In California, the demands on nurses are changing

in summary

The new rules will improve access to health care in many communities that lack health care, supporters say. Some doctors are concerned that the rules will expand the scope of the services nurses provide.

The California Nursing Administration this week approved rules that allow nurses to treat patients without medical supervision. It’s a move aimed at expanding access to healthcare in the Golden State at a time when labor shortages are plaguing almost every corner of healthcare.

Monday’s vote is one of the final big steps needed to fully implement a 2020 law that will allow nurses to practice more freely. Nursing practitioners with advanced degrees and training are currently required to have a written agreement with a doctor who oversees their work with patients.

Despite some earlier concerns about potential delays, nurses say they are now confident that applications to begin the certification process will go live as planned early in the new year.

“Hopefully we don’t crash the site, but we’re very excited,” said Cynthia Jovanov, president of the California Association of Nurse Practitioners. “It means that if I want to run a mobile clinic in Skid Row, I don’t have to be held hostage by paperwork to find a partner doctor who may not have the same desire.”

Nursing practitioners are a cost-effective way to bring more primary care providers into communities that need them, especially in rural areas, said Glenn Melnick, a health economist at the University of Southern California.

“And that can benefit the consumer as long as the quality of care is acceptable,” he said. However, there are a limited number of them.

Nurses in California have been fighting for years to free themselves from medical supervision. The greatest resistance came from doctors. During the legislative debate, the California Medical Association said nurses are less trained than doctors, so allowing them to practice independently could reduce the quality of care and even pose a risk to patients.

“If I want to do a mobile clinic in Skid Row, I don’t have to be held hostage by paperwork to get a partner doctor who might not have the same desire.”

Cynthia Jovanov, President of the California Association of Nurse Practitioners

Law is not a license

In 2020, Governor Gavin Newsom signed Assembly Bill 890 into law, authored by Santa Rosa Democrat Jim Wood. In order to be fully effective, the Board of Registered Nursing first had to iron out details, including how nursing practitioners would transition into their more independent role and what type of additional training or testing, if any, would be required to gain certification to obtain.

The law essentially created two new categories of nurses. Beginning in January, nurses who have completed 4,600 hours or three years of full-time clinical practice in California may apply for the first category. This first step allows them to work without panel doctor supervision, but only in designated facilities where at least one doctor or surgeon practices. The idea is that nurses can still consult a doctor if necessary.

“So that doesn’t give them (nurse practitioners) the carte blanche that I think some people have been afraid of,” Loretta Melby, a senior officer with the state’s Board of Registered Nursing, said during Monday’s meeting. “And then if they’re in that group with a doctor or surgeon for three years, that’s the only way they can move up to the[second category].”

This second designation will give nurses full authority to practice without any hiring restrictions. And theoretically, nurses could open their own medical practice. Given the phased approach, Qualified Nurses are expected to achieve full independence in January 2026.

According to an analysis by the California Health Care Foundation, California’s requirements for nurses to transition to full independence will be among the most robust in the country.

Nurses can perform physical exams, order lab tests, diagnose illnesses, and prescribe medications, but in California this had to be under the supervision of a physician. According to the California Association of Nurse Practitioners, an estimated 20,000 of California’s 31,000 registered nurses will be eligible to apply for an enhanced license by 2023.

Kenny Chen, a practicing family nurse in South Central Los Angeles, is an example of the kind of clinicians researchers say California needs more of: He’s interested in primary care; he speaks several languages, including Spanish and his native language Mandarin; and he enjoys working with underserved populations.

Chen said that while he doesn’t expect major changes to his current role at the Martin Luther King, Jr. Ambulatory Center, the new law would allow his clinic to hire more nurses without having to meet the doctor-to-nurse ratio. “It can be very difficult to recruit doctors to work in South Central LA,” Chen said.

He said giving nurses more authority could also attract more of them to California. All other western federal states, for example, already allow nursing staff to be more independent. California’s restrictions could be a deterrent, he said.

“It’s not like the nurse will now have the freedom to go out and do surgeries; that has never been a nurse’s purview.”

Loretta Melby, Executive Officer of the State Board of Registered Nursing

Ahead of Monday’s vote, the California Medical Association sent a letter to the Board of Registered Nursing, noting that the Nursing Board’s rules for transitioning nurses to their independent roles were not clear and provided no more robust guidance than those already mentioned contained the text of the law.

Melby, the executive director of the nursing committee, said she also heard concerns that the law would expand the range of services nurses can provide, but clarified that the law doesn’t really change the type of work nurses would do .

“What was updated was the duty of care,” Melby said. “And so it’s not like the nurse is going to be free now to go out and do surgeries; that has never been a nurse’s purview.”

New rules can improve access to health care

According to staffing researchers, it’s a small but important piece of the puzzle to alleviating California’s provider shortage by allowing nurses more flexibility.

Even before the pandemic, California suffered from a shortage of medical providers. A 2019 report by a commission of health experts estimated that the state would need an additional 4,100 family doctors by 2030. According to the report, approximately 7 million Californians already live in resource-constrained areas with primary, mental health and dental care needs.

Rural counties tend to have the greatest shortages – counties like Glenn, Trinity, San Benito and Imperial have more than 80% of people living without adequate access to medical care. And when patients find care, they often rely on nurses. Some studies have shown that although physicians still make up the bulk of primary care providers in rural areas, nursing practitioners choose to work in rural settings at a higher rate.

Alexa Curtis, a family and psychiatric mental health nurse at a Nevada County addiction facility, said the need in rural communities has driven most of her career. Curtis, who is also 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 issues and substance use disorders.

Once she is given more authority, “I will be able to pursue that goal without the hurdle and expense of finding a doctor to supervise,” she said.

However, working with other types of providers, including physicians, will always be part of their practice. “That’s how we’re trained and that’s how we function as nurses,” she said.

Earlier this year, Newsom also signed Senate Bill 1375, which authorizes nurses to offer reproductive medicine and first-trimester abortions without physician supervision.

Those two victories are huge for nurses, said Jovanov, the president of the nurses’ lobby. “I can tell you this will lead to many more regulation bills that need to be changed. We’re in this dynamic and it’s really exciting.”