HEALTH POLICY

The journey to independent nurse practitioner practice Rebecca Rigolosi, DNP, ANP-BC (Adult Nurse Practitioner) & Susan Salmond, RN, EdD, ANEF, FAAN (Dean) School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey

Keywords Nurse practitioners; legislation; independent practice; advanced practice nurse (APN). Correspondence Rebecca Rigolosi, DNP, ANP-BC, School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey 07103. Tel: 917-318-0846; Fax: 201-833-7221; E-mail: [email protected] Received: 19 December 2013; accepted: 11 March 2014 doi: 10.1002/2327-6924.12130

Abstract Purpose: The aim is to achieve a comprehensive understanding of the journey of states that achieved independent nurse practitioner (NP) practice from 2007 to 2011. Data sources: Qualitative, retrospective, descriptive study with interviews of NP state leaders in those states as well as literature review. Conclusions: There are key strategies that should be utilized by states when attempting to pass independent NP practice legislation. Strategies that have been tried and tested by states that have successfully passed legislation are collated and presented. Implications for practice: Data from key national movements and legislation with release of the 2010 Institute of Medicine Report The Future of Nursing and the passage of the Patient Protection and Affordable Care Act add weight and supportive context to the independent NP legislative process, and were used in addition to and as groundwork for arguments and evidence of a national trend toward increasing access to primary care services and decreasing barriers to practice. Kingdon’s model illustrates these research findings and suggests the open window for policy change is now.

The passage and implementation of the Patient Protection and Affordable Care Act (PPACA) and the publication of the Institute of Medicine (IOM) Report, The Future of Nursing: Leading Change, Advancing Health (The IOM of the National Academies, 2011) have brought national attention to the restrictions placed on nurse practitioner (NP) practice and how these restrictions have a detrimental effect on U.S. health care. The PPACA places significant focus on primary care as an avenue to increase quality and decrease costs. By expanding insurance coverage available, millions of individuals, previously uninsured, will be eligible for primary care services (IOM of the National Academies, 2011, p. 2; Mills, 2010). The Future of Nursing report provides substantial evidence in a usable, timely fashion highlighting the shortage of primary care physicians as well as the evidence that NPs providing primary care have equal or even better outcomes as compared to their colleague physicians. The combined context of more patients insured for primary care and insufficient number of physicians in primary care focus attention on the need to use the expertise of other providers in meeting this need. There are nearly 157,000 practicing or trained NPs in the workforce (AANP, n.d.) who could be called on to provide the much Journal of the American Association of Nurse Practitioners 26 (2014) 649–657  C 2014 American Association of Nurse Practitioners

needed primary care services. However, the inability to practice independently puts up barriers to NP practice, thus limiting the potential for NPs to fill the gap in primary care practice. The costs of restricting NP practice apply not only to access but to actual financial expenditures. It has been estimated that “underutilization of nurse practitioners costs the nation nearly $9 billion annually due to practice restrictions in state laws and other ‘denied access’ for consumers that is keeping the cost of basic health care inflated” (American Association of Colleges of Nursing [AACN], 2012, p. 2). A position statement paper from the American Association of Nurse Practitioners (AANP) cites a “solid body of evidence” (AANP, 2013a, p. 1) with a plethora of studies showing NPs provide high-quality, cost-effective care and services. NPs are expected to play a role in improving access to primary care and lowering costs while maintaining or improving outcomes (Naylor & Kurtzman, 2010; Newhouse et al., 2011). NP practice, including prescriptive authority, is overseen by each state’s regulatory bodies (State Boards of Nursing or State Education Departments) and legislatively defined based on input from these regulatory bodies. There is great variation across the country regarding scope and practice of NPs. While national NP education is 649

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becoming standardized, each state has different laws involving how NPs practice. A primary variation is on the states legally mandated level of physician involvement in NP practice. Although there is significant variation across states, generally the degree of physician involvement is categorized into three different models: supervisory, collaborative, and independent. The AANP categorizes the models developed as independent, reduced practice, or restricted practice. “Full practice” states reflect recommendations by “ . . . the Institute of Medicine and National Council of State Boards of Nursing,” where NPs practice and prescribe medications independently. “Reduced Practice” states “ . . . reduce the ability of nurse practitioners to engage in at least one element of NP practice.” “Restricted practice” states are those where “ . . . supervision, delegation or team management by an outside health discipline . . . ” is required for practice (AANP, 2013b). Full and effective utilization of NPs in primary care requires models of full practice authority. States with reduced or restricted models of care require statutory change to implement full practice authority. Securing statutory change is a complex process. Many states that have some form of restricted practice have active campaigns to change legislation to support independent practice models (Elwell, 2013). As states with restrictive barriers attempt to campaign for change, there are few resources to turn to for guidance with this journey. Understanding the driving and restraining forces exerted by stakeholder groups, and the specific strategies used by the other states could provide valuable information for planning successful strategies for campaigns for independent NP practice. To this end, the aim of this study was to achieve a comprehensive understanding of the journey taken by states that recently achieved independent practice.

Kingdon model of policy analysis The Kingdon model (Kingdon, 2011) of policy analysis served as the framework for analyzing and discussing state practices taken to achieve policy change supporting independent practice for NPs. It recognizes the complexity of the policy process while acknowledging that policy change is not totally grounded in rationalism and incremental problem solving. Kingdon contends that policy change occurs through actions taken in three “streams” of activity by both visible and invisible or behind the scenes individuals. The activity streams occur separately yet simultaneously. It is when the three streams converge in an “open window” that policy advocates can move their interests forward on the agenda and result in policy change. These three “streams” of activity include the 650

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Figure 1 Based on the Kingdon model.

problem, political, and policy streams and are illustrated in Figure 1. The problem stream consists of conditions or issues presented by different constituencies or events that have risen to the level where policy makers are paying attention. Not all issues and conditions presented to policy makers move to the problem stream. Rather issues or conditions may fade and reappear at different points. Problems receive consideration from policy makers based on the nature/importance of the problem, its recognition by the public, and whether there is agreement on solutions. The policy stream consists of various possible “solutions” proposed by different stakeholders and policy communities. These different solutions are considered and floated to different policy makers and final approaches (often more than one alternate proposal) emerge as a revision or combination of the solutions put forward by the original policy community. Whether a particular “solution” is given serious consideration is based in part on its feasibility, whether it is likely to accomplish the necessary change to address the problem, compatibility of the policy solution with the values of policy makers and policy agendas, and level of political support (Solati, 2009). The political stream also functions independently of the other two streams. It consists of influence from macro political contextual circumstances including the public mood, interest group tactics (those supporting and those against), campaign actions and promises, and changes in elected officials and staff. In part the political stream “mood” is influenced by communication that politicians receive, whether that be through the mail, news coverage, conversation with constituents, or visits made to constituents. Interest group influence is in part mediated by the degree of cohesion in the message and activities.

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Methods

Table 1 Driving forces

This was a qualitative, retrospective descriptive study interviewing key informants from six states that passed independent NP legislation in the last 5 years.

Problem finding collaborators Exorbitant fees and payment for a signature rather than a service Shortage of physicians Limited access to care Sunset laws The perfect storm

Sample and setting Six states transitioned to independent practice between 2007 and 2012. State leaders from within the state’s NP organizations were contacted. The purpose of the study was explained and the individuals were asked to identify other people within the state that played a key role in this legislative process. This snowball sampling technique was used to gather a comprehensive list of key informants that could tell the state’s story. The initial contact person was asked to reach out to those nominated individuals and inform them of the study before the investigator contacted them.

Data analysis Responses to each question from the interview guide were extracted with key responses and phrases noted. The corresponding phrases and sections were highlighted in the interview transcripts. Responses to each question, across all states, were then coded and common codes were collapsed into themes. Coding and themes were validated with a qualitative expert.

Results Instrument

All informants received a copy of the interview questions in advance. A date and time for the interview was arranged. Key informant interviews were conducted by phone. The investigator shared the purpose of the study and determined willingness of the person to be interviewed. Follow-up communication was done by e-mail. All phone interviews were audio-taped and transcribed by the investigator.

Representatives from six states were interviewed regarding passage of the legislation that permitted independent NP practice. In the course of the interviews it was unclear that Rhode Island had full practice authority. Consequently, data from these interviews were excluded from analysis. The results presented here include responses from the remaining five states: Colorado, Hawaii, Maryland, North Dakota, and Vermont. A total of 12 individuals from the states were interviewed. All state informants were integrally involved in passage of their states’ legislation, and served as leaders within their state NP organization during the time legislation was passed. Additionally, a national affairs consultant who is a recognized leader and active in a national NP organization was interviewed. Theme analysis identified two major themes, driving factors bringing the issue to the forefront of change and process approaches used to advocate and secure the change in statue supporting independent practice. Driving factors refer to those factors and concerns that brought the issue of mandatory collaborative agreement to light. Process strategies refer to approaches used over time, and how states were able to gain support and deal with barriers. Further findings and themes were collapsed into the components of the Kingdon policy analysis framework.

Ethics and human subjects protection

Driving forces

Approval from the University’s Institutional Review Board (IRB) was obtained. Informed consent and confidentiality of the interviewees was assured.

Table 1 summarizes the driving forces that were considered instrumental in making the issue emerge as a significant problem stream to be addressed by legislators.

The interview guide used in this study was an adaptation of that used for Pruitt, Wetsel, Smith, and Spitler’s (2002) qualitative study describing state processes used in achieving independent practice. Having received permission to make adaptations, changes were made to make the questions congruent with the Kingdon model. Questions were designed to capture information as to (a) how did NP legislation as a policy issue gain importance?, (b) what factors were critical to this change?, and (c) what interest groups were critical to effecting this change? The adapted interview schedule consisted of basic demographic information along with nine open-ended questions designed to elicit the “state story.”

Data collection

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“Problems finding collaborators” was a common discussion point especially in Maryland, North Dakota, and Vermont. As captured by one informant: Nurses were having a harder, more difficult time in getting a collaborating physician. So somebody who works out in Timbuktu, there was no other physician out there, and didn’t want to be their collaborator! And so . . . it was either they moved and go to a different community, and shut down the clinic in that town, or we eliminate the affidavit that had to be signed . . . and allow the nurse practitioners to work in these communities instead of shutting down a clinic.

Other informants reported that physician collaborators were increasingly difficult to find, and were charging solely for the collaborator position. Interestingly, some informants indicated that the contextual forces of healthcare reform, physician shortage, and an IOM Report validating the effectiveness of NP practice in primary care and grassroots efforts already in progress created the perfect storm. The concurrence of these different factors created a more powerful force and led to greater opportunity for change. One informant stated: We were doing this before the IOM report. We had a perfect storm situation for us, in that the Affordable Care Act got so much publicity for health care. And we had the physician shortage documented by the medical association and the hospital association. We had a very strong governor and lieutenant governor’s support for our health care initiative, because they were so supportive of the ACA. So putting all those things together, and then with the work we had done in the previous 3 years in lining everybody up, and we had bipartisan support, that was our perfect storm.

Process strategies Table 2 summarizes the different process strategies used by states in moving their legislative agenda forward. These process strategies were used to highlight/dramatize indicators of the problem (driving forces), advocate for a favored problem definition, and present specific policy recommendations. States used a combination of these approaches in arriving at their final goal of legislative change. Coalition support. Coalition support was found to be crucial to passage of legislation. Informants reported that while states certainly had Board of Nursing support, it did not carry enough weight to gain legislative support in passing legislation. Coalition building occurred internally within nursing groups; however, building collations external to nursing was noted as particularly powerful. In several states, the American Association of Retired Persons (AARP) was cited as being an extremely support652

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Table 2 Process strategies Coalition support The Board of Nursing and other health professionals Organizational support outside of nursing Legislative support Building APRN consensus Relationships with legislators and physician support Coalition opposition State medical societies Minority opposition from NPs Grass roots Face-to-face contact with legislators Use of patient stories Focus the conversation on patients Education, communication, and relationship building Speaking with solidarity Know the evidence Use appropriate language Utilization of a professional lobby firm Revising and negotiating a final bill The open window Recognizable situations

ive and important stakeholder group. Other states gained support from colleague health professional organizations: we (NP groups in the state) . . . . reach(ed) out to other players, the Hospital Association, Mental Health Association, the Allied Health Providers, which are the dentists, the podiatrists, physical therapists, chiropractors.

Many states strengthened their nursing coalitions by building APRN consensus, “ . . . because it was a bill for APRNs, not just nurse practitioners, support from the national groups was easily gotten.” Grass roots. Grassroots action was consistently identified as instrumental in bringing to light the driving forces and securing support for change. All states that were lobbying for independent practice had a grassroots effort to bring the problems associated with mandatory collaboration to the forefront. The complexities of developing grassroots efforts were described by one participant: Identify people who lead your state legislature . . . you have to have laid the groundwork to have a really strong relationship with them. Successes . . . take money, time, and physical presence. People need to show up at events, pay their dues, develop their relationship with the legislators, have that name recognition . . . there has to be that kind of engagement at the level of the educational institutions, at the level of nursing organizations, and at the level of the political organizations in the state . . .

Softening up strategies. Through coalition support, grassroots activities and planned lobbying efforts, the goal is to build legislative commitment for the proposed change with the ultimate goal of obtaining enough support for passage of the bill. Kingdon refers to this

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process of gaining support as “softening up.” Softening up is a process in which states pushed forward their definition of the problem and proposed solution in many ways and many forums, educating others and garnering support. There were many approaches that state informants described as effective in facilitating this “softening up.” Focus the conversation on patients was a recurring recommendation. In presenting to legislators the approach should be to focus on the patient and the impact that a change in legislation will have on access and patient care services. Patient stories delivered by grassroots NPs were seen to be particularly powerful. Delivered this way, the message was thought to be significantly stronger than when framed in the context of problems that NPs were having. As captured by two informants: . . . we need to go at this from a patient perspective . . . in the setting of health care reform, I think we have a perfect opportunity to put this forth as, and it will be, to the betterment of patient care, and not advancing the profession. and(we) went face to face with every single key player and talked about how this is good for patients. Not how it’s good for nurse practitioners, they don’t care . . . we talked about how eliminating the collaborating agreement would be good for patients and patients’ access to care.

The “softening up” process was described by all of the states to be a time-consuming process focused on educating and building relationships with legislators. This process can include personal meetings, writing papers, giving testimony, holding hearings, securing press coverage, and continuing to hold more meetings. As stated by one informant, “consistent effort in educating legislators over a twenty year period helped to ‘soften’ their position away from seeing physicians as being the gold standard.” The components of the softening up process were captured by different informants to include knowing the evidence, preparing for all interactions, key person identification, consistent, repetitive messaging and crafting of language, and approach to facilitate meaningful, ongoing, discussions with legislators. These approaches were integrated into coalition building, grass roots, and lobbying actions in order to move toward support for independent practice. The need for preparation, targeted and repetitive actions was captured by one informant: Do your homework. Find out who the key players are. Find out what the key issues are. And how do you use the key issues to get people to believe in your cause. You have to pound the pavement. You need to go and sit with legislatures . . . you have to have conversations that are meaningful and not emotional. And just keep on doing it over and over and over again.

Another respondent stressed the importance of knowing the evidence or having data to support one’s viewpoint. You have to know the economics of the issues. You have to know the positives, and the negatives, you have to know what it’s gonna cost if this doesn’t go through, and what it’s gonna cost if it does. Know your statistics.

Many suggested that messages should be crafted and that time should be taken to assure the use of appropriate language that is delivered similarly from person to person and state to state. Using terms such as “access, quality of care, patient engagement” were thought to be helpful and current within today’s context. I would say we need to adopt the language of the IOM report, we need to have one common voice, the language needs to be consistent state to state . . . I think the more consistency we get in our language the better.

Unsuccessful strategies were also identified by informants. These ineffective approaches generally involved selling one’s own credentials and value rather than focusing on the issue. The net result was to diminish the legislator’s attention on the driving forces and reinforce nursing’s inability to present a unified voice. As stated by one person “early on in this process, nurses brought their individual agendas and egos to the table.” Another described this in-fighting and the negative result of this presentation. Our legislators were not impressed with the nursing leaders trying to out credential each other, and one thing that really killed it early on was when physicians as well as the school deans and other nursing leaders would say, “I’m just as educated as you are,” and then the APRNs or the nursing leaders would get to the table, and try to impress the legislators with “I’m even more credentialed than this nurse,” you know that kind of thing? Got so old quickly.

Results and discussion within Kingdon’s framework Kingdon’s model suggests that the three streams of activity occur independently and the three streams merging creates or occurs at a point where there is a window of opportunity for policy change. Figure 2 illustrates the research findings into the Kingdon model.

Problem stream As noted by informants, the “issue” of moving to independent practice had been an issue brought forward for many years, for one state, 20 years. In this process, the issue never reached the “problem agenda,” but during this time relationships were built and ongoing education was

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Figure 2 Findings incorporated with the Kingdon model.

provided. Several focusing “events” pushed the issue on to the problem agenda. First the passage of the PPACA raised national attention about the state of primary health care in this country. The paradox of this, however, is that many people seeking a primary care physician will be unable to access care because of the national shortage of primary care physicians. Currently, only 2% of medical students and training physicians are planning to specialize in primary care/internal medicine (Schwartz, Durning, Linzer, & Hauer, 2011). Petterson et al. (2012) report the United States will require nearly 52,000 additional primary care physicians by 2025; Howell (2013) reports that fewer medical residents go into primary care and “flock” to the more lucrative specialty fields. While this national problem was being recognized, another event, the release of the 2010 IOM Report provided strong evidence of the efficacy of NPs as primary care providers. For these states, the “problem” was categorized as an access to primary care issue and a practical and sustainable answer to the problem was to use NPs to their full scope. Informants clearly articulated that the categorization or framing of the problem was critical to show that it was not an NP issue alone but a 654

broader health policy issue surrounding access to quality, cost-effective primary care. The access issue emerged not only in light of the possible inaccessibility of primary care providers but also because NPs who were providing primary care had many challenges in finding collaborating physicians. Whether because of disinterest or high costs charged, NPs reported needing to close practices and/or relocate. These problems, framed within the issue of access to care, became strong driving factors in the issue of independent NP practice reaching the active problem stream where policy makers wanted resolution.

Political stream The political stream captures the influence from macropolitical, contextual circumstances including the national mood, interest group tactics (those supporting and those against), newly elected officials who may be following through on campaign actions and promises, and changes in staff. In part the political stream “mood” is influenced by communication that politicians receive, whether that be through the mail, news

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Table 3 Recommendations for campaigns to move toward independent practice Strategies to employ Clearly identify national and state-specific driving force(s) behind need for change and legislation. Choose a bill sponsor who will be supportive of the legislation. Build coalition support inside and outside of nursing. Build and reach APRN consensus. Connect with stakeholders and potential supporters including schools of nursing, nursing boards, and organizations, hospitals and hospital associations that employ and support NPs, stakeholder associations where health care is an issue such as AARP. Physician support individually and through associations, if possible, is powerful. Engage grassroots campaign to target legislator’s home districts, communities that utilize NPs, and engage support from patients, legislators, and individuals supportive of NP legislation. Engage NPs in face-to-face contact with legislators who are consistent, planned, and purposeful. Collect patient stories that describe the problems and provide solutions. Focus the conversation on patients, not on NPs; clarify how elimination of barriers will solve a policy issue. Educate stakeholders, communicate often, build and maintain positive relationships. Speak with solidarity.

Know the evidence. Use appropriate language. Hire a professional lobby firm. Be willing to negotiate.

coverage, conversation with constituents, or visits made to constituents. The influence of interest groups is mediated by the degree of cohesion in the message and activities. Coalition building and support from those within and outside of the nursing community heavily influences the mood and priority of political stream issues. States all formed linkages with consumer, trade, and business groups that had a stakeholder interest in access to quality, cost-effective primary care. Coalition support was important in strengthening the political stream. Internal nursing coalitions were formed with State Boards of Nursing, other advanced practice nursing groups, specialty nursing organizations, and schools of nursing. These internal coalitions were critical to addressing the issue with a common voice and making it a priority on each groups’ political action committees. Coalitions with groups outside of nursing demonstrated a broad base of support and in-

Rationale Will allow for lobbyists and advocates to clearly articulate rationale for legislative change. The bill sponsor should be a champion for your legislation, one who is willing to educate and negotiate with colleagues in the legislature. More support will influence societal mood regarding need for change and will help elevate issue to top priority.

Grassroots efforts engage and garner supportive entities; also serves to soften up stakeholders and legislators. This allows building relationships with legislators and stakeholders; there is no substitute for being visible. Have a 2-min elevator speech prepared. This personalizes the issues and helps stakeholders and legislators connect issues to constituents in their regions. This enables stakeholders to see how elimination of NP practice barriers solve a current policy problem. Consistent education helps the message sink in, build and maintain positive relationships with legislators for current and future endeavors. It is imperative that groups speak with a united, cohesive voice on issue presented. Legislators will not listen to an issue until it is presented without discord from the group it is representing. Presenting evidence and having data give credence and validity to the conversation. Have a 2-min elevator speech prepared. Maintaining professionalism in even unpleasant exchanges; use consistent terms recognized nationally. Of the states that hired a lobby firm, this was identified as a key ingredient to passage of legislation. Know your bottom line. Advocates must agree and be clear about what, if any, concessions are willing to be made.

cluded hospitals and hospital associations, labor unions, and NAACP. Maryland and North Dakota especially note contributions to legislative efforts from the AARP. The primary special interest groups opposed to NPindependent practice were the state medical associations. Despite this opposition, coalitions were formed with medical schools and independent physician groups who supported and advocated for legislative change. “There was no push (back) from pharmacists, no push from healthcare consumers, no push from the regulatory agencies; it was all from physician groups.” The national affairs consultant reports that . . . the medical society, The AMA House of Delegates, has put out multiple statements and has funded multiple efforts to block what they define as the advancement of practice, or the expansion of scope, for any discipline other than medicine . . . and they’re basically viewing it as a turf war, and they’re looking at it as a threat to their

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financial security, because medicine has dominated the finances of healthcare for many, many years. So their job is to oppose whatever we do . . . we being the global, non physician provider community. And that community’s job is to go at this and say time is now, we have to look up and we have to say, patients want this, the country needs this and we need to move forward.

Effectiveness in gaining support within the political stream requires advocates to have a strong working knowledge of politics and a presence when health-related legislation is being discussed. This requires a grassroots investment in building relationships with legislators, legislative aides, and stakeholder groups so that when there are questions there are experts that can be called upon. While traditionally perhaps not active in this area it is important for APRNs to step outside their clinical boundaries and exert influence over laws and policies that affect their clinical practice.

Policy stream The policy stream is the stream of activity wherein different potential “solutions” are proposed by different stakeholders and policy communities. Working the policy stream is a cadre of visible players (elected officials, media, political parties, strong special interest groups) that determine what policies reach the agenda for action and invisible players (academics, researchers, consultants, congressional staffers, analysts) that influence the choice of policy alternatives. Within the policy stream there is a series of discussion, negotiations, and debates in which ideas are tested, reworked, and negotiated. Final policy recommendations often emerge as a revision or combination of the solutions put forward by the original policy community. Whether a particular “solution” is given serious consideration is based in part on its feasibility, whether it is likely to accomplish the necessary change to address the problem, compatibility of the policy solution with the values of policy makers and policy agendas, and level of political support (Solati, 2009). Results of this research show that most states agreed to compromise to achieve full independent practice. No state relinquished any terms of practice they previously held with the collaborative practice agreement. A complete and thorough working of the issue was completed by the stakeholders, and all states view the legislation that passed as progress, and not going backwards.

Conclusion Removal of the mandatory collaborative practice agreement has been achieved in five states from 2007 to 2011.

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Achieving this end goal was a journey over time involving coalitions of supporters and policy entrepreneurs who invested their time and wisdom in highlighting the problem, making the problem become real to others, and calling for support in removing barriers to practice. Achieving success involved building sustained relationships, a “softening up” process that required utter persistence in educating others about the role of NP and barriers to practice and getting this message out—through continuous meetings with legislators and legislative aides, writing papers, giving testimony, meeting with stakeholders to secure support, and seeking press coverage of the issue. While states had been active in their efforts for change, the focusing events of the PPACA, the shortage of primary care physicians, and the publication of the Future of Nursing report aided in broadening state attention on the problem as one of access to care and legitimized independent practice of NPs as a legitimate solution to the problem based on the evidence in the IOM Report. For these states there was a window of opportunity in which policy change could be achieved. The approaches described herein can be used by other state campaigns to move their agenda forward and create their window of opportunity. The findings of this study reinforce those of Pruitt et al. (2002), Madler, Kalanek, and Rising (2012), and Mathews, Boland, and Stanton (2010), who reported on other states’ journeys to independent practice. Table 3 provides recommendations for action from all four studies providing a comprehensive overview of the strategies used in 16 of the 19 states that are defined to have independent autonomous practice by The Pearson Report (2012). The consistency of the findings across these studies suggests that the approaches presented in this manuscript be a blueprint for action in other states moving toward independent practice. For each of the recommendations, the state planning committee should outline the efforts to date and additional efforts needed to mount their campaign.

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American Association of Nurse Practitioners (AANP). (2013b). State practice environment. Retrieved from http://www.aanp.org/legislation-regulation/state-practice-enviornment. American Association of Nurse Practitioners (AANP). (n.d.). Nurse practitioners in primary care. Retrieved from www.aanp.org/images/documents/ publications/primarycare.pdf Elwell, J. (2013). Personal communication, March 2013. Howell, T. (2013). U.S. facing shortage of 16,000 doctors as health care act kicks in. The Washington Times. Retrieved from http://www.washingtontimes. com/news/2013. Institute of Medicine (IOM) of the National Academies. (2011). The future of nursing: Leading change, advancing health, Washington, D.C.: The National Academies Press. Kingdon, J. W. (2011). Agendas, alternatives, and public policies (2nd ed.). Boston, MA: Longman. Madler, B., Kalanek, C. B., & Rising, C. (2012). An incremental regulatory approach to implementing the APRN consensus model. Journal of Nursing Regulation, 3(2), 11–15. Mathews, B. P., Boland, M. G., & Stanton, B. K. (2010). Removing barriers to APRN practice in the state of Hawaii. Policy, Politics & Nursing Practice, 11(4), 260–265. Mills, C. (2010). Nurse practitioners—Valuable but undervalued. Retrieved from http://www.maverickhealth.com.

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The journey to independent nurse practitioner practice.

The aim is to achieve a comprehensive understanding of the journey of states that achieved independent nurse practitioner (NP) practice from 2007 to 2...
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