Nurse practitioners say supervision requirements are a hindrance amid COVID-19 pandemic

As Virginia continues to grapple with a growing number of COVID-19 cases, nurse practitioners are calling for a waiver of regulations that still require many to practice under a doctor’s supervision.

Virginia relaxed some restrictions on nurse practitioners in 2018 with a new law allowing them to apply for an autonomous practice license after five years of full-time clinical experience. Previously, all nurse practitioners were required to practice under a collaborative agreement with a physician, requiring periodic chart review and “appropriate input” in emergencies and complex clinical cases, according to the Medical Society of Virginia.

The bill’s signing was called a “spectacular moment” by the Virginia Council of Nurse Practitioners. But a year after the law went into effect, Virginia still offers less autonomy to nurse practitioners than more than half the U.S., including neighboring Maryland, where they can practice independently after 18 months of oversight by a doctor or fellow nurse practitioner with full autonomy.

“We’ve got a situation in Virginia where it’s illegal for many NPs to provide services to their patients unless they have a physician relationship documented in writing,” said Tay Kopanos, the vice president of state government affairs for the American Association of Nurse Practitioners. 

VCNP President Becky Compton said that about half of Virginia’s roughly 8,000 nurse practitioners have five or more years of clinical experience. But only around 782 have autonomous practice licenses with the state.

Other states have waived practice agreement requirements during the pandemic, including Kentucky, Louisiana and New Jersey,  Kopanos said. Both she and Compton said that the existing regulations in Virginia often make it easier for nurse practitioners to find work out-of-state than treat patients in their own communities.

At the same time, other states are aggressively recruiting Virginia nurses to work in areas hit hardest by the pandemic, Compton added. The offers are especially appealing as more nurse practitioners find themselves with fewer hours — or without a job — and barriers when it comes to finding new work.

“One NP who was on a call with us the other evening said that for 21 days, she could go up to New York to work and be paid $40,000,” she said. “That’s significant. And we need to get ahead of this because there are NPs finding themselves without a job and patients finding themselves without a medical home.”

The current regulations have become a growing problem amid the pandemic, making it harder for most nurse practitioners to find work and volunteer in areas hit hardest by the virus. During an online question-and-answer session in early April with Gov. Ralph Northam, several people asked whether he would consider at least temporarily relaxing the requirements.

The problem is multi-fold, said Judy Jenks, an autonomous nurse practitioner in Pulaski County who contracts with rural health clinics. First, current requirements make it harder to divert nurse practitioners to areas of the state with large numbers of coronavirus cases. If nurses move to a new area, or take on a different scope of practice, they would likely be required to sign a new collaborative practice agreement — a challenge when it comes to quickly mobilizing health care providers.

“You have to find a collaborating physician where you’re working,” she said. “That means you have to go up, you have to negotiate a contact. And that agreement is going to tell you what you’ll be doing in that practice.”

That’s another problem when it comes to responding to COVID-19, she said. Health officials have emphasized the potential for doctors to practice outside their usual specialties during a surge. Dr. Clifford Deal, president of the Medical Society of Virginia, has said the state could streamline credentialing requirements for physicians, allowing them to work at short-staffed hospitals.

It’s not as easy for nurse practitioners under supervision, Jenks said. For a pediatric nurse to switch to pulmonary care, for instance, it generally would require a physician to sign off on a new agreement.

“A practice agreement tells you what you can and can’t do,” she added. “So you’d have to have a whole new contract.”

Some nurse practitioners are also reporting barriers as more private practices close their doors. While some emergency departments are responding to an influx of COVID-19 cases, many doctors — especially in rural areas — are transitioning to telemedicine or temporarily closing amid a statewide ban on elective surgeries. Jenks said. 

Jenks used to contract with a private health clinic in Pulaski County, but said she was recently laid off because patient volume had decreased over the last several weeks. And while Jenks has an autonomous license — making it easier for her to find work in other areas and independently treat patients — most nurse practitioners would have to find a new collaborating physician. 

“They’d have to approach it from an employee standpoint,” she said. “They would have to try to find a place that is looking for a nurse practitioner and try to get hired on at an established place that has a collaborating physician already in place.” 

“And you’d be surprised,” Jenks added. “Even hospitals and ICUs are cutting down on staff if they’re not seeing [COVID-19] cases. Because at the same time, you’re seeing fewer patients come into the emergency room for other reasons.”

Telemedicine options are also limited for nurse practitioners in Virginia, Compton said. Current regulations require non-autonomous license holders to collaborate with a physician to treat patients remotely. It’s unclear, under the current circumstances, if nurses could be penalized for continuing to see patients without their supervising doctor.

The uncertainty over how regulations will be applied and enforced amid the pandemic is driving anxiety among many nurse practitioners, she added. 

“There’s a lot of fear over what happens if the physician on the practice agreement becomes ill, or I’m asked to practice in a different area or department outside where my collaborative practice agreement is,” Compton said. “There are all these questions out there, and they’re being hampered by these archaic barriers.”

Northam has loosened some testing requirements for pending nurse practitioners during the pandemic. In March, he waived certain licensure regulations, allowing nurse practitioners to practice provisionally while waiting to sit for their board exam or receive their results.

So far, though, he hasn’t decided to waive regulations requiring physician supervision. At a news briefing Friday, Northam said both he and the state’s Department of Health would be “interested in hearing” from nurse practitioners experiencing difficulties during the coronavirus outbreak.

“We’d be glad to work with them if there are challenges out there,” he added. “But as I said the other day — the relationship that we have between our [physician assistants], nurse practitioners and physicians, I think, is working well, and will continue.”