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Virginia’s medical turf war appeared to come to an end earlier this year when nurse practitioners won the right to practice autonomously without physician supervision, despite objections from many of the state’s doctors.

But the battle still rages on quietly behind the scenes as the state works to create the regulations that would govern the newly independent nurse practitioners.

Autonomous practice authority has been a goal of nurse practitioners for years. They shouldn’t have to work under a physician’s supervision, they argue, if they’re doing what they’ve been trained to do and have enough experience.

Doctors disagree. As House Bill 793 made its way precariously through the General Assembly earlier this year, physicians argued in packed committee rooms that nurse practitioners just don’t have enough training or education.

Lawmakers ultimately sided with nurse practitioners, though, requiring them to have five years of clinical experience before practicing independently.

But now the state boards of medicine and nursing have been tasked with developing the regulations governing autonomous nurse practitioners, revealing continued friction among some medical groups over what nurse practitioners should be able to do and what five years really means.

It’s been a cumbersome process since the law was passed earlier this year because the boards must reach a joint consensus.

So far in joint board meetings, one of the biggest areas of contention has been how many hours nurse practitioners should be required to work in those five years. Doctors argue fiercely that 40 hours a week and 2,000 hours a year should be the minimum requirement.

But nurse practitioners have pointed out that some hospital jobs are considered full-time with 32- or 36-hour work weeks, and so 1,600 hours per year, equaling 8,000 hours in five years, is more reasonable, they contend.

In public comments, the Virginia Hospital and Healthcare Association supported 1,600 hours, while the Medical Society of Virginia, the Virginia Academy of Family Physicians, the American Academy of Pediatrics and the Virginia College of Emergency Physicians expressed support for 2,000 hours a year, or 10,000 over the five years.

Several doctors on the Board of Medicine’s executive committee expressed similar concerns during Friday’s meeting, and ultimately agreed on a compromise of 9,000 hours within those five years.

But the Board of Nursing must sign off on that decision before it becomes final.

The debate over autonomous practice has revealed the rifts in the state’s medical landscape, where different providers have conflicting ideas of how to ensure patient safety.

Nurse practitioners say they should be able to practice to the full extent of their training, particularly in light of the nationwide provider shortage that is most keenly felt in rural areas. Many argue that, even when they have a collaborating physician to work with, they often make decisions about patient care on their own.

Doctors claim that nurse practitioners don’t have the same training and education, and that working without a collaborating physician could erode patient safety.

Nurse practitioners are typically required to complete master’s programs that can take one to three years, while doctors must complete four years of medical school, then residency programs that can last three to five years.

That’s why nurse practitioners need closer to 10,000 hours of practice before they can be autonomous, said Ralston King, assistant vice president of government affairs with the Medical Society of Virginia. Medical residents would likely have at least that many hours under the belt before they are allowed to practice autonomously as doctors.

But Cindy Fagan, the government relations chair with the Virginia Council of Nurse Practitioners, pointed out that nurse practitioners are qualified, licensed nurses before they pursue their higher education.

“We practice for a number of years as registered nurses before we go on to attain additional education,” she said.

And autonomous nurse practitioners aren’t trying to provide the services licensed doctors do, she added. They are trying to operate within the scope of their practice, which is not as broad as a doctor’s.

She said most other states that allow autonomous practice require around 3,000 hours. If Virginia’s regulations ultimately require 9,000 hours, she said, the state would be a significant outlier.

“There’s absolutely no evidence to support that this number of hours yields higher quality care or more competent practitioners,” she said.

Winifred Y. Carson-Smith, a lawyer representing the Virginia Council of Nurse Practitioners, said she suspects doctors don’t want nurse practitioners to practice autonomously because they fear they’ll lose money.

She said some physicians see nurse practitioners as “taking away from their practices and the money that they will make.”

King denied that was a motive, adding that doctors are first and foremost concerned with their patients’ well-being.

“The entire purpose of becoming a physician is to take care of patients and to maintain patient safety,” he said.