Ask a Professor: Autonomous Practice Licensure for Virginia’s NPs
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“When we talk about what’s important to the health of Virginians, access to care is one of the most important factors. NPs are an important part of the solution.”
Kathryn Reid, PhD, Associate Professor at the University of Virginia School of Nursing
As the Baby Boomers retire, the nation is set to experience a primary care crunch. Medical schools can’t graduate enough physicians at a fast enough rate to meet the needs of a rapidly aging population. A 2020 report from the Association of American Medical Colleges (AAMC) found that the US could see a shortage of between 54,100 and 139,000 primary care physicians by 2033. Some states, like Virginia, are already beginning to feel the squeeze.
According to the Kaiser Family Foundation, Virginia currently has 113 health professional shortage areas (HPSAs), which are home to 1.85 million people. The problem will get worse. The Virginia Department of Health projects the state’s senior population to increase nearly 75 percent by 2040, and the number of residents over the age of 85 to double. These demographic shifts are largely taking place in rural rather than urban and suburban areas.
But patients aren’t the only ones aging: 39 percent of Virginia’s physicians are over the age of 55, and will be difficult to replace at the rate necessary to meet the state’s growing primary care needs.
Government initiatives, such as the Conrad 30 program, have sought to bring in foreign doctors to help alleviate the problem. It’s not enough. Virginia can and should do more to empower a homegrown resource: the state’s 8,000 licensed nurse practitioners.
Meet the Expert: Kathryn B. Reid, PhD, University of Virginia
Dr. Kathryn Reid is an Associate Professor at the University of Virginia School of Nursing, the Lead Nurse Planner in the School of Nursing Continuing Education, and the Coordinator of Nursing Research and EBP at a local community hospital. She teaches across academic programs and provides expert mentorship to BSN, MSN, and DNP students. She also has held past academic leadership positions and is a past Fellow in the American Association of Colleges of Nursing Leadership in Academic Nursing Program.
Dr. Reid earned her BSN, MSN, and post-MSN from the University of Virginia, and her PhD from Virginia Commonwealth University. She currently serves on the state board of the Virginia Council of Nurse Practitioners (VCNP) and maintains an active practice as a Family Nurse Practitioner.
Dr. Reid graciously shared her perspective on the role of NPs in Virginia.
How NPs Can Expand Access to Affordable High-Quality Healthcare in Virginia
“When we talk about what’s important to the health of Virginians, access to care is one of the most important factors,” says Dr. Reid. “NPs are an important part of the solution.”
Nationwide, nurse practitioners make up an increasing share of the primary care workforce. These are highly trained, board-certified health professionals who take a holistic and collaborative approach to care; they’re also far more likely than physicians to serve in rural areas. While nurse practitioners and primary care physicians have distinct roles, NPs are qualified to perform many of the same tasks as doctors. 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 physicians have raised concerns that NPs are not trained enough to be able to practice autonomously, which is not really true,” Dr. Reid says. “What is true is that NPs are not trained the same way that physicians are trained, but NPs are still highly trained. They come with usually at least two years of professional experience before they even enter their graduate degree program. NP students go through rigorous clinical training during their clinical program, and their competencies are verified before they graduate.”
There’s even a suggestion in some studies that the outcomes for patients with chronic diseases are better when their care is managed by an NP. This may be, in part, due to the NP’s holistic approach: taking into account not just medical and treatment considerations, but also a patient’s lifestyle, nutrition, physical activity, and other determinants of health.
Time-strapped physicians being pressed to increase their patient volume don’t necessarily have the resources to dedicate to such a holistic approach, but it’s central to NP practice. Holistic approaches and patient education are particularly valuable in chronic disease management in rural and underserved areas.
Virginia: Autonomous Practice Licensure (APL) and Other Steps to Overcome Restricted NP Practice
Unfortunately, Virginia is still a restricted practice state, according to the American Association of Nurse Practitioners (AANP). That means Virginia’s NPs encounter barriers to practicing to the full extent of their training: the state’s recently graduated NPs are required to enter into a collaborative agreement with a supervising physician. This impacts their ability to prescribe medications and practice independently; it also significantly undercuts the force-multiplying benefit that the state’s NPs could have in counteracting the primary care shortage.
“Over the last few decades, our federal government has been pouring money into trying to incentivize medical students to enter into primary care, family practice, and general practice,” Dr. Reid says. “And there has never been any demonstrable improvement. Yet here we stand: hundreds of thousands of NPs across the country are ready to help be a major part of the solution for access to care.”
Virginia is making progress, albeit slowly. In 2012, the state removed the requirement for physical, on-site supervision, and replaced it with a collaborative agreement between physician and NP. And, in April 2018, the state approved a transitional licensing model for its NPs, allowing those with five years (or 10,000 hours) of full-time work equivalence in their certification area to apply for Autonomous Practice Licensure (APL), and practice independent of physician oversight.
“APL is a really important step for NPs to take, especially in rural and underserved areas,” Dr. Reid says. “With APL, an NP can practice without the burden of having to find a physician to sign a collaborating agreement, especially when the physician may not live in the geographic area, or may charge lots of money just to sign the agreement to support the NP (but not actually be a part of providing the service with the NP).”
Virginia’s APL is a step forward, but it’s still a relatively restrictive measure by national standards. Over half the states in the country have chosen more relaxed licensure models, ones that align with national standards of practice and demonstrably increase access to care. Notably, eight of the ten healthiest states have enacted such models for their NPs, while the ten least healthy states all still have restrictive laws in place.
“There are a number of states that do not require clinical practice as a part of APL,” Dr. Reid says. “Their NPs are able to practice to the full extent of their education and training at the time that they are licensed, without restriction. I think that should be true also for NPs in Virginia. And I have yet to be presented with any data to show that it would put anybody at risk or pose a threat to public safety.”
The Future of NP Practice in Virginia
In 2021, Virginia’s General Assembly will introduce HB1737, a bill that would reduce that transitional period from five years to two years—something that’s already been enacted, temporarily, during the coronavirus pandemic. Organizations like the Virginia Council of Nurse Practitioners (VCNP) are continuing to advocate for this legislation, and the nurse practitioner profession, as a way of boosting patients’ access to care. VCNP held two virtual town hall meetings on January 6, 2021, to review HB1737, share resources, and help members connect with their legislators and garner support.
“We are very lucky here in Virginia,” Dr. Reid says. “We’ve got some really strong advocates.”
In Dr. Reid’s eyes, it’s not just advocating for the NPs, but for a more evolved and collaborative healthcare system. As part of her faculty role at the University of Virginia School of Nursing, she’s helping to transition the continuing education program beyond nursing and into interprofessional education. By educating different health professionals together, and empowering them to practice to the full extent of their training, each provider can better understand the other team members’ unique contributions to care.
“There’s a lot of healthcare that needs to be delivered,” Dr. Reid says. “If we can just engage our teams and our collaborations better, that’s going to help us all in the long run.”
The last ten years have brought significant and positive changes for Virginia’s NPs—the coming years could, and should, continue the trend.
“I’m so optimistic,” Dr. Reid says. “If we can move out from the silos of our individual professions and realize the power of true collaborative care, true team-based care, then our patients are going to do better. Our patients are going to be happier and have better experiences, and I honestly believe that it’s going to make the providers’ work easier, too.”
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.