Scope-of-practice (SOP) laws and regulations governing health care professionals (HCPs) is an active and growing area of debate in health care workforce policy. SOP refers to the services that HCPs are allowed to provide under the terms of their professional licensure. State SOP laws and regulations vary considerably; for example, California recognizes nurse practitioners (NPs) as primary care providers but requires them to practice in consultation with supervising physicians. In contrast, the neighboring states of Oregon and Arizona allow NPs to have full independent practice authority. Growing evidence suggests that removing these restrictions is associated with improvements in some aspects of access to care.
Over the years, states have expanded HCPs’ SOP; approaches have varied depending on the strength of HCPs’ lobbying groups, the political landscape in individual states, and the type and magnitude of SOP changes. States have been debating SOP for NPs since the profession was established in the 1960s. Before the COVID-19 pandemic, leaders of health workforce research centers around the country called for state and HCP leaders to expand SOP to maximize the potential of health care transformation and reduce variability in care delivery across states.
State Responses To The Surge
At the start of the COVID-19 pandemic, major workforce changes were needed to build capacity to handle the patient surge. States such as New York asked retired health care workers to return to action; schools accelerated the graduation of health professional students; and health systems redeployed HCPs who were no longer conducting elective procedures and routine care to the front lines of emergency and critical care. US Secretary of Health and Human Services Alex Azar called for all states to relax SOP policies, and states quickly responded. Pennsylvania, Tennessee, and Wisconsin relaxed their SOP regulations for NPs by removing physician supervision requirements and allowing greater prescriptive authority. Michigan relaxed supervision and delegation requirements for a wide spectrum of HCPs, including physician assistants (PAs), advanced practice registered nurses (APRNs), registered nurses, licensed practical nurses, and pharmacists. Other states have taken more limited approaches. For example, an executive order by California Governor Gavin Newsom relaxed but did not eliminate requirements for physician supervision of APRNs.
Transitioning To A Post-Pandemic Normal
Changes to state SOP regulations were intended to be temporary; however, the time lines for these changes were not firmly established. The timing of recovery from the pandemic is uncertain and will likely vary among states. When the health care system is able to go back to a “new normal,” many HCPs may not wish to return to their pre-pandemic roles or to the limits placed on their SOP. Concerns about HCPs’ job satisfaction, burnout, and professional well-being—defined as the quality of work-life based on physical, cognitive, emotional, and social aspects of work activities and environments—were widespread before COVID-19. Any changes to SOP regulations will directly affect what HCPs can and cannot do at work, as well as how they structure their workflows. Hasty reversal of SOP expansions would likely have adverse effects on HCPs’ job satisfaction and professional well-being. Therefore, any roll-back of changes to SOP regulations when a pandemic workforce response is no longer necessary will require careful deliberation among state authorities.
Urgency often is a force for change, and changes to SOP regulations were justified in the face of COVID-19, given the surge in case volume and concerns about hospital capacity. What happens when the pandemic subsides and we transition to a post-pandemic normal, although this time without the same urgency?
Key Considerations For Policy And Communication
Because telehealth has helped expand capacity during the pandemic, it potentially could play a larger role in health care delivery once the pandemic ends. The Centers for Medicare and Medicaid Services and private payers have granted greater autonomy for a broad range of providers, including NPs and PAs, to deliver telehealth by relaxing supervision and billing requirements. Telehealth visits jumped from 11,000 per week in the week ending March 7 to more than one million visits per week in the week ending April 18, thus suggesting expanded access for patients. If telehealth has turned out to be an effective mode of care delivery during the pandemic, as has been found in the past for patients with chronic neurological disorders, will it make sense to revert to pre-pandemic restrictions on telehealth? If the expansion of hospital-at-home programs during the COVID-19 crisis can indeed save lives and costs, shouldn’t we continue? If the relaxation of SOP restrictions catalyzed by COVID-19 has alleviated workforce shortages and allowed HCPs to maximize their potential without compromising health care quality or patient safety, we believe that states should not revert to the pre-pandemic state of SOP policy. For telehealth and other services benefiting from relaxed SOP, how state authorities recalibrate SOP rules and how health systems and organizations implement any SOP changes could have major implications for patients’ access to care, health care workforce capacity, and HCPs’ professional well-being.
The Organizational Justice Imperative
State authorities and health care organizations could pay a high price for reinstating SOP restrictions when the pandemic ends. Such decisions could seriously damage relationships with HCPs who perceive lack of reciprocity from institutions for which they have risked their health and sacrificed their personal needs. If SOP changes are suddenly or even gradually reversed when the pandemic subsides, many HCPs may feel that they were treated unfairly. Based on the literature on organizational justice, we know that this sense of unfairness is profoundly dissatisfying and detrimental to professional well-being.
Justifying SOP reinstatements because they are “business as usual” will not be sufficient. If reinstatement occurs, policy makers and regulators should make decisions based on empirical evidence that indicates why SOP expansion was warranted only during the pandemic; whether health care delivery, quality, and patient safety differed under expanded versus usual SOP; and why it would not be appropriate to integrate improvements in care delivery discovered during the pandemic into HCP practice and workflows in the future.
A Focus On Evidence And Gratitude
Regardless of whether temporary relaxation of SOP policies are continued, modified, or discontinued, public- and private-sector health care leadership should clearly communicate the evidence base for these decisions, including any research findings on the clinical impact of changes to SOP policy. To address perceptions of unfairness and avoid compromising professional well-being, these communications should consistently acknowledge the tremendous contributions and sacrifices HCPs have made during the pandemic.
Swift relaxation of SOP regulations was necessary to build health care workforce capacity during the pandemic. To avoid detrimental effects on the well-being of HCPs, decisions on whether to roll-back SOP changes should not be equally swift. The COVID-19 crisis has led health systems and organizations to implement changes to their health workforce to meet unprecedented care needs, and HCPs on the front lines have reported burnout, depression, anxiety, and post-traumatic stress disorder. To support HCPs’ professional well-being and advance organizational justice, decisions about returning to pre-pandemic SOP policies should be informed by careful evaluations of outcomes. In communicating these decisions, health care leaders in the public and private sectors need to carefully explain the evidence base and acknowledge the tremendous contributions and sacrifices HCPs have made throughout the pandemic.