The Tennessee Nurses Association, which represents more than 15,000 Advanced Practice Registered Nurses (APRNs) in the state, is writing in response to an op-ed published on March 24 by the Coalition for Collaborative Care regarding legislation to allow APRNs to practice to the full extent of their education and training (HB 184 / SB 176).

The legislation in question would relieve APRNs from the antiquated laws that place an administrative and financial hold on their ability to practice to the full extent of their training and education – a relief that would only increase access to care for Tennesseans; it would not enable APRNs to do anything that they are not already allowed to do.

APRNs are highly trained registered nurses who have completed either a master’s or doctoral degree program and received credentials from national boards including the American Nurses Credentialing Center (ANCC) and the American Association of Nurse Practitioners (AANP). These are trained, highly skilled individuals whose expertise in physical assessment and critical thinking is essential in assessing, diagnosing, and managing patients. They are more than capable of providing care to the extent that their education and training provides. Treatment that requires a physician would still be performed by a physician; this legislation does not grant APRNs the ability to provide care that is outside of their education and training.

Currently, Tennessee is one of only 11 states with the highest level of restrictions for APRNs, as APRNs are required to work under a collaborative practice agreement with a physician for their entire time they practice in the state.

This agreement means that APRNs must pay a doctor to review charts and prescriptions several weeks after the patient in question has received their care. Not only is there no added health or safety benefit for a patient when their chart is reviewed 30 days after receiving treatment, but the patient is usually billed for this mandate even if the approving physician had never personally seen or treated them.

A patient chart that is reviewed weeks after treatment has been given is not a team-based model that provides patients with the highest quality care, as the Coalition noted in their op-ed – nor is it that collaborative, as it is more often than not a delayed approval of the care the patient has already received. Rather, it is an archaic model that delays care approval, puts unnecessary costs on APRNs and does not provide the patient with any health benefits. In fact, multiple research studies confirm that APRNs provide care of equal quality to that provided by a physician. According to the Institute of Medicine’s Future of Nursing report, the contention that APRNs are less able than physicians to deliver care that is safe, effective and efficient is not supported by the decades of research that has examined this question.     

The collaborative practice agreement limits care options for Tennesseans who would greatly benefit from the added access to care, as it is difficult for APRNs to set up their own practice and sustain the monthly fee to their designated physician, which is on average $1,500 each month.

Legislation that allows APRNs to independently serve patients will provide relief for Tennessee’s rural communities, which make up 82 percent of the state and whose options are becoming more limited as Tennessee maintains the second highest rate of rural hospital closures in the nation. APRNs would also be able to provide care in urban areas of the state designated as practitioner shortage areas.

The Increased Access to Care legislation through Full Practice Authority for APRNs would also yield major economic benefits and employment opportunities. A 2019 study on the macroeconomic benefits of granting APRNs Full Practice Authority in Tennessee projected an increase of 69,263 additional jobs and $8.63 billion in economic growth over the next eight years – proving that freedom from collaborative practice agreements would have significant economic impact. This is supported by a statement made by the Federal Trade Commission: “We have not seen research suggesting that the safety or quality of primary care services declines when APRN supervision or collaborative practice requirements are lessened or eliminated. Reduced access has the greatest impact on America’s poorest citizens, including Medicaid beneficiaries.  Physicians are less likely to practice in low-income areas or to participate in state Medicaid programs.  Rural communities too are particularly vulnerable to provider shortages and access problems.”

The relief from collaborative practice agreements that was briefly granted from March to May 2020 in Executive Orders 15 (provision 5) and 28 (provision 5.1) and proved to be an effective and necessary part of Tennessee’s COVID-19 relief efforts. Under these provisions, APRNs were able to build temporary assessment sites for COVID-19 patients and treat patients at primary care clinics, in private offices and through telemedicine – all measures that kept hospitalizations down and freed up beds for patients with severe complications. During this period, APRNs were not providing care that they were not trained to give but were providing care without antiquated physician oversight regulations; care deemed needing physician consultation or referral by the APRN was performed by physicians.

This is the way collaborative care is supposed to work with APRNs providing the care they are trained and educated to give, without the need for administrative and financial holds that bring no added benefit to the patients.

If relief from the collaborative practice agreement was necessary during the height of the pandemic, there is no reason it should not continue as we move into a post-pandemic world. If the COVID-19 pandemic has taught us anything, it is that nurses are the backbone of our healthcare system and any laws limiting their ability to provide direct and focused patient care is not an example of true collaboration – it’s a detriment to Tennesseans everywhere.

Read: OpEd: Coalition for Collaborative Care Shares Concerns about SB0176/HB0184