Aw

Issue Brief

CHCF

 

NOVEMBER 2021

Transition to Practice for California's Nurse
Practitioners: Lessons from Other States

n September 2020, with the signing of AB 890 (Wood),

California Governor Gavin Newsom and the California

legislature opened the pathway for nurse practitioners
(NPs) to treat patients without physician supervision, a
change that has the potential to improve access to health
care for millions of state residents, particularly those most
impacted by health care provider shortages.' This new
law, among other changes, added Article 8.5, Advanced
Practice Registered Nurses, to Chapter 6, Division 2 of
the California Business and Professions Code (Cal. Bus.
& Prof. Code). This new article establishes authorization
for NPs to practice to the fullest extent of their educa-
tion and training following a transition-to-practice (TTP)
period of no less than three full-time equivalent years or
4,600 hours in specified settings (Cal. Bus. & Prof. Code
§ 2837.103(a)(1)(D)). Additionally, the new law provides
authorization for NPs to practice to the fullest extent of
their education and training following an additional three
years of practice beyond the TTP in all other settings (§
2837.104(b){1)). Section 2837.100 establishes the intent
of the legislature, that the article shall not be an unnec-
essary burden to licensure or practice. California's Board
of Registered Nursing (BRN) is in the process of promul-
gating regulations that will further specify details of the
transition-to-practice period. The regulatory process is a
critical next step on the path to the implementation of
AB 890.

Sometimes called "periods of mentoring" or "required
collaborative practice" for new nurse practitioners, tran-
sition-to-practice periods are neither uniformly required
nor uniformly defined across the country. However, some
helpful lessons for California might be gleaned from the
states that have adopted them. In balancing the desire
to expand the health care workforce while ensuring NPs
provide safe, high-quality care, states often define the
critical elements of the transition to practice in statute
and leave only administrative details for regulation, thus

minimizing the chance of relegislating the policy issues
or slowing down implementation when drafting the
regulations.

Specifically, statutes in other states detail the num-
ber of hours and/or years required; the professional(s)
with whom the NPs must practice during the transition
period (e.g., experienced NP, medical doctor, or doctor
of osteopathy); key standards expected; any restrictions
on settings; and an exemption clause for those NPs
who meet the criteria when the legislation is enacted.
The regulations can then focus on - and be limited to
- operationalizing the administrative process for imple-
mentation and oversight of the various components of
the statute. For example, after detailing the number of
clinical experience hours and documentation required
of new NPs, Illinois' statute notes that "the Department
may adopt rules necessary to administer this Section,
including, but not limited to, requiring the completion
of forms and the payment of fees" (225 Ill. Comp. Stat.
§ 65/65-43).

In California, many of these important issues about the
transition-to-practice period are being decided in the
context of the regulatory process, which is led by the
BRN. Given the importance of the regulatory process in
the context of AB 890 implementation, the experience
of other states should inform the development of regula-
tions in California.

This brief seeks to support the regulatory process in
California by shedding light on how transition to practice
has played out around the country, sharing the existing
evidence on how full practice authority (FPA) and TTP
periods for NPs affect patients' access to care and out-
comes, and providing an update on where California
currently stands in developing its regulation to define its
transition-to-practice period for NPs.
Transition to Practice in the
United States

Nurse practitioner (NP) practice authority varies signifi-
cantly across the United States. The laws of 15 states
authorize an NP to practice to the fullest extent of the NP's
education and training, including prescriptive authority
upon completion of graduate education, passage of a
national board certification examination, and licensure
or certification by a board of nursing (see Table 1).? In
2021, Delaware became the 15th state to attain FPA
without a postlicensure TTP period by removing its pre-
viously required two-year FTE (full-time equivalent) and
4,000-hour TTP period. Another 10 states authorize NPs
to practice to the fullest extent of their education and

training following a period of collaboration or supervi-
sion, elsewhere known as a TTP period. In June 2021,
the Massachusetts board of nursing adopted an emer
gency Department of Public Health Order (issued March
2020) granting full prescriptive authority without supervi-
sion and written guidelines to NPs with two or more years
of supervised practice. Prior to the emergency order and
regulatory adoption, NPs were required to be supervised
and have written protocols for prescriptive authority. Now,
NPs are granted full independent prescribing authority*
following a two-year supervisory period, after which they
have FPA.® The laws and regulations of an additional six
states require a TTP period. However, these states are not
considered FPA states once the TTP period is concluded,
but rather reduced or restricted practice authority.°

Table 1. Nurse Practitioner Practice Authority in the United States, Selected States

TTP OR POST-LICENSURE PRACTICE PERIODt

FPA FOLLOWING TTP#

 

Colorado 750 hours

 

Connecticut 3 years and minimum of 2,000 hours

 

Maryland 18 months

The laws of 15 states

 

Massachusetts 2 years

authorize a nurse

 

Maine 24 months

 

Minnesota 2,080 hours

practitioner to practice to
the fullest extent of their

 

Nebraska 2,000 hours

education and training,

 

Nevada 2 years or 2,000 hours

including prescriptive

 

South Dakota 1,040 hours

 

Vermont 2 years and 2,400 hours

authority upon completion

XS 8S 8 8 SON NK

 

Arkansas 6,240 hours

of graduate education,
passage of a national

 

California 3 years FTE or 4,600 hours

board certification

 

Florida 3,000 hours

examination, and licensure

 

Illinois 4,000 hours and 250 hours of CEUs

 

New York 3,600 hours

or certification by a board

 

Virginia* 2 years

of nursing.

 

* Updated for 34th Annual Legislative Update 2022

t Susanne J. Phillips, "33rd Annual APRN Legislative Update: Unprecedented Changes to APRN Practice

Authority in Unprecedented Times," Nurse Practitioner 44, no.1 Jan. 2021): 27-55.

* For more details, see "State Practice Environment," Amer. Assn. of Nurse Practitioners, January 1, 2021.

Note: TPP is transition to practice; FPA is full practice authority.

 

California Health Care Foundation

www.chcf.org 2
Transition to Practice in

California

AB 890, Chapter 265, Statutes of 2020, which became
effective January 2021, defines the TTP period as "addi-
tional clinical experience and mentorship provided to
prepare a nurse practitioner to practice independently"
and requires the California Board of Registered Nursing
(BRN) to define minimum standards for transition to prac-
tice (Cal. Bus. & Prof. Code § 2837.101[c]). Pursuant to
the legislation, some code sections may be implemented
without further regulatory action, while others require
action by the BRN. Those that may be implemented
without further regulatory action include these:

» Holding professional liability insurance (Cal. Bus. &
Prof. Code § 2837.103[g], § 2837.104[f])

» Posting notice of BRN contact information where
NPs work (§ 2837.103[el, § 2837.104[e])

» Advising new patients that they are being seen
by an NP in Spanish or appropriate language
(§§ 650.01 et seq.)

» Peer review (pursuant to §§ 805 et seq.)

Provisions to be implemented following BRN action
include:

» An NP advisory committee is to be established to
advise and make recommendations to the board
on all matters pertaining to NPs (§ 2837.102[a)).

» Implementation of the NP scope of practice without
standardized procedures (§ 2837.103[c]) requires
the BRN to define minimum standards for transition
to practice under regulation.

» Additionally, the Office of Professional Evaluation
Services (OPES) is required to evaluate all national
NP certification examinations for possible construc-
tion of a new additional California-instituted exam
(§§ 2837.105 et seq.). OPES has until January 2023
to complete this work.

Other code sections are to be implemented following
action from the BRN, and still others are to be imple-
mented on or after January 1, 2023. For AB 890 to be
fully implemented, the BRN's regulatory action com-
bined with timely completion of OPES''s evaluation must
still occur.

The Evidence: The Impact of
FPA and TTP on Patient Care

In 2014, Oliver, Pennington, Revell, and Rantz concluded
that states with FPA have statistically higher rankings in
national health outcomes when compared to states with-
out FPA.' Oliver, Pennington, Revelle, and Rantz, as well
as Traczynski and Udalova, also found lower hospitaliza-
tion rates, improved outcomes in ambulatory and acute
care settings, and lower utilization of emergency depart-
ment care in states with FPA.®

More recently, in 2017, Carthon, Sammarco, Panci,
Chittams, and Nicely found that Americans have difficulty
accessing nonacute health care.' In 2018, Traczynski and
Udalova went on to find that NPs practicing in FPA states
positively impact medical care for underserved popula-
tions and continue to reduce emergency care for primary
care conditions.'° In 2019, Perloff, Clarke, DesRoches,
O'Reilly-Jacob, and Buerhaus found that states with FPA
have lower rates of readmission to hospitals." These
findings are consistent with the findings of two other
studies that failed to identify benefits to patients in states
where the scope of practice is restricted or limited.'?
Finally, Cimiotti, Li, Sloane, Barnes, Brom, and Aiken
encourage policymakers and health care administrators
to quickly modify or remove barriers to NP practice.'?
With documented positive impact of medical care deliv-
ered to vulnerable populations, higher health rankings,
and reduction in emergency care for primary care condi-
tions and readmission to hospitals, there is evidence to
support positive health outcomes when barriers to FPA
are removed.

 

Transition to Practice for California's Nurse Practitioners: Lessons from Other States

www.chcf.org 3
Implementation of

Regulations Around AB 890
and California's TTP to Date

The BRN has established certain important provisions for
implementing AB 890:

» In February 2021, the BRN established the NP
Advisory Committee, where regulations for further
implementation of code sections will be discussed
among NP experts, physicians, and the public. The
nine-member advisory committee includes four
nurse practitioners, two physicians and surgeons,
and one public member.

» Additionally, in April 2021, the BRN requested an
evaluation of national board certification examina-
tions by OPES, and contact with the national board
certification organizations has been established.
This process must be completed by January 1,
2023.

» A scope of practice has been codified in Cal. Bus.
& Prof. Code § 2837.103(c). This law allows NPs to
practice without standardized procedures and phy-
sician oversight.

However, NPs are not yet authorized to practice under
§ 2837.103 until the BRN, with the assistance of OPES,
determines whether a second examination is necessary
beyond passing the national certification examination,
and regulations are drafted and adopted establishing cri-
teria for the TTP period. During this period of evaluation
by OPES, the BRN has authority to establish and adopt
regulations pertaining to the TTP period.

Conclusion

Though more research is necessary, evidence to date
does not demonstrate that care has improved as a result
of a required TTP. As such, a TTP period that is seam-
less and minimizes barriers to practice could best serve
California policymakers' goals of improving access to
health care for state residents impacted by provider
shortages.

 

California Health Care Foundation

www.chcf.org 4
About the Author

Susanne J. Phillips, DNP, APRN, FNP-BC, FAANP, FAAN,
is a clinical professor and associate dean of clinical affairs
at the University of California, Irvine. Her area of scholarly
work includes changes in scope of practice and transi-
tion to practice throughout the country as these relate to
advanced practice registered nurses.

About the Foundation

The California Health Care Foundation is dedicated to
advancing meaningful, measurable improvements in the
way the health care delivery system provides care to the
people of California, particularly those with low incomes
and those whose needs are not well served by the status
quo. We work to ensure that people have access to the
care they need, when they need it, at a price they can
afford,

CHCF informs policymakers and industry leaders, invests
in ideas and innovations, and connects with changemak-
ers to create a more responsive, patient-centered health
care system.

Endnotes

1.

10

11.

12.

13.

"Bill History: AB-890 Nurse Practitioners: Scope of Practice:
Practice Without Standardized Procedures" (2019-2020), 2020
Cal. Stat. ch. 265.

. Susanne J. Phillips, "33rd Annual APRN Legislative Update:

Unprecedented Changes to APRN Practice Authority in
Unprecedented Times," Nurse Practitioner 46, no.1 (Jan. 2021):
27-55.

. Phillips, "33rd Annual."

. Massachusetts and a few other states grant full practice authority

without a TTP period for all practice except prescriptive authority.
These states require a TTP period of supervision or collaboration
for the purposes of prescriptive authority only.

. "Advanced Practice Registered Nursing" (PDR, 244 Mass. Code

Regs. 4.00 (effective June 10, 2021).

. For more details, see "State Practice Environment," Amer. Assn.

of Nurse Practitioners, January 1, 2021.

. Gina M. Oliver et al., "Impact of Nurse Practitioners on Health

Outcomes of Medicare and Medicaid Patients," Nursing Outlook
62, no. 6 (Nov. 1, 2014): 440-7.

. Jeffrey Traczynski and Victoria Udalova, "Nurse Practitioner

Independence, Health Care Utilization, and Health Outcomes,"
Journal of Health Economics 58 (Mar. 2018): 90-109.

. J. Margo Brooks Carthon et al., "Growth in Retail-Based Clinics

After Nurse Practitioner Scope of Practice Reform," Nursing
Outlook 65, no. 2 (Mar-Apr. 2017): 195-201.

. Traczynski and Udalova, "Nurse Practitioner

Independence."

Jennifer Perloff et al., "Association of State-Level
Restrictions in Nurse Practitioner Scope of Practice with the
Quality of Primary Care Provided to Medicare Beneficiaries,"
Medical Care Research and Review 76, no. 5 (Oct. 1, 2019):
597-626.

Sara Markowitz et al., "Competitive Effects of Scope of
Practice Restrictions: Public Health or Public Harm?," NBER
Working Paper 22780 (Oct. 2016).

Jeannie P. Cimiotti et al., "Regulation of the Nurse
Practitioner Workforce: Implications for Care Across Settings,"
Journal of Nursing Regulation 10, no. 2 July 1, 2019): 31-37.

 

Transition to Practice for California's Nurse Practitioners: Lessons from Other States

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