RESTRICTIVE SCOPE OF PRACTICE FOR APRN

• Efficiency: The current healthcare landscape is marked by increasing patient volumes, an aging population, and persistent provider shortages, especially in specialized areas and remote regions. APRNs are highly educated and skilled healthcare professionals capable of performing a wide range of services. Imposing unnecessary supervisory requirements or limiting their practice capabilities leads to underutilization of a valuable workforce, exacerbating efficiency challenges. The National Academies of Sciences, Engineering, and Medicine (2021) strongly recommend removing scope-of-practice barriers for APRNs to ensure an agile and responsive healthcare system. By allowing APRNs to operate with full practice authority, this project anticipates demonstrating improved patient flow, reduced wait times, and a more streamlined delivery of care, thereby enhancing overall system efficiency.

Background on the Problem or Population of Interest

Advanced Practice Registered Nurses (APRNs) – including Nurse Practitioners (NPs), Certified Nurse-Midwives (CNMs), Certified Registered Nurse Anesthetists (CRNAs), and Clinical Nurse Specialists (CNSs) – are highly educated and clinically experienced healthcare providers. They hold master's or doctoral degrees, are nationally certified in their specialties, and undergo rigorous clinical training. Despite this extensive preparation, their scope of practice is often curtailed by state-level regulations, creating significant disparities in how they can contribute to patient care.

In states with restrictive scope of practice laws, APRNs are typically required to operate under the direct supervision or collaborative agreement of a physician to diagnose, treat, and/or prescribe medications. This contrasts sharply with states that grant full practice authority (FPA), where APRNs can perform these functions independently within their scope of education and national certification.

Primary Source Data:

• State-level legislative data: A review of legislative acts and regulatory bodies (e.g., Boards of Nursing, Boards of Medicine) in restrictive states (e.g., Florida, California prior to recent changes, or Texas in the US context) reveals specific statutes that mandate physician oversight or collaboration for APRN practice (National Council of State Boards of Nursing, 2020). These primary sources explicitly detail the limitations imposed on APRN autonomy, ranging from requiring physician signatures for prescriptions to limitations on admitting privileges or ordering certain diagnostic tests.
• Professional organization position statements: Organizations like the American Association of Nurse Practitioners (AANP) and the National Organization of Nurse Practitioner Faculties (NONPF) regularly publish position statements and data briefs advocating for full practice authority based on extensive research. These documents often cite studies on patient outcomes, cost-effectiveness, and healthcare access in FPA states versus restrictive states (e.g., AANP, 2023 Facts About NPs). This project would specifically cite data from these organizations demonstrating the impact of restrictive laws on the APRN workforce and healthcare delivery.
• Academic research on practice environments: Scholarly articles published in nursing and health policy journals provide empirical data comparing patient access, quality of care, and cost in states with varying APRN regulations. For example, studies might utilize datasets from state health departments, Medicare/Medicaid claims, or large hospital systems to analyze differences in health outcomes or resource utilization (e.g., studies by authors like Auerbach, Buerhaus, Pittman, Fraher). These studies directly provide the quantitative evidence of the problem.

This background demonstrates that the problem is not merely a theoretical debate but a tangible regulatory barrier with documented consequences for healthcare delivery and the optimal utilization of the highly skilled APRN workforce. The focused need for this project is to provide specific, localized evidence to support a transition towards full practice authority within the identified acute care settings, showcasing its benefits in the immediate context.

Significance of the Problem to Nursing and Health Care

The restrictive scope of practice for APRNs carries profound significance for both the nursing profession and the broader healthcare system, aligning directly with overarching health care goals in the community.

• Addressing Healthcare Access and Disparities: In many communities, especially rural, underserved, and low-income areas, there is a critical shortage of primary care providers and specialists. APRNs are often the frontline providers in these settings, providing essential services. Restrictive regulations impede their ability to independently serve these vulnerable populations, worsening health disparities and leaving many without adequate access to care. This problem directly undermines the community's interest in achieving health equity and ensuring that all citizens have access to necessary medical attention. For Kisumu, this is particularly relevant given the emphasis on accessible primary healthcare.

• Optimizing Workforce Utilization and Retention: Nursing is the largest healthcare profession globally, and APRNs represent a highly specialized segment. When APRNs are unable to practice to the full extent of their education and national certification, it leads to professional frustration, burnout, and may contribute to their departure from restrictive environments. This underutilization of a valuable workforce is a significant inefficiency in healthcare delivery. The community has a vested interest in retaining skilled healthcare professionals and ensuring their talents are maximized to meet healthcare needs. The problem directly impacts the sustainability and effectiveness of the nursing workforce, a critical component of community health infrastructure.

• Enhancing Healthcare Quality and Patient Safety: While often argued as a means to ensure quality, restrictive practices can paradoxically compromise it. Delays in care due to unnecessary physician consultation, fragmented care coordination, and administrative burdens can negatively impact patient outcomes. Numerous studies have demonstrated that APRNs provide care that is equivalent in quality to that of physicians for many conditions, with comparable or better patient satisfaction rates (Institute of Medicine, 2011; National Academies of Sciences, Engineering, and Medicine, 2021). The problem directly challenges the community's interest in receiving high-quality, safe, and efficient care from all qualified providers.

• Economic Impact on Health Systems and Patients: Restrictive regulations often increase healthcare costs due to mandated physician oversight, extended patient wait times for appointments, and increased administrative burdens. These additional costs can be passed on to patients, insurers, and the healthcare system as a whole. The community's financial health is intertwined with an efficient and cost-effective healthcare system. Therefore, the problem of restrictive scope of practice has significant economic implications that are important to address for the fiscal well-being of the healthcare system and the community.

By addressing the restrictive scope of practice for APRNs, this project aims to support the larger healthcare interest of the community by improving access, optimizing workforce utilization, enhancing quality, and promoting cost-effectiveness. It creates a context where the highly skilled APRN workforce can be fully leveraged to meet the complex and evolving health needs of the population.

Benefit of the Project to Nursing Practice

This scholarly project will yield significant benefits to nursing practice, particularly for APRNs and the healthcare teams they collaborate with. The expected outcomes are grounded in evidence-based guidelines and have the potential for broader influence beyond the immediate setting.

What will be gained from your project:

• Evidence-Based Justification for Policy Change: The primary gain will be the generation of specific, localized evidence from acute care settings that directly illustrates the benefits of full practice authority for APRNs. This data will serve as a powerful tool for advocating for legislative and institutional policy changes. It moves the discussion from theoretical arguments to demonstrable improvements in patient care and operational efficiency within a relevant context.
• Empowerment and Professional Autonomy for APRNs: By showcasing the positive impact of reduced restrictions, the project will contribute to a professional environment where APRNs can practice to the full extent of their education and certification. This increased autonomy fosters job satisfaction, reduces burnout, and strengthens the professional identity of APRNs, leading to better recruitment and retention within the nursing workforce.
• Enhanced Interprofessional Collaboration: While advocating for autonomy, the project implicitly promotes a new model of interprofessional collaboration, where each team member's skills are optimally utilized. It moves away from a hierarchical "supervision" model to a more collaborative "partnership" model, recognizing the unique contributions of all healthcare professionals.

Expected Outcomes of your project to practice within your population and setting:

Within the identified acute care settings (e.g., specific hospital units, emergency departments):

• Improved Patient Flow and Reduced Wait Times: We expect to see a measurable decrease in patient wait times for initial assessment and treatment. This would be observed through reduced emergency department boarding times or quicker access to consultations within the hospital.
• Increased Access to Care: For certain acute conditions, APRN-led care could directly increase access to necessary services, potentially leading to fewer transfers, earlier interventions, and reduced delays in discharge.
• Enhanced APRN Job Satisfaction and Retention: Qualitative data (e.g., surveys or interviews with APRNs) may reveal an increase in job satisfaction and a decrease in intentions to leave the practice setting, attributed to greater professional autonomy.
• Optimized Resource Utilization: Fiscal benefits, such as reduced costs associated with physician oversight for routine APRN tasks or more efficient use of physical space and equipment, are anticipated.
• Potentially Reduced Readmission Rates: For specific conditions managed by APRNs, we might observe a reduction in 30-day readmission rates due to improved follow-up, patient education, and comprehensive discharge planning facilitated by autonomous APRN practice.

Relation to Evidence-Based Guidelines and Outcomes:

The expected outcomes align directly with recommendations from leading national and international healthcare bodies and nursing organizations.

• Institute of Medicine (now National Academy of Medicine) "The Future of Nursing" Reports (2011, 2021): These foundational reports strongly advocate for APRNs to practice to the full extent of their education and training, citing evidence that this improves access to care, quality of care, and cost-effectiveness. Our project outcomes will provide localized data supporting these national recommendations.
• National Council of State Boards of Nursing (NCSBN) Consensus Model for APRN Regulation: The NCSBN Consensus Model provides a framework for consistent APRN regulation across states, including full practice authority. Our project aims to provide evidence that supports the adoption of this model, demonstrating its practical benefits.
• World Health Organization (WHO) Guidelines: The WHO consistently emphasizes the importance of optimizing the health workforce to achieve universal health coverage. Empowering APRNs aligns with global efforts to strengthen primary healthcare and expand access, particularly in resource-constrained environments like Kenya.

How your project may influence other populations or settings:

• Catalyst for Statewide Policy Change: The evidence generated from this project in specific acute care settings could serve as a powerful case study for broader legislative reform at the state level. If improvements in patient outcomes, efficiency, and cost savings are demonstrated, it provides a strong argument for extending full practice authority to all APRNs across various healthcare settings (e.g., primary care clinics, long-term care facilities, schools).

Scholarly Project Proposal: Addressing Restrictive Scope of Practice for APRNs

Your PICOT Question

P (Population): In acute care settings (e.g., hospitals, emergency departments) within states with restrictive scope of practice laws, I (Intervention): does implementing full practice authority for Advanced Practice Registered Nurses (APRNs), C (Comparison): compared to maintaining current restrictive scope of practice regulations, O (Outcome): lead to improved patient outcomes (e.g., reduced wait times, lower readmission rates, enhanced access to care) and increased healthcare efficiency (e.g., cost savings, optimized workforce utilization), T (Time): over a 12-month period?

Purpose of or Rationale for the Scholarly Project

The purpose of this scholarly project is to evaluate the impact of restrictive scope of practice regulations on Advanced Practice Registered Nurses (APRNs) within acute care settings and to propose evidence-based policy recommendations for the implementation of full practice authority. This project is necessary due to the demonstrable misalignment between current restrictive regulations and the growing healthcare demands, particularly in areas experiencing provider shortages or increased patient acuity.

Evidence-Based Explanation of Necessity and Benefits:

• Health Promotion/Patient Outcomes: Restrictive scope of practice laws for APRNs, which limit their ability to diagnose, treat, and prescribe independently, create unnecessary barriers to accessing essential healthcare services. Evidence consistently shows that states with full practice authority (FPA) for APRNs have better health outcomes, including lower rates of preventable hospitalizations and emergency department visits, especially in rural and underserved areas (Fraher et al., 2021; Buerhaus et al., 2017). This project will highlight how FPA can enhance patient access to timely, high-quality care, thereby promoting health and preventing disease progression. For instance, allowing APRNs to independently manage chronic conditions or provide immediate care in emergency departments can significantly reduce delays in treatment, a critical factor in positive patient outcomes.

• Fiscal Benefit: Healthcare expenditures are a significant concern. Restrictive regulations often necessitate physician oversight for tasks that APRNs are fully qualified to perform, leading to duplicative billing, increased administrative overhead, and inefficient use of highly compensated physician time. Studies have shown that healthcare costs can be significantly reduced when APRNs are allowed to practice to the full extent of their education and training (Yang et al., 2018; Buerhaus et al., 2017). For example, a project demonstrating reduced physician consultation fees, lower overall visit costs, or optimized resource allocation due to APRN autonomy would illustrate substantial fiscal benefits. This is particularly relevant in the current economic climate in Kenya, where resource optimization in healthcare is paramount.