The California Nursing Association has approved rules that would allow nurses to treat patients without a doctor’s supervision. It’s a move aimed at expanding access to care in the Golden State at a time when staffing shortages plague nearly every health care department.
The vote earlier this month is one of the last major steps needed to fully implement the 2020 law that would allow nurses to practice freely. Nurses, who have advanced degrees and training, currently must enter into a written agreement with the physician who oversees their work with patients.
Despite previous concerns about possible delays, nurses say they are now hopeful that applications to start the certification program will be processed early in the new year as planned.
“We’re hoping we won’t be forced into 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 need to get caught up in paperwork to find a doctor who might 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 the consumer as long as the quality of care is acceptable,” he said. However, there is a limited number of them.
Nurse practitioners in California have been fighting to break free from physician supervision for years. The biggest setback came from the doctors. During the legislative debate, the California Medical Association said nurses have less training than doctors, so allowing them to practice independently could lower the quality of care and put patients at risk.
The law is not ‘carte blanche’
In 2020, Gov. Gavin Newsom signed Assembly Bill 890, which was sponsored by Assemblyman Jim Wood, a Santa Rosa Democrat. To be fully effective, the Board of Registered Nurses would first have to release details, including how nurses would transition into their independent role and what type of additional training or testing, if any, would be required to obtain certification.
The law created two new categories of nursing staff. Starting in January, nurses 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 will allow them to work without the supervision of a doctor according to the contract, but only in certain institutions where at least one doctor or surgeon works. The idea is that nurses will still be able to see doctors if needed.
“So that doesn’t give (nurses) the carte blanche that I think some people were afraid of,” said Loretta Melby, chief executive officer of the State Board of Registered Nursing. “And then, when they have been in that group for three years sitting with a doctor or a surgeon, that’s the only time they can go to the second stage.”
This second designation will allow nurses full authority to practice, without restrictions. And in theory, nurses will be able to open their medical career. Given the phased approach, eligible nurses will receive full freedom around January of 2026.
California’s requirements for nurses to transition to full independence will be among the strictest in the nation, according to a study by the California Health Care Foundation.
Nurses could perform physical exams, order lab tests, diagnose illnesses and prescribe medications, but in California it had to be under the supervision of a physician. Of the 31,000 nurse practitioners in California, an estimated 20,000 will be eligible to apply for extended credentialing by 2023, according to the California Association of Nurse Practitioners.
Kenny Chen, a family nurse practitioner in South Central Los Angeles, exemplifies the type of doctors researchers say California needs more of: He’s interested in primary care; speaks many languages, including Spanish and his native Mandarin; and enjoys working with marginalized people.
Chen said that while he does not expect major changes in his current role at Martin Luther King, Jr. Outpatient Center, the new law will allow his clinic to hire more nurses without meeting the doctor-nurse ratio.
“It would be very difficult to recruit doctors to come and work in South Central LA,” Chen said.
Giving nurses more authority, he said, would attract more of them to California. All other western states, for example, already allow nurses greater autonomy. California’s restrictions can be a hindrance, he said.
Before the vote, the California Medical Association sent a letter to the Board of Registered Nurses saying the board’s rules for nurses transitioning into private roles were unclear and did not provide any meaningful guidance beyond what was already stated. legal document.
Melby, the chief executive officer of the nursing board, said that he has heard concerns that the law will increase the level of services that nurses can provide, but he clarified that the law does not really change the type of work that nurses will be doing.
“What was reviewed was the need for supervision,” Melby said. “Also, it’s not like the nurse will now have the freedom to go out and operate; that has never been the profession of nurses.”
New laws may increase access to health care
According to staff researchers, allowing nurses to have more flexibility is a small but key piece of the puzzle in reducing California’s provider shortage.
Even before the pandemic, California was facing a shortage of medical providers. A 2019 report by a commission of health care professionals estimates that by 2030, the state will need 4,100 more primary care physicians. About 7 million Californians already live in underserved areas with basic, mental and dental health care needs, according to the report.
Rural counties tend to have the greatest shortages — in counties like Glenn, Trinity, San Benito and Imperial, more than 80 percent of people live without adequate access to care. And when patients receive care, they often rely on nurses. Some studies have shown that while doctors make up the majority of primary care providers in rural areas, nurses are choosing to work in rural areas at a faster rate.
Alexa Curtis, a family and psychiatric nurse at the Nevada County Addiction Center, said the need in rural communities has driven much of her work. Curtis, who is also dean of the School of Nursing at the University of San Francisco, plans to develop a rural medicine program that focuses on homeless people with mental health needs and substance use disorders.
Once he is given greater authority, “I will be able to pursue that goal without the barrier and expense of needing to protect a physician supervisor,” he said.
But working with other types of providers, including doctors, will always be part of his practice. “The way we are trained and the way we work as nurses,” she said.
Earlier this year, Newsom also signed into law Senate Bill 1375, which authorizes nurses to provide reproductive care and first-trimester abortions without medical supervision.
These two wins were big for nurses, said Jovanov, president of the nursing lobby. “I can tell you that this will lead to many more bills and laws that need to be changed. We are in this momentum and it is really exciting.”