Ask a Professor: The NP Practice Environment in North Carolina
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“Our mission and vision is to take primary care workers and put them in these rural and underserved areas in North Carolina. I believe that if you can take a nurse from rural North Carolina, bring her in and give her the education to be an NP, then that nurse will go back to that rural community and serve there.”
Michelle Taylor Skipper, DNP, Clinical Professor at East Carolina University College of Nursing
As the largest generation ever enters retirement, the nation is facing a widening primary care gap. Medical schools aren’t graduating enough primary care physicians fast enough to meet the growing healthcare needs of the nation’s aging population. According to the Association of American Medical Colleges (AAMC), the US could see a shortage of between 54,100 and 139,000 primary care physicians by 2033.
Some states, like North Carolina, are already feeling the squeeze. As of 2019, 87 out of North Carolina’s 100 counties have Health Professional Shortage Areas (HPSAs) in primary care. Altogether, less than half of the state’s primary care needs are capable of being met, according to the Kaiser Family Foundation (KFF).
The gap is widening. By 2025, one in five North Carolinians will be over the age of 65. In the next two decades, the state expects its senior population to increase by 61 percent. As the state continues to age, its healthcare needs will grow in tandem: recent surveys found that of North Carolina’s senior population, 84 percent had at least one chronic disease. The need is particularly acute in rural areas.
North Carolina’s nurse practitioners (NPs) could be the answer.
Meet the Expert: Michelle Taylor Skipper, DNP, FNP-BC, FAANP
Dr. Michelle Taylor Skipper, DNP, FNP-BC, FAANP, is a Clinical Professor and the Director of the DNP Adult-Gerontology and Family Nurse Practitioner Concentration at East Carolina University College of Nursing. She earned her BSN from UNC-Chapel Hill, her MSN from Duke University, and her DNP from Gardner-Webb University.
Dr. Skipper has practiced as a family nurse practitioner for more than 20 years, working primarily in rural family practice and OB-GYN settings. Her research interests are centered around women’s healthcare and access to contraception, adolescent healthcare, and international experiences with nurse practitioners.
Dr. Skipper graciously shared her perspective on the NP practice environment within North Carolina.
The Promise of Expanded Practice Authority for North Carolina NPs
“Our mission and vision is to take primary care workers and put them in these rural and underserved areas in North Carolina,” says Dr. Michelle Taylor Skipper, a Clinical Professor and the Director of the DNP Adult-Gerontology and Family Nurse Practitioner Concentration at East Carolina University College of Nursing. “I believe that if you can take a nurse from rural North Carolina, bring her in and give her the education to be an NP, then that nurse will go back to that rural community and serve there.”
Between 2000 and 2017, North Carolina’s NP workforce grew by 216 percent in non-rural counties and 187 percent in rural counties, a rate that vastly outpaces the state’s physicians. NPs are highly trained, board-certified health professionals and a majority of them are focused on primary care. A 2019 study in the American Journal of Managed Care found that for routine patients, NPs can provide the same quality of care as physicians; some studies even suggest that the outcomes for patients with chronic diseases are better when their care is managed by an NP.
Unfortunately, North Carolina is classified still as a restricted practice state by the American Association of Nurse Practitioners (AANP), meaning that North Carolina’s NPs face regulatory barriers in practicing to the full extent of their training and their capability. One of the main barriers is what’s known as a collaborative practice agreement, which requires an NP to work under a physician’s supervision.
What is a Collaborative Practice Agreement?
“In North Carolina, an NP with 25 years of experience might have to be mentored by a physician who is only a month out of medical school,” Dr. Skipper says. “That doesn’t make any logical sense for patient access or patient safety. If we didn’t have this supervisory language in NC, you’d have a whole lot more people who would open their own practices, who would stay in rural communities.”
In North Carolina, state law dictates that a supervising physician must be continuously available for consultation, collaboration, referral, and evaluation of an NP’s care. Collaboration with physicians and other healthcare professionals is a core tenet of NP practice, but mandating it in such strict terms severely undercuts the NP workforce from being able to handle the widening gap in primary care services.
“Nobody is asking for the removal of physician supervision because we think we don’t need physician colleagues,” Dr. Skipper says. “What we’re asking for is full practice authority, matched to the scope of our training and education. We’re still going to professionally collaborate with whoever we need to, whether that be a seasoned physician, a seasoned NP, a seasoned PA, or a specialist.”
Over half the states in the US have more relaxed standards of practice than North Carolina. These models of full practice authority align more closely with national standards of practice and demonstrably increase access to care. Notably, eight of the ten healthiest states have enacted these more progressive models for their NPs, while the ten least healthy states all still have restrictive laws in place.
The Future of NP Practice Within NC
North Carolinians are pushing for change. In 2019, the state’s lawmakers introduced the SAVE Act, which would remove physician supervision requirements for NPs and modernize the state’s healthcare system. It will be reintroduced for consideration this year, with support from a wide range of nonprofit professional organizations.
“Early on, North Carolina was a frontrunner for this kind of progressive legislation,” Dr. Skipper says. “In the ‘70s, UNC-Chapel Hill took in the first group of primary care NPs, and they had to ask for the authority to do blood pressure, to draw labs, to do all kinds of things. When all of that first went into the Nursing Practice Act for NPs, we were ahead of the ball game nationally. We were early adopters of this model. But our rules have not kept up.”
It wouldn’t just increase access to care for millions of North Carolinians, it’d also result in an economic windfall: according to a 2015 study by Dr. Chris Conover from the Duke University Center for Health Policy and Inequalities Research, this type of legislation could save North Carolina between $433 million and $4.3 billion per year, and create more than 3,800 new jobs.
“I’m a born-and-bred North Carolina girl, and I’m not going anywhere,” Dr. Skipper says. “But it’s not a very attractive state for other NPs to come to. Subsequently, you’re hurting the state economy because you’re not getting those people to move here, to pay tax dollars here, to bring their families and their expertise, which we need in North Carolina, and especially in rural areas.”
NPs are a critical tool in the nation’s fight to close the primary care gap. In restricted practice states like North Carolina, anachronistic regulations are preventing NPs from doing all they can to help. The Council of Nurse Practitioners (CNP), an active entity within the North Carolina Nurses Association (NCNA), and the American Association of Nurse Practitioners (AANP) are committed to a grassroots campaign of professional and patient advocacy that may yet bring the state in line with healthier, and more progressive, states. With full practice authority, North Carolina can once again be at the forefront of NP practice, home to new and innovative models of collaborative primary care.
“This fall, I will have been in practice for 25 years, and I’ve always joked that I’m not going to retire until we have full practice authority in North Carolina,” Dr. Skipper says, with a laugh. “I sure would like to be able to retire at some point in the next few years.”
Matt Zbrog
WriterMatt 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.