When it comes to fixing Nevada’s well-documented doctor shortage, much of the attention has focused on the opening of UNLV’s medical school and the expansion of physician residency options in Southern Nevada. But there is another, often-overlooked piece of the state’s healthcare puzzle.
More specifically, advanced practice registered nurses, or APRNs. These medical professionals, who have at least a master’s degree and have worked as registered nurses, are formally trained to provide much of the same care that a standard doctor does. Over the past six years, the number of APRNs in Nevada has more than doubled and the rate of growth continues to be strong, offering hope for the future of healthcare access across the state.
Prior to 2013, APRNs were required to work under the supervision of a physician. That meant any nurse practitioner who wanted to operate her own practice had to sign a contract with a physician who would often sign off on charts despite not being an actual part of the practice. Such contracts were often costly. Furthermore, nurse practitioners couldn’t sign off on certain forms — from death certificates to paperwork approving a handicap placard. That lead to patients dealing with delays or duplication of service by having to schedule appointments with a physician.
Despite some pushback, which included a touch of wild speculation that it would lead to nurses attempting neurosurgery, state lawmakers removed the supervisory provision during the 2013 Legislative Session, essentially granting them full autonomy as health care professionals. The prevailing assumption was that APRNS — especially nurse practitioners — could help fill health care gaps across the state, particularly in rural areas that have the most difficult time recruiting doctors.
It was a bet that now appears to be paying off.
In 2012, there were only 760 licensed APRNs in Nevada, and the industry had seen an average of 7 percent growth over the previous four years.
In 2013 — the year the legislature granted loosened its reins on the profession — the growth rate spiked to 17.7 percent.
By 2017, there were 1,595 — more than double the number pre-autonomy. And now more than 1,800 are licensed.
Jeanine Packham of the Nevada Advanced Practice Nurses Association says the growth is impressive but not surprising.
“There was no incentive to get a license here,” she says, “and likewise there was no incentive for an APRN from another state to move to a restrictive state. That was one of the promises (of the 2013 legislation) — if you build it, they will come.”
She adds, “That promise did come.”
One analysis done in 2016 found the majority of APRNs who transferred their license from out of state originated from places where laws on the profession are more restrictive. That includes our golden neighbor, California.
Since that pivotal 2013 legislation, the Nevada Advanced Practice Nurses Association has returned to legislators almost every session to advocate for related bills that cleaned up or clarified language related to APRNs and what types of documents they are allowed to sign. In 2017, the association pushed a bill that would best be described as a catchall — a “global signature statement” — but that was met with resistance by the Nevada State Board of Nursing, which wanted things more explicit. As such, the Legislative Counsel Bureau has opted to go line-by-line through statute to find references to physicians signing off on medical documents.
Packham likens it to peeling an onion.
“For example, we could sign for handicap placard but not a medical form saying you can’t drive because of a seizure,” she said. “It is within our scope of practice. It’s common sense.”
During this year’s session, lawmakers passed Senate Bill 134 to clear up that DMV paperwork issue as well as many others that align with the spirit of the 2013 autonomy bill. Largely, pushback against APRNs has dissipated as lawmakers and the medical community acknowledge that the state’s health care access gap requires an “all-hands-on-deck” approach, says Packham.
Still, the work is far from over.
“There are certain things left out,” adds Packham.
That includes issues related to workman’s compensation and guardianship. The latter is an especially touchy subject because it involves APRNs who specialize in psychiatric and mental health.
“That’s a newer concept,” says Packham. “We’re working on educating folks about that because they don’t know what mental health nurse practitioners can do. I’m projecting that in the next session, or maybe the one after that, it’ll be a good time for them to come up front and speak to and share what their abilities are.”
The majority of APRNs are family nurse practitioners. Others focus specifically on adults or children. According to the most recent annual report from the Nevada State Board of Nursing, only 76 of the 1,854 APRNs licensed in Nevada last year specialized in psychiatric/mental health.
Those psychiatric nurse practitioners are able to prescribe and manage medications and are qualified to sign-off on some of the things psychiatrists can, says Packham. If there were more of them, they could play a vital role in improving mental health access across the state.
If UNLV has their way, that’s exactly what will happen. Its School of Nursing currently has a program leading to licensure as a family nurse practitioner, but by next year should be offering programs in psychiatric and emergency room specializations.
Dean Angela Amar says the decision to add those programs is a direct response to the needs across the state.
Both the School of Nursing and the School of Medicine have also expressed interest in exploring midwifery — another APRN specialty. Although no programs are yet planned the idea is that having more providers could help improve the state’s infant and maternal mortality and morbidity rates.
Once you dive into the world of nursing, you see endless potential, says Amar.
“When you think about the healthcare system, there isn’t a place within that system where nurses aren’t a part.”
Advanced practice nurses can work as genetic counselors, forensic nurses, legal consultants, and in research positions. A master’s degree is currently required to become an APRN, and nationally there is a push toward requiring a doctorate.
“I often think the problem-solving, creativity and brain power required for nursing is underestimated,” continues Amar. “They really do have to be a smart. The level of thinking isn’t just waiting for one to tell them what to do. That will not make you a great nurse. It’s about anticipating.”
Amar says the more APRNs there are to do routine healthcare, the more doctors will be freed to focus on those patients who need the most advanced cares. Studies have shown that receiving medical care from an APRN results in equal (or sometimes better) outcomes for patients.
Packham adds that there is a financial component to consider too. Doctors typically graduate medical school with six-figure debt and have an incentive to specialize and take high-paying jobs. Areas like primary care and pediatrics are not that.
“They’re not very glamorous,” says Packham. “They don’t pay a lot. The return on investment is not as attractive … I’m not bad-mouthing anything. It’s just a fact.”
Similarly, Packham often asks naysayers which health professional is more likely to move to a rural county and fulfill the major healthcare needs of a small community: a doctor who can find plenty of high-paying work in urban areas, or an APRN whose nursing background involves more hands-on time with patients and less student loan debt?
She thinks the answer is obvious.
According to the Nevada Division of Public and Behavioral Health, all 17 counties in Nevada have some type of health professional shortage. But shortages are particularly pronounced in rural counties. When it comes to the number of active physicians per capita, Nevada has consistently appeared toward the bottom.
“There are huge voids,” says Packham.