the day, it’s not about us [NPs]. We’re just trying to increase access to care. That means plugging people in with primary care providers, because 95 percent of our state is in a primary care provider shortage.”

Melissa Nunn, DNP, President of the Louisiana Association of Nurse Practitioners (LANP)

As the Baby Boomer generation retires and moves into old age, the nation’s healthcare needs are larger than ever before and growing. Medical schools aren’t graduating enough physicians at a quick enough rate to meet the need. A 2024 report from the Association of American Medical Colleges (AAMC) forecasts that the US could face a shortage of up to 86,000 primary care physicians by 2036. But the healthcare needs of Americans also reach beyond the Baby Boomers, and beyond primary care.

In many states, such as Louisiana, the gap in access to quality healthcare services is already acutely felt. According to the Kaiser Family Foundation (KFF), Louisiana has 172 Health Professional Shortage Areas (HPSAs) that are home to a collective 1.95 million people. The state has higher-than-average mortality rates in almost every category tracked by the National Institute on Minority Health and Health Disparities. America’s Health Rankings, by United Health Foundation, ranks Louisiana last in the nation for health (UHF 2024).

The data may look dour, but there are thousands of reasons to be optimistic: Louisiana has over 4,400 nurse practitioners (NPs) who are expertly trained in providing high-quality, patient-centered care across a wide range of specialties—and utilizing them to their full capabilities would be a windfall for all Louisianans.

Meet the Expert: Leanne H. Fowler, DNP, MBA, APRN, AGACNP-BC, CNE

Dr. Leanne H. Fowler is the program director of nurse practitioner programs at LSU Health New Orleans School of Nursing, where she is also an associate professor of clinical nursing and the program coordinator of the adult-gerontology acute care nurse practitioner (AGACNP) concentration. She received her BSN from Southern University and A&M College, her MSN/MBA from the University of Phoenix, and her DNP from the University of South Alabama.

Dr. Fowler has over 25 years of nursing experience and more than 16 years in academic nursing education. Her clinical expertise is focused on acute and critically ill adults within hospital settings. Dr. Fowler is an active member of several professional nursing and medical organizations, and health-related or faith-based community organizations. She has formerly served or currently serves in various leadership roles at the state and national levels. Most notably, Dr. Fowler currently serves as the President-Elect for the National Organization of Nurse Practitioner Faculties steering quality NP education nation-wide and supporting models for NP education through global partnerships.

Dr. Fowler is recognized internationally as an Institute for Healthcare Improvement Fellow (2020) for leadership in quality improvement, nationally recognized in the American Association of Critical-Care Nurses’ 2017 Circle of Excellence for contributions to the development of critical care nurses, and was recognized as a Governor John Bel Edwards-appointed member of the Covid-19 Health Equity Task Force for Louisiana.

Dr. Fowler was interviewed for this feature in 2021.

Meet the Expert: Melissa Nunn, DNP

Dr. Melissa Nunn is assistant dean for student services and an assistant professor of clinical nursing at LSU Health School of Nursing. She also serves as Program Coordinator for the BSN-DNP pediatric nurse practitioner programs, overseeing both the primary care and acute care concentrations.

Dr. Nunn is a dual-certified pediatric nurse practitioner, holding board certifications in both primary and acute care from the Pediatric Nursing Certification Board (PNCB). She earned her Doctor of Nursing Practice (DNP) from LSU Health in 2019 and her Master of Science in Nursing from Vanderbilt University in 2015. Before becoming a nurse practitioner, she spent five years as a pediatric nurse at Children’s Hospital, where she later served as the inaugural Director of Advanced Practice. She currently practices in the pediatric emergency department.

An experienced educator and leader, Dr. Nunn is a Certified Nurse Educator (CNE) and holds advanced certification in nursing education administration (NEA-BC) and clinical instruction (CNEcl). Her academic and research interests include student success, leadership development, pediatric healthcare, and nurse practitioner transition to practice. Dr. Nunn is president of the Louisiana Association of Nurse Practitioners (LANP).

Dr. Nunn was interviewed for an update to this feature in 2025.

The Value of Louisiana’s NPs

“Unfortunately, we have a lot of health concerns in Louisiana,” Dr. Fowler says. “The primary issues we could help address as NPs are the health disparities among different populations of patients. We could also help increase healthcare access. Over 95 percent of the state is medically underserved, and 100 percent of the state is underserved when it comes to psychiatric and mental health. There is a lot of workforce capacity that we as NPs could contribute to.”

Over 50 years of research has shown that NPs can and do improve patient outcomes through providing high-quality care across a wide range of healthcare services. They are instrumental in providing primary care: 72 percent of NPs in Louisiana practice primary care, contrasted with less than 12 percent of physicians.

But NPs can also specialize in areas such as family care, acute care, neonatal care, pediatric care, psychiatric care, and women’s and gender health. And the role of the NP extends beyond diagnosis and treatment to counseling and education, which are particularly important when managing chronic conditions.

“We have this large body of healthcare professionals in advanced practice nurses that can meet the needs of several populations, across any setting,” Dr. Fowler says.

NPs are not only highly educated and expertly trained but they’re also members of the most trusted profession in America for 23 years running. Unfortunately, Louisiana’s practice laws don’t seem to trust NPs as much as patients do and outdated restrictions prevent the state’s NPs from practicing to the full extent of their education and training.

The Burdens of Reduced Practice

According to the American Association of Nurse Practitioners (AANP), Louisiana is a reduced practice state, which means that state laws reduce the NP’s ability to engage in at least one element of NP practice. Louisiana’s primary limitation is the requirement of collaborative practice agreements (CPAs), which mandate that NPs must enter into a contract with a collaborating physician in order to practice. In most cases, this doesn’t amount to an added level of meaningful collaboration, but it can and does reduce an NP’s ability to practice, particularly in healthcare shortage areas.

“Collaboration is in our nature,” Dr. Fowler says. “It’s not just in the nature of an NP—it’s in the nature of every medical provider. That’s how safety is upheld: by teamwork and interprofessional collaboration. Safety has nothing to do with a contract. Furthermore, the contracts mandated to be in place now do not guarantee true collaboration.”

By requiring forms of collaboration where they may not be necessary, Louisiana’s laws are creating gaps and delays in care for patients in need. An NP may need to make payments to a physician in order to maintain their collaborative agreement, and they may also have issues being fully reimbursed for routine services. All of the burdens associated with reduced practice are amplified in rural and underserved areas, where the needs of patients are the greatest.

“In the Mississippi Delta, there is very poor health and healthcare access,” Dr. Fowler says. “We have huge healthcare provider shortage areas and great deficiencies in the social determinants of health, meaning education, income, safety, clean water, healthy and affordable food—all of the things that support good public health. We need more practitioners there, and we need the restrictions lifted so people can get the care that they need when they need it.”

Nationally, NPs are more likely than their physician counterparts to practice in rural areas. Together, they comprise approximately a quarter of all healthcare providers in rural areas. And research has shown that expanding scope of practice can improve provider supply, healthcare access, and healthcare utilization.

“The need is there,” Dr. Fowler says. “And I’m confident that we have a workforce who can meet that need.”

The Fight for Full Practice Authority in Louisiana

Half of the states in the US have permanently enacted full practice authority, which empowers NPs to practice to the full extent of their education and training. So far, the results have been positive. Notably, ten out of the ten healthiest states all have full practice authority.

“If we get full practice authority in Louisiana, we would see NPs partnering even more with patients, with communities, with healthcare agencies, and with healthcare teams in general,” Dr. Fowler says.

In states that have earned full practice authority, it’s NPs themselves who have been the biggest agents of change. In Louisiana, it’s no different. The Louisiana Association of Nurse Practitioners (LANP) and the American Association of Nurse Practitioners (AANP) are working together in a grassroots effort to make full practice authority permanent for Louisiana’s NPs and more importantly, for Louisiana’s citizens.

NPs can get involved in advocacy at several different levels, from simply being organizational members all the way to leading entire initiatives; each individual’s participation is valuable.

“It is very important that new NPs and NP students attend conferences, look at the newsletters, get involved in the legislative sessions, and learn how to engage in the community, where the needs are,” Dr. Fowler says. “All of those things increase the presence of our profession, but also demonstrate where we can help the most.”

In May 2021, the Louisiana House passed HB 495, which would’ve facilitated full practice authority for the state’s NPs. Unfortunately, it was not taken up for a vote by the Senate, effectively killing the bill.

But the fight is far from over. Every month, more data is collected that confirms what states with full practice authority all know to be true: NPs are a vital resource in providing citizens with access to high-quality, affordable care.

“I’m optimistic,” Dr. Fowler says. “I feel like full practice authority will happen. It will just require some tenacity, patience, and negotiation. But it’s important that this not be seen as a competition with our medical colleagues. It should be more about our patients than it is about us.”

Update 2025: Lessons Learned & Looking Forward

The failure of HB 495 resulted in some critical lessons learned for Louisiana’s NPs. While the bill did make it further than any other full practice authority bill, it was heavily amended. Those changes split support for the bill, and sometimes in unexpected ways: Louisiana NPs even encountered pushback from some RNs. The next attempt at full practice authority will take a more prepared path.

“Since 2021, we’ve been building our coalition within the nursing profession, but also with different healthcare organizations and other professions,” Dr. Nunn says. “And, since the last bill was blocked by Senate leadership, we’ve started prioritizing that area with outreach and education.”

In the intervening years, there have been some small victories. Louisiana’s NPs are being included in a wider range of healthcare conversations at the regulatory level. Individual but impactful changes are being fought for in allowing NPs to provide home services for birthing parents, or allowing psychiatric mental health NPs admitting privileges. Other states that have won full practice authority for their NPs often stand on a platform of similar small victories.

The ultimate goal remains the removal of the collaborative practice agreement requirement in Louisiana. Today, the state’s NPs still need a physician in the same specialty signing an agreement that says they’ll be there for real-time communication, consultation, and collaboration if needed. But in practice, it does little: NPs are trained medical professionals who already collaborate and consult with their colleagues when needed.

“When I walk into that room, I’m the provider, I’m carrying all the liability, and I’m making all the decisions,” Dr. Nunn says of her day-to-day practice in pediatric emergency medicine. “Yes, if something’s out of my scope of practice, I know that and I’ll refer appropriately. But I can do my job without that piece of paper.”

What the collaborative practice agreement does is restrict NPs from practicing to the full extent of their education and training. It also disincentivizes NPs who may otherwise want to practice in rural areas or operate their own clinic; and if they can’t find a collaborating physician, practicing in rural areas or operating their own clinic isn’t even possible. Louisiana, which is facing down a multipronged healthcare crisis, can’t afford to restrict its providers in this way.

“At the end of the day, it’s not about us,” Dr. Nunn says. “We’re just trying to increase access to care. That means plugging people in with primary care providers, because 95 percent of our state is in a primary care provider shortage.”

It also means addressing the shortages of psychiatric mental health care providers, maternal health providers, geriatric health providers, specialty providers, and those in critical access hospitals. NPs are found in all of those areas, increasing critical access to patient care by reducing wait times, improving inefficiencies, and improving the progression of chronic or acute illness — often among very vulnerable populations.

Louisiana needs all the help it can get. It has the second-highest STI rate in the nation. Over 14 percent of Louisiana adults have three or more chronic conditions (UHF 2023). The state repeatedly ranks towards the bottom of national health scores, and the situation is significantly worse in rural areas, where physicians are lacking, and where NPs are more likely to practice. NPs are well-suited to manage chronic conditions; collaborative practice agreements (CPAs) make it harder for them to apply themselves to the areas where they’re needed most.

Technically, a CPA is site-specific and specific to the physician(s) agreeing to collaborate with an NP. That represents a significant trade restriction to NP services. Louisiana’s citizens deserve and need the ability to choose unlimited access to the time-tested, person- and family-centered, quality care.

Louisiana has an extremely short legislative session: 45 to 60 legislative days a year. Louisiana’s NPs intend to be ready when it re-opens. They’re talking to Senate leadership, getting to know the new governor, coalition-building with internal and external stakeholders, and engaging in outreach and education—all while still seeing patients. The legislative session may be closed until March, but Louisiana’s NPs are working overtime.

“In the past, we thought when the session was over, it was time to relax,” Dr. Nunn says. “But now, we don’t want to lose any momentum.”

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.