Ask a Professor: The Fight for Expanded Practice Authority for Ohio’s NPs
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“NPs before me paved the way for the future. I see the profession continuing to evolve over time. It’s going to have to because our health system has become so complex.”
Lisa M. Onesko, DNP, Associate Professor at Kent State University’s College of Nursing
As the Baby Boomers retire, the nation is experiencing a dire lack of primary care providers. Medical schools are not graduating enough primary care physicians to meet the needs of an aging population—and Ohio is not immune to the crisis. The state has 173 federally-designated health professional shortage areas, where just over half of the patients’ needs are met. An estimated 1.9 million Ohioans lack access to vital primary care services (KFF 2024).
The state’s nurse practitioners (NPs) could be part of the solution, but outdated restrictions are preventing them from practicing to the full extent of their training.
“NPs provide a quality of care that’s equivalent to physicians, as shown in many studies,” says Lisa M. Onesko, DNP, APRN-BC, Director of the DNP Program and Associate Professor at Kent State University’s College of Nursing. “We’re cost-effective; we provide high-quality care; and we would be able to increase healthcare access because the number of NPs coming out right now is greater than the number of physicians coming out and specializing in primary care or family practice.”
Meet the Expert: Lisa M. Onesko, DNP, APRN-BC
Dr. Lisa M. Onesko is director of the DNP program and associate professor at Kent State University’s College of Nursing. She currently teaches classes in adult-gerontology primary care, organizational systems, quality improvement in healthcare systems, and applications to evidence-based practice.
Dr. Onesko has also previously served as the director of NP programs and the director of the adult-gerontology program at Kent State. A nurse practitioner since 2002, she works for an internal medicine practice at the Cleveland Clinic. Notably, in 2012 and 2015, Dr. Onesko won the Barbara Donaho Distinguished Leadership in Learning Award.
She spoke to NPSchools.com in late 2020.
The Problem with Ohio’s Standard Care Arrangement
What’s standing in the way of Ohio’s NPs is what’s known as a Standard Care Arrangement (SCA). An SCA requires Ohio’s NPs to enter into a collaborative contract with a physician in order to practice. But the reality is far from collaborative: NPs must submit a subset of their patient charts to their collaborating physician for approval and pay a hefty fee for the privilege. Often, there’s little interaction. And while the intent of the SCA is to ensure the quality of care, it’s much more of a burden than an asset.
In urban settings, SCAs and other restrictions on practice can mean that an NP is unable to admit their own patient to an emergency department (ED). Instead, a physician must admit that patient and follow them throughout the length of their stay. This not only can burden the physician’s workload, but it can cause a break in the continuity of care, and put patients in the hands of providers who do not know their full history or needs.
“NPs are great patient advocates,” Dr. Onesko says. “Not that physicians are not, but it’s at the heart of what we do as NPs—to advocate for our patients. And it’s difficult to do that when your patient is in the hospital and they’re seeing a lot of specialists at once. A lot of times they don’t know what’s going on; they don’t know what medications they need to take at home and that can cause further readmissions and problems down the road.”
A Shortage of Healthcare Services in Rural Settings
The damaging side effects of SCAs are even more pronounced in rural settings, where the primary care need is greatest. Since rural residents often lack access to the same hospital systems that urban settings have, patients have chronic illnesses that are poorly managed. They also have a high number of comorbidities, lower medication adherence, and poor health literacy. Those patient characteristics are precisely what NPs are good at treating, but in rural areas, it can be difficult for NPs to find physicians with whom they can collaborate.
“For a lot of physicians, it’s not appealing to go to a rural area and start practicing,” Dr. Onesko says. “But I know a lot of our students have precepted in rural areas because there’s limited access. They’re very busy and they have very complicated patients who need a lot of care. That’s really challenging in and of itself.”
A 2015 RAND study found that removing restrictions to NP practice in Ohio could lead to significantly increased healthcare access, as well as 70,000 fewer emergency department visits in the state. That not only translates to better patient outcomes but also millions in cost savings. Furthermore, within one or two years of the removal of restrictions, an estimated 330,000 more Ohioans could receive preventative care visits and 1.5 million Ohioans would find better access to care in general.
The Fight for Expanded Practice Authority in Ohio
Over the last few years, Ohio lawmakers have introduced several related bills aimed at reducing or eliminating the standard care arrangement (SCA) requirement for nurse practitioners. While these proposals have varied in structure and scope, they’ve shared a common framework: allowing NPs to practice without a physician-mandated SCA after completing a defined amount of supervised clinical experience, typically on the order of 2,000 or more clinical hours.
These efforts have drawn consistent support from nursing and patient-advocacy organizations, including the Ohio Nurses Association, the Ohio Association of Advanced Practice Nurses, AARP, and other groups that frame SCA repeal as a workforce and access-to-care issue—particularly in rural and underserved parts of the state. Supporters argue that Ohio’s current model creates administrative bottlenecks, limits practice flexibility, and discourages NPs from remaining in or relocating to the state.
Opposition has remained largely consistent as well, primarily through physician organizations such as the Ohio State Medical Association and the Ohio Academy of Family Physicians. Their objections tend to focus less on the concept of collaboration itself and more on the sufficiency of post-graduate clinical experience: arguing that 2,000 hours does not approximate the depth or duration of physician residency training. Some opponents have proposed significantly higher experience thresholds or permanent collaborative requirements instead. What the final requirements are and how they’re implemented remains to be seen.
“There are different perceptions about what an NP does and is able to do, or what someone first coming out of school would feel comfortable doing,” Dr. Onesko says. “I don’t think that all of the graduates now are prepared to hit the ground running. They shouldn’t necessarily have full practice authority right out of school, and may need the extra clinical hours to get up to speed.”
The Future of NP Practice in Ohio
Dr. Onesko began practicing in 2002, and she’s seen a lot of changes in the last 24 years. The advent of online NP programs has led to a massive influx of new students, not all of whom are held to the same standards as traditional brick-and-mortar students. Educating them on the importance of full practice authority is critical in shaping the next generation of autonomous and capable nurse practitioners.
“NPs before me paved the way for the future,” Dr. Onesko says. “I see the profession continuing to evolve over time. It’s going to have to because our health system has become so complex. But NPs are in an ideal position because they understand healthcare systems. They understand patient population outcomes and how to achieve those through lower cost.”
It wasn’t so long ago that Dr. Onesko remembers having to have a physician approve the prescriptions she would write. And she hopes that in the future, the changes will continue, eventually allowing NPs to practice independently and become leaders of interdisciplinary collaborations.
“Current and aspiring NPs should understand what legislation does for our practice; it’s where everything starts,” Dr. Onesko says. “If we need a change, want a change, or have had a change, that’s where it begins—in legislation and getting bills passed.”
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.