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The U.S. health care system should learn many lessons from the Covid-19 pandemic. A key one is that it’s time to unleash the power of the country’s nursing workforce.

Nurses have been essential in combating Covid-19, from their work caring for patients hospitalized with severe Covid-19 to treating people in their homes and administering vaccines. But even without a pandemic, it’s clear that when nurses are free to fully deploy their expertise and training, they not only improve health care quality and access but can also help dismantle systemic inequities tied to geography, racism, and poverty that affect people’s health.

Full practice authority allows advanced practiced registered nurses, including nurse practitioners and nurse midwives, to prescribe medications, make diagnoses, and provide treatment independent of a physician.

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In the 23 states and the District of Columbia where advance practice nurses have full practice authority, quality of care has improved and gaps in access to care have narrowed. In contrast, the 27 states that do not give nurses full practice authority are more likely to have geographic disparities, higher burdens of chronic disease, difficulty accessing primary care, and higher costs.

As the largest and most trusted segment of the health workforce, the nation’s 4 million nurses are well positioned to more forcefully take on health inequities.

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Nurses practice across a broad range of settings, from clinics and hospitals to schools, homes, public health departments, and more. They see firsthand the link for a child between health, learning, and unstable housing. They teach people how to prevent disease and stay healthy. They refer food-insecure families to food assistance programs. And they are often the only source of care for people living in remote areas.

Harnessing the full potential of nurses can help achieve what the U.S. must aim for: that all Americans, no matter who they are or where they live, have what they need to live healthy lives. But tapping into that potential requires a commitment to reframing nursing education and expanding the environments in which nurses practice and train; diversifying nursing schools so nurses reflect the communities they serve; fully leveraging nurses’ knowledge and skills by removing artificial regulatory and practice barriers that place unjustifiable limits on the work they do; and supporting nurse’s well-being so they can support the well-being of others.

Nursing will face many challenges over the next decade. Addressing the rampant and long-standing health inequities that were magnified by Covid-19 must be a core goal. As detailed in a National Academy of Medicine report on nursing, which we helped develop, meeting those challenges starts with fixing the maldistribution of the health workforce that leaves too many communities short of nurses, adequately paying and investing in school and public health nurses, and better preparing nurses to work in and with communities.

It also means addressing the burnout and trauma among nurses that were magnified by the pandemic. Policymakers and health care systems must ensure that personal protective equipment and safety plans are in place so nurses never again have to sacrifice their health for their jobs. Of the 3,600 health workers who died from Covid-19 so far, roughly one in three have been nurses.

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There are steps we can take now to support and leverage nurses’ expertise and make progress on health equity.

  • State and federal policymakers should permanently lift regulatory barriers that keep nurses from practicing at the top of their education, including scope-of-practice policies that limit full practice authority and restrict access to nursing care, the quality of which is well-established. In fact, the Biden administration recently lifted barriers so advanced practice nurses can now prescribe buprenorphine, widening access to care for opioid addiction. During the pandemic, eight states temporarily lifted practice barriers for nurses without degrading the care quality. California and Massachusetts have made these changes permanent. With health equity as a goal, all states should follow suit by 2022.
  • Educators and health care leaders must work to diversify the nurse workforce, which has historically been white and female. People from ethnic and racial minority groups account for 40% of the U.S. population but comprise just 20% of nurses.
  • Health care institutions and other employers should better empower nurses to use their expertise to improve health and well-being. They must ensure that nurses have the training, experience, support, and exposure to people in the community so they can meaningfully contribute to addressing the social factors that influence health. This includes partnering with other professions and sectors like housing and leading efforts to tackle the social needs of individuals and families and conditions impacting neighborhoods and communities that limit health.

Everyone in America should have a fair shot at being healthy. As leaders, innovators, and advocates, nurses across a wide array of settings are key to achieving this essential goal. But they must have the support and autonomy they need to do it.

Regina Cunningham is the chief executive officer of the Hospital of the University of Pennsylvania, an adjunct professor and assistant dean for clinical practice at the University of Pennsylvania School of Nursing, and a member of the National Academy of Medicine’s Committee on the Future of Nursing. David R. Williams is a professor of public health and African and African American Studies at Harvard University and co-chair of the Future of Nursing committee.

You can hear Cunningham talk more about nursing on an episode of the “First Opinion Podcast.”

  • I’m saddened to see the comments devolve into the usual claims that nurses with the knowledge and skills to provide excellent care do not actually have such skills. The National Academy of Medicine committee reviewed the literature, and NAM is obligated to ensure that every one of their recommendations are backed by evidence. A far more productive conversation would center on how teams of colleagues can work together to achieve the best care for our population. Hierarchies and claims of superiority do not achieve this goal, and it’s well-established in the research that physician “supervision” does not improve quality of care, and it only adds costs and bureaucracy to the system. Patients pay those costs, both in dollars and lack of access to patient-centered care. Let’s take the NAM recommendations and focus on how to advance population health, rather than take the protectionist positions that we sadly see in these comments.

    • “…it’s well-established in the research that physician “supervision” does not improve quality of care, and it only adds costs and bureaucracy to the system.”

      That is absolutely not true – show me a study with a head-to-head comparison of completely independent NPs with independent physicians – NO collaboration or relationship whatsoever. Until you have that (and have it in pretty large trials), you really can’t make this claim on any firm evidence-based ground.

      I echo what I said below – individuals and organizations touting NP equivalence need to come out and say it: that you think medical school, residency, and fellowship are worthless and can be easily replaced by online school at diploma mills and 500 hours of non-standardized training/shadowing. You can call these protectionist positions, but that’s true only insofar as we care about the safety of patients over the greed of corporate medicine seeking to replace physicians with significantly less trained NPPs with no basis of evidence in order to save money (and put it in the pockets of wealthy CEOs and shareholders).

  • Saying that nurses require full practice authority to practice at the “top of their education” is saying that physicians who already have full practice authority go through unnecessary schooling and training. You are equating a nurse, who may or may not have bedside nursing experience, who then goes on to do a poorly defined and unstandardized educational program whether MSN or DNP with a mere fraction of the clinical exposure, to a physician who has spent years learning MEDICINE from the ground up. Nursing is an incredibly important profession. But bedside nursing is nowhere near the clinical experience that medical students and residents obtain. Nursing lobbies posit that NPs do not practice medicine but instead practice “advanced nursing” which is the most bogus thing I have ever heard. You want all the rights a physician practicing medicine has, but you want to call it “advanced nursing” so you don’t get regulated and monitor by the medical boards and instead fall under the nursing board which doesn’t seem to care that NPs are out here misdiagnosing, mistreating, and putting patients at risk. Why would the CEO of UPenn want NPs to have FPA? Is it so they can start to cut physicians across the board and instead hire NPs which are cheaper, can bill the same amount, and do not need supervising physicians? It’s already happening across the nation. The lack of access to care isn’t due to a true physician shortage as we have thousands of physicians who go unmatched every year. So the problem with access to care won’t be solved by giving NPs FPA, who as a population by the way do not work in rural and underserved areas any more than physicians do, it will be solved by increased training spots for unmatched physicians and by subsidizing medical education. Let’s not lower our standards for healthcare just to make it cheaper, because I personally wouldn’t want the cheaper, less experienced NP who got their degree online to be the only one taking care of my family member. Midlevels have a role in healthcare, but ONLY with physician supervision.

    • The extensive research literature details equal or better outcomes for NPs in the areas they practice in, from managing chronic conditions to dealing with healthcare issues that do not need a physician.

    • Disagree w/ Maggie Morris. The studies that apparently show “equal or better” actually do nothing of the sort. They were all done with NPs being supervised, or in direct collaboration with, a physician. And the NPs in many of those studies were already highly experienced and at well-respected academic institutions. No study has been done examining completely independent NPs and comparing their outcomes directly to physicians. These studies are being manipulated well beyond their scope to justify allowing grossly undertrained NPs (many of who are going to online diploma mills with no standardized clinical training) to practice medicine without a license, and replace physicians much to the delight of corporate medicine. Additionally, NPs seem to believe that just “shadowing” a highly trained specialist physician for a few hundred hours essentially entitles them to practice that field independently in spite of never having gone to medical school, or completed the thousands of training hours in residency and/or fellowship. Just look at Dermatology as an example. I also wonder what dear old Regina has to say about the nursing shortage? How does putting all the pressure on nurses to go to NP school, and now pushing FPA, address the nursing shortage? As commented above, we have thousands of unmatched medical school graduates. We need residency training for them, not NP replacements. Instead we’re propping up one-year “NP residencies” for people who circumvented medical school and instead got their degree online. At a certain point, you are going to have to acknowledge what you’re really saying about doctors when you push FPA for NPs: You think the hard work of medical school and residency, a burden physicians bear for the betterment of our patients, is a complete waste and can be substituted by a nice online degree and 500 hours of wishy-washy non-standardized clinical shadowing. Why don’t we stop dancing around the point and call a spade a spade?

  • Nurse practitioners have a minuscule fraction of training as a board certified physician. They are not the same and are not equal. A physician trains minimum 7 years. An NP can take online courses and minimum clinical experience and become an NP and aren’t even required to work as a nurse prior. Please stop trying to push this dangerous agenda on patients. Physicians should lead and supervise all mid level healthcare workers.

  • What statistics were used to make the point that the quality of care is improved where advanced practice nurses are fully licensed ?

  • This ‘scope of practice’ argument likely has merit. That said, empty equivalency statements like the one below open the door for quick dismissal as hyperbole by “organized medicine.” Nor is it clear how calls to “diversify the workforce” fits in to a scope of practice discussion aside from virtue signaling.

    “In the 23 states and the District of Columbia where advance practice nurses have full practice authority, quality of care has improved and gaps in access to care have narrowed. In contrast, the 27 states that do not give nurses full practice authority are more likely to have geographic disparities, higher burdens of chronic disease, difficulty accessing primary care, and higher costs.

  • Nurses are not physicians. Nurse practitioners can obtain a degree via online diploma mills, and their education lacks rigor and any sort of verification of skill and knowledge at a level comparable to a family medicine or internal medicine primary care physician. This push to make NPs into PCPs is dangerous and is a race to the bottom in quality of care.

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