Full practice authority for all Florida Advanced Practice Registered Nurses (APRNs) has been on the legislative priority list for more than 20 years. We have advocated year after year, educating legislators and their legislative aides, meeting with key individuals, and working with our lobbyist at the state level. Unfortunately, the stars have never aligned for us due to the negative climate with medical associations. Finally, we found two legislators who believed in us and recognized what we can do for our patients and the community and wanted to see us obtain autonomous practice. Those two legislators became our champions and bill sponsors on House Bill (HB) 607, Direct Care Workers (the autonomous practice bill). They were determined that this bill would get passed in the March 2020 session, and we finally felt hopeful for the first time ever. There was a request that we have a strong presence in the Capital before the bill being heard; therefore, we had a large number of APRNs in White laboratory coats attend the opening session and line the halls of the Capital as the House members made their way into the double doors. We were also given passes to be in the gallery during the session, to listen to the Speaker discuss the bill, and to recognize all APRNs in the chamber, where we received a standing ovation.
The Speaker of the House wanted to recognize four APRNs on the House floor during the start of the first weeks' session and also requested all four of us to serve as NP of the Day for a total of 4 days in the Capital Legislative Clinic. Dr. Doreen Cassarino was the first to be recognized on the House floor and serve in the Capital Legislative Clinic, and I was the second to do so. All of us received a standing ovation from all House members as our colleagues witnessed this historic event from the balcony of the chamber. It was truly an honor and a privilege to be chosen for this opportunity and one we will never forget. In addition, Dr. Cassarino had her picture on a poster reflecting HB607 displayed in various areas throughout the Capital for everyone to see. When we were scheduled on specific days to work the legislative clinic, we did actually take care of patients if they needed to be seen. This was never done before by an APRN; it was always a physician who was in the clinic seeing patients.
After many long years and endless fights, HB607 passed on March 11, 2020, during the legislative session with a vote of 107 yeas and 8 nays, allowing all Florida APRNs to apply for autonomous practice. The Speaker of the House and the Senate President mutually agreed that if this bill was going to move forward to the Governor's desk for signing, it could only include primary care, which includes family practice, general internal medicine, pediatrics, and certified nurse midwives but only with a transfer agreement, which addresses specific circumstances on why an emergency transfer to a hospital facility should takes place and who makes that decision. This was a last-minute surprise, and we were disheartened to read the final version of the bill and to realize this excluded many specialties that could not have autonomous status.
Our bill sponsors were termed out of their prospective seats, so we knew if we did not take the contents of this bill, it could be a long time before we got another chance to put a bill through. Our sponsors also informed us if we did not take the bill with its current content, it would be frowned upon by the legislators and would not be positive for us moving forward; therefore, after discussion with our lobbyists and among the APRN group members in attendance, it was determined we had no choice but to take something rather than nothing. At least it would be a start and we could always go back and work on another bill. Having a time lapse in between may also give the legislators some data to prove we are safe to practice autonomously. After this decision, the Speaker of the House requested a same-day signing by the Governor, and while unusual, the request was granted. The Governor usually waits until July to sign all bills into law, but the Speaker of the House did not want that as an option because there was a chance something could change, and it would be vetoed.
The legislature also required the Board of Nursing and the Board of Medicine to appoint a Council on Autonomous Advanced Practice to develop the standards of practice. The council was to consist of four APRN members and four physician members, with an attorney overseeing the council. I was appointed to the council by the Board of Nursing, along with three other APRNs, one being a Certified Nurse Midwife. We met one time for introductions and then a second time when we defined the standards of practice, although the APRNs in the council were not in agreement of the definition and all of the physicians were, the attorney broke the tie vote. The APRN members wanted the wording as "similarly situated advanced practice registered nurses" and not "similarly situated health care providers" as requested by the physicians because we are not the same. Eventually, when this went to the Joint Administrative Procedure Committee for approval, it was sent back for revisions to the definition, and the original recommendation by the APRN members was accepted.
In October of 2020, the Board of Nursing opened the registration to apply for autonomous practice if the following criteria was met: 1) 3,000 practice hours with physician under protocol 5 years preceding; 2) three credit hours or 45 continuing education units of differential diagnosis and advanced pharmacology; 3) malpractice insurance; 4) an unencumbered license; and 5) no licensure discipline in the past 5 years. As soon as the application went up on the site, I applied and then notified my daughter it was up. I then became the first licensed autonomous APRN in Florida, and my daughter was the second. This was exciting, but it was not as much about being first because it was about the journey in getting there and watching the growth over the years and knowing that it actually had come to fruition. It has not been easy, and Florida APRNs still have a long road ahead to ensure that we have autonomous practice for all. Currently, there are more than 12,000 licensed autonomous APRNs but that does not mean that they can all practice autonomously, which is a huge problem and causing confusion in our state.
With the onset of Covid-19 in 2020 and over the next 2 years, many older physicians chose to retire from practice and the APRNs working for them lost their practice partners and therefore were no longer able to serve the patients in the rural communities and even in other areas that were not underserved. They had to find other jobs, which was difficult. Autonomous APRN practice has opened the door for us to provide quality health care to patients who otherwise would not have health care in the rural areas of Florida. Health care is now being provided to patients in rural areas such as the panhandle and northern Florida, where it may be 2 hours to a clinic. Many free clinics closed or lost the ability to care for the underserved.
There are many APRNs who chose not to become autonomous and stay in their current roles under a protocol, and those working in the hospital setting have no choice because most hospitals have made the decision not to allow APRNs to practice autonomously in their facilities. If the law was expanded to allow specialty care APRNs to practice autonomously, we would be able to serve more patients in need. The mental health system in Florida is broken and in significant need of psychiatric mental health providers. If psychiatric mental health nurse practitioners could practice autonomously, it would open doors for so many patients who are not able to access care in the mental health system.
Our goal is to clean up HB607 to include all nurse practitioners in the state. This will provide an opportunity for patients in all areas to access high-quality health care. Unfortunately, we do not have a House Speaker now that is interested in health care and we have a Senate President that does not want to hear any scope of practice bills. It will continue to be a strong fight for a few years to come, but we will not give up until every APRN in Florida can practice to the fullest extent of their education and training and have full practice authority.
"Ambition is the path to success. Persistence is the vehicle you arrive in." -Bill Bradley
"Change will not come if we wait for some other person or some other time. We are the ones we have been waiting for. We are the change that we seek." -Barack Obama