1. Shea, Joyce M. DNSc, APRN, PMHCNS-BC

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Coming together is a beginning; keeping together is progress; working together is success.


-Henry Ford


On May 12, 2014, Florence Nightingale's birthday, Connecticut's Governor Dannel Malloy signed into law Public Act No. 14-12, An Act Concerning the Governor's Recommendations to Improve Access to Health Care. With his signature, Connecticut became the 18th state to grant independence for advanced practice registered nurses (APRNs). Twenty-five years after the initial statutory provisions for an APRN license had been established in Connecticut, and building on the work of countless individual nurses and multiple professional nursing organizations, APRNs who have been practicing for at least 3 years with a collaborative agreement and have completed at least 2000 clinical hours now qualify for independent practice. This article highlights key events along the journey, describes the confluence of factors that set the stage for the historic turn of events, and reviews key lessons learned in the quest for independent practice.


Paving the Way. It is likely that only the most visionary of Connecticut's nurse leaders in 1976 could have foreseen the events that have recently unfolded. In that year, the first Nurse Practice Act was entered into state statute with the word "diagnosis" being used for the first time in defining the practice of nursing. By the early 1980s, in response to a call by the American Nurses Association's Council of Specialists in Psychiatric Mental Health Nursing, a group of Connecticut psychiatric clinical nurse specialists (CNSs) had formed a task force to examine legal barriers to independent practice in the state. After 18 months, the group had identified that the state statute needed to be changed to allow for insurance reimbursement for psychiatric CNSs; in 1984, they were instrumental in achieving direct insurance reimbursement for CNSs, nurse practitioners, and certified nurse midwives in Connecticut.


Initial statutory provision for the license of APRN was set forth in 1989, which formally defined advanced nursing practice and the activities such a nurse could perform. Prescriptive authority was also introduced at this time, limited to actions performed under the direction of a physician and in accordance with written protocols. One year later, the Connecticut Society of Nurse Psychotherapists was formed, in part due to the increasing need for an organized group of advanced practice nurses who would monitor the policy arena and advocate for the profession and the clients they served. Revisions were made to the general statutes in 1991-1992 that addressed controlled substances and cosignature requirements; regulations at this time still required a "directing physician." Prescribing had by now become the act that differentiated the APRN from the RN; in fact, the APRN license was not needed if a master's degree-prepared nurse was not prescribing. Finally, in 1999, APRNs went from a direct supervision to a "collaborative practice" model; state statute now required APRNs to have a legal contract in place, which identified a physician who was in the same field of practice and who had agreed to provide consultation and supervision on a regular basis to the APRN. Such a contract usually involved the APRN paying a fee for the service of the physician. Over the ensuing 12 years, multiple unsuccessful efforts were launched to remove the collaborative practice requirement.


Setting the Stage. In 2013, the Connecticut Advanced Practice Registered Nurse Society, representing the interests of all APRNs throughout the state, had submitted a scope of practice request to Connecticut's Department of Public Health (DPH) that would allow "licensed advanced practice registered nurses the flexibility to establish independent practices while continuing to collaborate with a variety of healthcare providers, including physicians."1 This request was made against the backdrop of the Institute of Medicine's report entitled "The Future of Nursing: Leading Change, Advancing Health," which gave specific recommendations to Congress, state legislatures, the Federal Trade Commission, and others about allowing nurses to practice to the full extent of their education and training.2 In order to meet the healthcare needs of Americans now covered under the 2010 Affordable Care Act, the Institute of Medicine strongly urged the removal of barriers to full scope of practice for APRNs. In addition, the National Governors Association had recently issued a paper, "The Role of Nurse Practitioners in Meeting Increasing Demands for Primary Care," which supported the use of nurse practitioners in meeting primary healthcare needs, particularly in underserved areas.3 The Scope of Practice Review Committee for Connecticut's DPH then undertook extensive hearings to consider (1) whether the request constituted a change in the APRNs' established scope of practice and (2) whether such a change presented any risks to the health and well-being of the state's citizens. The committee received written impact statements from 17 organizations and several individuals. In February of 2014, the Connecticut DPH issued their formal report1 to the Connecticut General Assembly, having determined that there was no discernible public health or safety risks associated with the request and that it posed no significant changes to the APRNs' recognized scope of practice.


Concurrent with the release of the DPH report, Governor Malloy sent Senate Bill (S.B.) No. 36 to the state legislature, An Act Concerning the Governor's Recommendations to Improve Access to Health Care, which called for the removal of the mandatory collaborative practice agreement for APRNs in the interest of increasing access to primary care around the state. The bill was referred to the Joint Committee on Public Health, which once again scheduled hearings to review the proposed legislation; many of the same individuals and organizations who had testified before the Scope of Practice Review Committee for Connecticut DPH found themselves again presenting testimony for the joint legislative committee. Members of the Connecticut Advanced Practice Registered Nurse Society, with assistance from the Connecticut Nurses Association (CNA), rallied nurses from across the state to contact the legislators who were on the committee, provide testimony at the hearing, or attend the hearing to show support in numbers. In a fortuitous twist of fate, the Federal Trade Commission happened to issue their paper, "Policy Perspectives: Competition and the Regulation of Advanced PracticeNurses," in March 2014, which warned states against the restrictions on APRN scope of practice posed by physician supervision requirements or mandated collaborative agreements.4 Upon favorable conclusion of the Joint Committee hearings, S.B. 36 was sent on to the Office of Fiscal Analysis to determine whether there would be any costs associated with the legislation and then to the State Senate and House of Representatives for a vote. Once again, RNs and APRNs throughout the state were asked to contact their legislators, write to local newspapers, and seek to inform their patients and the general public about the pending legislation. Many APRNs (including this author) left their work obligations to meet individually with legislators and lobbyists as the bill moved forward. By the end of April 2014, the bill had passed both houses and was forwarded to the governor for his signature.


Lessons Learned. Experience is often considered to be the best teacher, and the experience of this author in following the previously described legislative process through to its successful conclusion is no exception. Since the fight for independent practice continues throughout the country, the following suggestions are offered to improve the likelihood of a positive outcome for the next group of APRNs:


1. There is no room for professional silos in these fights for full scope of practice. Organizers need to involve ALL APRNs in the process, so that nursing is seen as speaking with 1 voice by those outside the discipline.


2. If it is not already in place, APRNs should form a professional group that can represent their interests and retain lobbyists to provide support and counsel.


3. Be aware of what is happening from a policy point of view at both the state and national level. Plan ahead and be prepared for the right moment and the right circumstances under which your group will begin the movement.


4. Line up ahead of time the experts who can give testimony about the impact of independent practice on health outcomes for patients. Those who are familiar with the legislative process may be best prepared to speak the language of policy makers.


5. Have a system in place that can get RNs and APRNs motivated to repeatedly e-mail, phone, or come out to speak directly with their legislators.


6. Anticipate that erroneous and at times extremely negative publicity will come from other health professional groups; be prepared to address the charges made.



Perhaps most importantly, all nurses-RNs and APRNs-need to be able to define clearly and succinctly what it is that nurses do and to speak about how the care provided by an APRN differs from that provided by physicians and other health professionals. If we do not define what we do for ourselves, and take control over the circumstances under which we deliver our care, then others will define and control it for us. Achieving independent practice for APRNs is not the end, but the beginning of a new era in healthcare. We need to carefully monitor and collect data on the outcomes of our care, or we will be shirking the very responsibilities that we seek to take on. More than a century ago, Florence Nightingale showed us the importance of data in improving patient care; may we be today's leaders who use the lamp of knowledge to shine the way forward for nursing.


The author wishes to acknowledge the assistance of countless nurses who laid the groundwork for this success story over the past 40 years. In particular, she offers her gratitude to Mary Moller, DNP, APRN, PMHCNS-BC, FAAN, and Lisabeth Johnston, MSN, APRN, PMHCNS-BC, who led key phases of this fight and shared much of the history described above during the Independent Practice celebration.




1. CT Department of Public Health. Report to the General Assembly. An Act Concerning the Department of Public Health's Oversight Responsibilities Relating to scope of Practice Determinations: Scope of Practice Review Committee Report on Advanced Practice Registered Nurses. Hartford, CT: CT Department of Public Health; 2014. [Context Link]


2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. [Context Link]


3. National Governors Association. The role of nurse practitioners in meeting increasing demand for primary care. 2012. Accessed November 6, 2014. [Context Link]


4. Federal Trade Commission. Policy Perspectives. Competition and the Regulation of Advanced Practice Nurses. 2014. Accessed November 6, 2014. [Context Link]