Virginia Nurse Practitioners Join Others Who Practice Independently

[Melissa Mills, BSN]

House Bill 793 passed in the state of Virginia in 2018 and went into effect in January of this year. The legislation allows nurse practitioners (NP) in specialty practices to open a private practice and work without the oversight of a medical doctor. Since nearly half of the states across the country have similar legislation, this appears to be a win, but also possibly just part of the natural progression for NPs.

Marsha Stonehill, a psychiatric NP recently opened her own practice, Melt the Ice. Her doors opened in March, just a few months after the bill went into effect. She described her practice and why she decided to go out on her own in a recent Fredericksburg.com article.

Stonehill has previously worked in large health systems that required her to see many patients in a day and even cut sessions short. Today, she truly is a one-woman show who answers her own phone and emails and even set her times directly with her clients. She leaves extra time between patients in case there are emergencies or care issues that need further discussion beyond the scheduled appointment limits. She has chosen to be a private pay practice to avoid some of the limitations set by health insurance plans.

While Stonehill is enjoying the freedoms of her practice, not everyone in Virginia or even across the nation agrees that nurse practitioners should be allowed to practice alone.

The Debate

Virginia’s law requires NPs to have a minimum of five years of full-time clinical practice. They must submit documentation from a physician who can attest that there was collaboration between the two during that time. If an NP wants to go out on their own but doesn’t meet this qualification, they must provide a plan to the state detailing how they will refer complex cases and emergencies to a doctor or other provider.

Some doctors, like Dr. Davis Liu, who practices in California and runs a start-up called Lemonaid Health doesn’t feel that nurse practitioners should be allowed to practice on their own. He was quoted saying, “It boils down to training. Primary care is a cognitively challenging specialty. The amount of training doctors receive is far greater than that of nurse practitioners.”

However, Lui might be in the minority for a few reasons. And, it’s not just nurses who question if his opinions are correct.

Understanding the State Practice Environment

According to the American Association of Nurse Practitioners, across the U.S., there are three categories of practice that governs the care provided by NPs. Full practice states allow the clinician to evaluate, diagnose, order and interpret diagnostic tests and start and manage treatments. They can also prescribe medications, including controlled substances under their license. This model of care is supported by the National Academy of Medicine and the National Council of State Boards of Nursing. States in this category include Washington, Hawaii, and Iowa.

Reduced practice states include Ohio, Utah, and New Jersey. NPs in these states have a reduced ability to engage in at least one element of the NP practice. They must have career-long collaboration with a provider under a set agreement. The final category is restricted practice in which the NP have a restricted ability to engage in at least one element of the NP practice. They also must maintain career-long supervision, delegation, or team management by another provider. States who continue to restrict NP practice to the fullest include California, Texas, and North Carolina.

What’s Next?

Using NPs as an integral part of the healthcare team has been proven successful many times over the years. They’re a cost-effective solution to the shortage of physicians, and many patients prefer the care they provide. As more states adopt similar laws to Virginia will the naysayers finally believe in the value of NPs at work?

What’s your opinion?

[Jory, MSN, APRN, CNM]

There is one major flaw in the Virginia regulations, unless I read something incorrectly.

It did not include Certified Nurse Midwives in the mix, but included Women's Health Nurse Practitioners. This makes zero sense.

The scope of practice of a WHNP is the same as CNM, except CNMs can additionally attend delivers in the hospital and care for newborns up to 28 days of life. CNM programs are longer because of this.

Not all CNMs attend deliveries.

This is what happens when bills at not thought through.

[Naturally Brilliant, BSN, RN]

The AANP website must not be up-to-date. Look at this map:

https://www.aanp.org/advocacy/state/state-practice-environment

It shows Virginia as a restricted practice state.