Lawmakers revive effort to expand nurses' authority to help ease shortage of health care workers

MADISON – Supporters of a proposal to expand the scope of authority for some Wisconsin nurses are reviving their effort, hoping to change the legislation's fate after a veto from Gov. Tony Evers last year.

The legislative sponsors of the "APRN Modernization Act" recently launched a website sharing stories of registered nurses who say they — and their patients — would benefit from the bill becoming law. But the proposal still faces an uncertain future as it contains provisions that have drawn objections from physician groups and the governor.

The bill would create a new system that would allow registered nurses who meet certain qualifications to be licensed by the state board of nursing as advanced practice registered nurses, or APRNs.

Under the legislation, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and certified nurse-midwives would automatically receive APRN licenses. APRNs would generally have the authority to practice independently without a collaborative or supervisory agreement with a physician, prescribe medication, delegate some tasks to other clinically trained health care workers and use the title “A.P.R.N.”

Sens. Patrick Testin, R-Stevens Point, and Rachael Cabral-Guevara, R-Appleton, are spearheading the legislation in the state Senate alongside Rep. Gae Magnafici, R-Dresser, in the Assembly. The legislation has Republican support in both chambers, along with the backing of Sens. Kelda Roys, D-Madison, and Lena Taylor, D-Milwaukee.

"We should be doing everything that we can to empower health care professionals, rather than limit their ability to do their jobs," Testin told the Milwaukee Journal Sentinel. "This bill is much needed; it's going to provide the relief that we need, especially in underserved areas where we have physician shortages. And so really, what we're trying to do is just empower our health care professionals to go out there and deliver the best health care possible."

The proposal is backed by groups including the Wisconsin Nurses Association, the Wisconsin Association of Nurse Anesthetists, the Wisconsin Counties Association, Americans for Prosperity, the Oneida Nation and several health insurance providers.

It is opposed by groups including the Wisconsin Medical Society, the Wisconsin Academy of Family Physicians, the Wisconsin Dermatological Society, the Wisconsin Society of Anesthesiologists and the Wisconsin Chapter of the American Academy of Pediatrics.

Evers vetoed a version of the legislation passed with bipartisan support last spring, noting that it did not address several issues raised by physician groups. In his veto message, the governor wrote that he objects to "altering current licensure standards for APRNs, allowing practices functionally equivalent to those of physicians or potentially omitting physicians from a patient's care altogether notwithstanding significant differences in required education, training, and expertise."

Still, both the governor's office and a lobbyist for the state's medical society indicated that a path to an agreement on the proposal remains open.

"Our office is having ongoing, positive conversations with Republican legislators and stakeholders regarding both the APRN bill and companion legislation relating to titling, and we remain hopeful that both bills will be passed with the necessary changes to ensure the governor’s support this session," Evers spokeswoman Britt Cudaback said in an email.

Supporters say the bill would expand access to care

If the bill becomes law, Wisconsin would join more than two dozen other states that grant "full practice" authority to advanced practice registered nurses. The bill's authors estimate that Wisconsin has about 8,000 registered nurses who would qualify as APRNs under the legislation, about 80% of whom are nurse practitioners.

Under current law, advanced practice nurses are required to have a documented collaborative agreement with a physician. The legislation would generally remove that requirement once an APRN had worked for two years under a physician's supervision.

Similar proposals have been introduced dating back to 2015, but the COVID-19 pandemic reinvigorated the effort. That's in part because the collaborative agreement requirement was temporarily suspended under the state's public health emergency — and, Testin said, "the sky didn't fall."

Nurses backing the legislation argue that if it was OK for them to practice independently during the pandemic, there's no reason they shouldn't be able to continue.

"It was very disappointing, what can I say? — in that it was OK during the pandemic but not OK now," Wisconsin Nurses Association CEO Gina Dennik-Champion told the Journal Sentinel regarding the governor's veto. "We know we’re safe, we know that we can provide access. We know that looking at the other 27 states (with full-practice authority) there’s the evidence that shows that we’re safe practitioners."

In protest of the veto, Dr. Peter Kallio resigned from his post as head of the Wisconsin Board of Nursing last spring, accusing Evers of making a "politically motivated" move "to appease a small group of doctors who want to dictate nursing practice."

As the state faces a health care workforce shortage, backers of the APRN bill say it would expand access to quality, affordable health care throughout the state, especially in underserved areas.

Jenna Palzkill, president of the Wisconsin Association of Nurse Anesthetists who works in Platteville, told the Journal Sentinel the changes in the bill would also make it easier to recruit advanced practice nurses across state lines, especially from border states like Iowa and Minnesota that already grant full-practice authority.

"We're not asking to push our practice or (do) anything really a different way," Palzkill said. "We just want to keep doing what we're doing. Making it easier to bring people in-state and help us out so we have more providers in the state would be wonderful."

Opponents say compromise is possible

During a recent hearing in the state Senate health committee, Wisconsin Medical Society chief policy and advocacy officer Mark Grapentine began his testimony by saying that while the organization — along with nine other physician groups — opposes the legislation in its current form, "we are all very optimistic that a deal can be reached this session on a bill."

"We have such a great health care system," Grapentine told the committee. "But any changes that are made to the system, we want to be very cautious about. We want to be very wary to make sure that we're going in the right direction."

In his 2023-25 budget proposal, Evers included a provision with language similar to that of the APRN bill. The measure was one of hundreds stripped from the governor's proposal as the Legislature revised it.

The governor's proposal would have required four years of work in collaboration with a physician or dentist rather than the two required in the current bill. Both proposals would require APRNs providing pain management to collaborate with a physician, but the governor's version included an additional requirement that the physician must specialize in pain medicine.

Grapentine noted that many advanced practice nurses in Wisconsin would likely already have met a four-year collaboration requirement, adding that such a provision would be intended to guard against brand-new nurses launching independent practices shortly after obtaining their degrees.

"I don't know why it's a bad thing to try to make sure that any health care provider has experience in providing care before they're allowed to let loose, before they're allowed to practice completely independently. Physicians can't do that," Grapentine told the committee.

Testin said he would support meeting "in the middle" at a three-year requirement; the governor's office and the physician groups have not said whether they would agree to that, and have maintained that four years is an appropriate requirement.

Evers' budget also included a provision that would restrict a person without an M.D. or D.O. degree from using language representing them as a physician. That measure is not included in the APRN legislation but has been introduced as a separate bill by Cabral-Guevara. The governor's office has indicated that Evers will not support the APRN changes without the titling legislation.

"The bottom line is, there is a path to 'yes' on this bill that I don't think has been there before, in the many years that we've been talking about this," Grapentine said.

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This article originally appeared on Milwaukee Journal Sentinel: Lawmakers revive effort to expand nurses' authority