Ask a Professor: The Practice Environment in South Carolina

“I’m a South Carolinian for life. And when it’s your state and your home, you understand it, you know the culture, and you know the improvement that you want to see. I’m optimistic that we can have full practice authority in South Carolina. It’s not going to happen overnight, but I think it’s the future of NP practice in the state.”

Dr. Sheryl Mitchell, Assistant Dean for Graduate Studies and Associate Professor at the University of South Carolina College of Nursing

America is increasingly struggling to provide comprehensive healthcare services to its citizens. As the nation’s largest generation enters retirement and heads into old age, medical schools can’t graduate primary care physicians fast enough to meet the population’s growing healthcare needs. A 2020 report from the Association of American Medical Colleges (AAMC) estimates that America could face a shortage of up to 55,000 primary care providers by 2033. But in many states, including South Carolina, the gap is already acutely felt.

Nearly a quarter of all South Carolinians don’t have a personal healthcare provider, and each year approximately 14.9 percent of South Carolina’s adults report not seeing one because of concerns around cost. Altogether, the state has 95 primary care shortage areas, which affect nearly two million citizens in total. With a high obesity rate and over 12 percent of the population uninsured, South Carolinians desperately need access to high-quality, affordable healthcare.

The state has more than 1,750 nurse practitioners (NPs) who could be an elegant part of the solution.

Meet the Expert: Sheryl Mitchell, DNP, APRN, FNP-BC, ACNP-BC, FAANP

Dr. Sheryl Mitchell is Assistant Dean for Graduate Studies and Associate Professor at the University of South Carolina College of Nursing. A South Carolina native, she earned her bachelor of science in nursing, her bachelor of science in biology and psychology, and her doctor of nursing practice all from the University of South Carolina.

Dr. Mitchell teaches in the graduate nursing program at the University of South Carolina and has served as project chair for DNP students. Her research interests include vulnerable populations, graduate nursing education, simulation, policy, and breast cancer survivorship.

Dr. Mitchell currently serves as Vice-Chair of the South Carolina Nurses Association’s APRN Chapter, and as Treasurer for the Coalition for Access to Health Care. She has previously served on the South Carolina Nurses Association Board of Directors as President, President-Elect, and the Commission Chair on Public Policy and Legislation. She also is a Fellow of the American Association of Nurse Practitioners.

The Value of South Carolina’s NPs

“Nurse practitioners (NPs) have the ability to increase access to healthcare for patients in South Carolina,” Dr. Mitchell says. “NPs can practice in primary and specialty care. They can provide patient education and counseling. And they can assess, diagnose, and treat acute and chronic diseases. In general, NPs focus on preventing disease and promoting the health and wellbeing of patients. There’s so much that NPs can do.”

A large body of research has shown that NPs provide high-quality primary, acute, and specialty healthcare services. And NPs are especially valuable in rural areas, where they are more likely to practice than physicians. That’s particularly relevant in a state like South Carolina, where over a quarter of residents live in rural areas. Through patient education and treatment, South Carolina’s NPs can play a critical role in fighting the state’s top health concerns, including heart disease, diabetes, respiratory disease, and infant and maternal mortality.

Unfortunately, some of South Carolina’s current legislation is preventing NPs from practicing to the full extent of their education and training.

The Burdens of Restricted Practice for South Carolina’s NPs

“In South Carolina, we’re considered a restricted practice state, because NPs have to have a practice agreement with a physician in order to practice and to obtain prescriptive authority,” Dr. Mitchell says. “And that physician has to be within the borders of South Carolina. So, if the physician travels outside of the state for a conference or for a vacation, and the nurse practitioner does not have an alternate physician listed on their license, then they can’t practice during that time.”

Furthermore, the state mandates that a physician cannot enter into a practice agreement with more than the equivalent of six full-time NPs at once. As the workforce of primary care physicians ages into retirement, NPs who would otherwise practice in rural areas may instead have to close their practice due to being unable to secure a practice agreement with a physician. Even in situations where NPs are able to find a physician, restrictions around NP practice can cause delays in care for patients.

It doesn’t have to be this way. Half of the states in the US have enacted full practice authority, which allows NPs to practice to the full extent of their education and training without added restrictions. So far, the results are positive: a case study by the Centers for Disease Control and Prevention (CDC) found that lifting burdensome rules on NP practice in Nevada and Minnesota increased access to care in rural and underserved areas.

“Full practice authority means the removal of delays in care for our patients,” Dr. Mitchell says. “It means providing better, high-quality care, and it also means a decrease in cost, because there would be fewer steps for NPs to go through in providing care. Full practice authority would allow us to practice to the fullest extent of how we’ve been educated and how we’ve been trained.”

Advocacy Efforts of South Carolina’s NPs

Things are getting better in South Carolina. In 2018, the state passed legislation that relaxed some restrictions around NP practice: a 45-mile radius limit between NPs and collaborating physicians was changed to anywhere within the state; the number of NPs a physician could have a practice agreement with at once was expanded from three NPs to the equivalent of six full-time NPs; and NPs were given the right to prescribe not only Schedule III-V drugs but Schedule II drugs as well.

“We had significant changes in 2018, but it didn’t happen in one or two years,” Dr. Mitchell says. “I’m optimistic that we’ll have more changes in the future, but it’s going to take additional time.”

Legislative progress has largely come through grassroots efforts by NPs themselves. In South Carolina, the South Carolina Nurses Association (SCNA) and the Coalition for Access to Health Care (CAHC) have been instrumental in coordinating advocacy efforts. South Carolina NPs can find multiple ways to get involved at the local, state, and federal levels.

“In addition to joining professional organizations, I always tell my NP colleagues and students to become the experts of their practice,” Dr. Mitchell says. “What I mean by that is in your local community, you need to be an expert, so that if a legislator asks questions about healthcare, or has questions about the healthcare that their constituents are receiving or are not receiving because there’s a lack of access, then you can be that resource for the legislator.”

When the Covid-19 pandemic hit the US, a majority of states with restrictions on NP practice waived those restrictions to better address the healthcare needs of their populations. In South Carolina, those waivers weren’t as comprehensive as they were in other states; they were also rescinded when the state of emergency ended. But South Carolina’s NPs are hopeful that it’s a sign that the state can and should turn to its NPs to help ensure the health of its citizens.

“I’m a South Carolinian for life,” Dr. Mitchell says. “And when it’s your state and your home, you understand it, you know the culture, and you know the improvement that you want to see. I’m optimistic that we can have full practice authority in South Carolina. It’s not going to happen overnight, but I think it’s the future of NP practice in the state.”

Matt Zbrog

Matt Zbrog


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.