The California nursing agency has approved rules that allow nurses to treat patients without a doctor’s supervision. It’s a move that aims to expand access to healthcare in the Golden State at a time when labor shortages are plaguing just about every corner of the healthcare system.
The vote earlier this month is one of the last major steps needed to fully implement a 2020 law that will allow nurses to practice more freely. Nurses, who have advanced degrees and training, are currently required to enter into a written agreement with a physician who oversees their work with patients.
Despite some previous concerns about potential delays, nurses say they are now confident that applications to begin the certification process will go live early in the new year as planned.
“Hopefully we don’t crash the website, but we’re very excited,” said Cynthia Jovanov, president of the California Association of Nurse Practitioners. “This means that if I want to do a mobile clinic in Skid Row, I don’t have to be held hostage by paperwork to get a collaborating doctor who may not have the same desire.”
Nurses are a cost-effective way to bring more primary care providers to communities that need them, especially in rural areas, said Glenn Melnick, a health economist at the University of Southern California.
“And that can benefit consumers as long as the quality of care is acceptable,” he said. Yet there are only a limited number.
California nurses have been fighting for years to break away from physician oversight. The biggest pushback came from doctors. During the legislative debate, the California Medical Association said nurse practitioners have less training than physicians, so allowing them to practice independently could reduce the quality of care and even put patients at risk.
Law is not a carte blanche
In 2020, Governor Gavin Newsom signed into law Assembly Bill 890, which was drafted by Councilman Jim Wood, a Democrat from Santa Rosa. To go into full effect, the Board of Registered Nursing first had to iron out details, including how nurse specialists would transition into their more independent role and what type of additional training or testing, if any, would be required to earn certification.
The law essentially created two new categories of nurse practitioners. Beginning in January, nurse practitioners who have completed 4,600 hours or three years of full-time clinical practice in California can apply for the first category. This first step allows them to work without the contractual supervision of a physician, but only in certain facilities where at least one physician or surgeon is also employed. The idea is that nurse specialists can still see a doctor when needed.
“So that doesn’t give them (nurse practitioners) the carte blanche that I think some people feared,” said Loretta Melby, executive officer of the state’s Board of Registered Nursing. “And then, if they spend three years there in that group setting with a doctor or surgeon, only then can they move on to the (second category).”
This second designation gives the practice nurse full authority, without any restriction. And, in theory, practice nurses could open their own medical practice. Given the phased approach, eligible nurse practitioners are likely to become fully independent around January 2026.
California’s requirements for nurse practitioners to transition to full independence will be among the most robust in the country, according to an analysis by the California Health Care Foundation.
Nurses can perform physical exams, order lab tests, diagnose conditions and prescribe medications, but in California this had to be done under the supervision of a physician. According to the California Association of Nurse Practitioners, an estimated 20,000 of California’s 31,000 nurse practitioners will be eligible for expanded licensing by 2023.
Kenny Chen, a family physician in South Central Los Angeles, is an example of the type of clinicians researchers say California needs more of: He’s interested in primary care; he speaks several languages, including Spanish and his native Mandarin; and he enjoys working with disadvantaged populations.
Chen said that while he doesn’t expect any major changes in his current role at Martin Luther King, Jr. Outpatient Center, the new law would allow his clinic to hire more nurse specialists without having to comply with the doctor-to-nurse ratio.
“It can be very difficult to recruit physicians to come and work in South Central LA,” Chen said.
Giving nurse practitioners more authority, he said, could also draw more of them to California. For example, all other Western states already allow nurse specialists more independence. California’s restrictions could be a deterrent, he said.
Prior to the vote, the California Medical Association sent a letter to the Board of Registered Nursing stating that the nursing board’s rules for nurse practitioners to transition into their independent role were unclear and did not provide more meaningful guidance beyond what was already stated in the text of the law.
Melby, the nursing division’s executive officer, said she had also heard concerns that the law would expand the scope of services nurse practitioners can provide, but clarified that the law doesn’t really change the type of work nurse practitioners will do.
“What was updated was the oversight requirement,” Melby said. “And so it’s not like the NP is now free to go out and perform surgery; that has never been the practice of a nurse specialist.
New rules can increase access to health care
More flexibility for nurses is a small but important piece of the puzzle for alleviating California’s caregiver shortage, according to staffing researchers.
Even before the pandemic, California was short of medical providers. A 2019 report from a committee of health experts estimated that the state would need an additional 4,100 primary care physicians by 2030. About 7 million Californians already live in areas with a shortage of providers in need of primary, mental and dental care, according to the report.
Rural counties often have the greatest deficits – in counties such as Glenn, Trinity, San Benito and Imperial, more than 80 percent of people live without adequate access to care. And if patients do find care, they often call on practice nurses. Some studies have shown that while physicians still make up the bulk of primary care providers in rural areas, nurse specialists are more likely to choose to work in rural settings.
Alexa Curtis, a family and psychiatric mental health nurse at a Nevada County addiction disorder facility, said the need in rural communities has defined most of her career. Curtis, who is also an associate dean at the School of Nursing at the University of San Francisco, plans to develop a rural street medicine program with a focus on homeless people with mental health needs and substance use disorders.
Once she gains more authority, “I will be able to pursue that goal without the barrier and cost of needing a physician supervisor,” she said.
But working with other types of healthcare providers, including physicians, will always be part of her practice. “It’s how we are trained and how we function as nurse practitioners,” she said.
Earlier this year, Newsom also signed Senate Bill 1375, which authorizes nurses to provide reproductive care and first-trimester abortions without a doctor’s supervision.
These two wins were huge for nurses, said Jovanov, the president of the nurses’ lobby. “I can tell you that this is going to lead to a lot more bills for regulations that need to change. We are gaining momentum and that is really exciting.”
