Ask a Professor: Georgia’s NPs and the Fight for Full Practice Authority
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“It’s one thing to talk about advocacy, and it’s another thing to actually put on that white coat and hit the capital and shake hands with these individuals in the legislature. It’s pretty eye-opening.”
Dr. Humberto Reinoso, Assistant Professor and Nurse Practitioner Coordinator at Mercer University
As the Baby Boomers enter retirement, the nation is experiencing a worsening primary care crunch: more and more Americans need primary care services, but medical schools aren’t supplying enough primary care physicians to meet that need. The problem is particularly acute in Georgia, which ranks poorly in national health scores (KFF 2023). There are 241 counties in Georgia that are designated as Health Professional Shortage Areas (HPSAs), and lack consistent primary care access.
“The fact that there are not enough primary care providers available in the rural parts of the state makes it more difficult to maintain preventative services and keep patients outside of hospitals,” says Humberto Reinoso, PhD, FNP-BC, ENP-BC, an assistant professor and the nurse practitioner coordinator at Georgia Baptist College of Nursing at Mercer University. “Nurse practitioners (NPs) could help bridge the gap of primary care providers in Georgia, especially in rural areas.”
Georgia is home to over 7,690 nurse practitioners (GSU 2021). As highly trained clinicians, NPs could act as an immediate force multiplier in the fight against the primary care crunch: NPs and physicians share some of the same responsibilities, and NPs are more likely to work in underserved and rural areas. But outdated legislation is preventing Georgia’s NPs from contributing as much as they could.
Meet the Experts
Humberto Reinoso, PhD, FNP-BC, ENP-BC, PMHNP-BC
Dr. Humberto Reinoso serves as an associate professor and nurse practitioner coordinator at Georgia Baptist College of Nursing of Mercer University. He received his PhD from Barry University in Miami, Florida.
Prior to joining Mercer University, Dr. Reinoso served as an adjunct faculty member at the University of Miami and Barry University, where he taught undergraduate and graduate nursing students. At Mercer, he coordinates the NP programs: family; adult-gerontology acute care; and adult-gerontology primary care.
Dr. Reinoso maintains current practice in the emergency department and urgent care center. As a practicing advanced practice professional, Dr. Reinoso incorporates current guidelines and real-world scenarios as innovative pedagogical methods of content delivery.
Dr. Reinoso was interviewed in both February 2021 and April 2024 for this article.
Stephanie Bennett, DNP, FNP-BC, PMHNP-BC
Dr. Stephanie Bennett is a clinical assistant professor and graduate clinical coordinator at Georgia Baptist College of Nursing of Mercer University. She received both her MSN and DNP from Mercer University.
Dr. Bennett held positions in multiple areas of acute care, including ICU, house supervision, and management. She’s also held positions as ICU charge nurse, ICU director, and clinical supervisor. After completing the master of science in nursing program, she was employed as a full-time hospitalist at a regional hospital. She also practices as a nurse practitioner in a mental health office and volunteers at a free clinic providing primary care.
Prior to accepting her full-time appointment at Mercer, Dr. Bennett held an adjunct clinical faculty position in the College and also provided guest lectures.
Dr. Bennett was interviewed for an update to this article in April 2024.
The State of Play for NPs in Georgia
A majority of states in the US grant full practice authority to their NPs, which means that those states’ NPs are allowed to provide care to the full extent of their education and training. Those states with full practice authority are also among the best-ranked states in terms of overall health; Georgia is not one of them. Instead, Georgia’s NP practice laws are some of the most prohibitive in the nation.
Under Georgia’s Nurse Protocol Act of 1989, Georgia’s NPs must have a protocol agreement with a supervising physician, and they’re also prohibited from prescribing Schedule II medications or ordering certain diagnostic tests. Those requirements act as barriers to otherwise routine care. They place a burden on the NP’s time, the supervising physician’s time, and the patient’s time—they do not improve the quality of care. Georgia’s 31-year-old law governing the increasingly advanced work of nurse practitioners needs an update.
“If I feel a patient needs a certain test or a certain medication, at times that gets pushed back because I’m an NP and I need to contact my supervising physician, and the physician has to be the one that orders that particular test or medication,” Dr. Reinoso says. “Not being recognized as a primary provider for a patient also delays care for that patient. The patient ends up in limbo, and it’s also a burden to the NP who is trying to see the other patients who are in the waiting room.”
Removing the requirement for NPs to have a supervising physician doesn’t mean NPs will stop collaborating with their physician colleagues. The medical profession is intrinsically collaborative and interconnected, and it’s a part of an NP’s education and training to seek out specialty advice and expert opinions while delivering holistic care. Most states trust NPs to collaborate with physicians when necessary, but Georgia requires them to collaborate even when it isn’t necessary. By stipulating that each NP must have a supervising physician, the state massively undercuts its ability to meet its primary care needs.
“What these restrictions are doing is imposing regulations into the otherwise natural process of collaboration,” Dr. Reinoso says. “And we know that in other parts of the country, where you don’t have those regulations—and where NPs are practicing to the full extent that they’re educated—you don’t have a decrease in care quality. The care is equivalent to what our physician colleagues are providing, and in some cases better, because NPs are able to follow up and do what they can do for that patient.”
The Road to Full Practice Authority in Georgia
Georgia is one of the fastest-growing states in the nation, but its laws regarding NPs haven’t followed suit. Until recently, Georgia was the only state in the union that still restricted NPs from ordering radiological imaging tests. Organizations at the state and federal levels are taking a grassroots approach to modernize NP practice in Georgia.
For Dr. Reinoso, getting involved in those efforts is part of being a nurse practitioner and another way of advocating for patients. In his nurse practitioner program at Georgia Baptist School of Nursing, students take a policy course highlighting health disparities in the state and exploring how they could be improved. Dr. Reinoso emphasizes to his students the importance of getting to know their state representatives and taking a seat at the table to make their voices heard.
“It’s one thing to talk about advocacy, and it’s another thing to actually put on that white coat and hit the capital and shake hands with these individuals in the legislature,” Dr. Reinoso says. “It’s pretty eye-opening. Just being able to put a face with a name, and also a cause, is important.”
In other states, the road to full practice authority has been paved with small legislative victories: allowing NPs to order a wide range of diagnostic tests; allowing NPs to prescribe the medications that their patients need; or allowing NPs to earn the right to operate autonomously after a certain number of years of supervised experience. Along the way, more evidence accrues that patients benefit when NPs can practice to the full extent of their education and training. And more states are learning that the solution to their primary care problems might be right in front of them.
“I think ultimately we will get to full practice authority,” Dr. Reinoso says. “It’s a slow process, especially in Georgia, but with ongoing education regarding NP education and practice it is very achievable.”
Update 2024: Incremental Progress & Guarded Optimism
Since late 2020, there have not been any radical changes for Georgia’s NPs or their patients. The state is still one of the most restrictive states for NPs to practice. Health professional shortages persist. And burdensome protocol agreements are still required for NPs, restricting their ability to practice independently in areas of need. Still, some incremental progress has been made.
“As far as state legislation, there have been a few things that have changed since 2020,” Dr. Bennett says. “A bill was passed that allowed us to order radiological tests without a physician agreement. We’re also able to order home healthcare now, and this year we got the ability to sign death certificates in certain situations. But it’s been very slow moving.”
Georgia was close to passing legislation that would’ve made it an APRN compact state — in essence, allowing Georgia’s APRNs to have their license to practice recognized in other states who’ve passed similar legislation, and vice versa — but after passing the House and Senate, the bill was killed for lack of detail around implementation. That bill would’ve had many positive impacts for Georgia’s APRNs and their patients. Its defeat was a major disappointment. Other, more progressive legislation has failed to make it far.
“If you’re ranked towards the bottom of the nation when it comes to healthcare and physician shortages, you would think it would be a no-brainer to expand practice and get those patients the preventative care and the mental health services that they need,” Dr. Reinoso says. “But for some reason or another, it doesn’t move forward with our legislature, unfortunately.”
Georgia’s nurse practitioners still have a lot to give. Like all NPs, they are more likely to work in rural and underserved areas. Research has repeatedly shown their ability to provide high-quality care that produces equal or better outcomes with that of a physician. And NPs bring an assortment of other benefits to patient interactions: a holistic mindset, longer visit times, and a patient-centered experience.
“As nurses, I feel we are well-equipped to be agents for change, because we know the health system from multiple perspectives,” Dr. Bennett says. “Our potential is tremendous.”
There are still reasons to be positive about the future. The proliferation of telehealth is changing the notion of where care is delivered and, at the same time, reopening the conversation on who should be allowed to count as an independent-practicing provider. More people in Georgia and nationwide are getting acquainted with the NP role—sometimes firsthand.
In April 2024, Georgia’s governor signed HB557 into law. It authorizes APRNs, after one year of post-licensure clinical experience, to prescribe Schedule II substances such as hydrocodone, oxycodone, or compounds thereof in emergency situations (though not to exceed five-day supply for individuals 18 years of age or older). It also authorizes APRNs to write orders for disability parking permits. While these authorizations must be included in the APRN’s nurse protocol agreement, they are a significant win in the overall battle for more progressive legislation. The state’s NPs hope it’s a sign of more to come.
“We’ve seen dramatic changes in the time that we’ve practiced,” Dr. Reinoso says. “My optimism for the future is maintained by the fact that we have a strong presence in our numbers, and there remains a strong need. At some point, this state will realize that the resources are here, the skill sets are here, the knowledge is here. It’s just a matter of removing some barriers so patients can get the care they need.”
Matt Zbrog
WriterMatt Zbrog is a writer and researcher from Southern California, and he believes nurse practitioners (NP) are an indispensable component of America’s current and future healthcare workforce. Since 2018, he’s written extensively about the work and advocacy of NPs, with a particular focus on the rapid growth of specialization programs, residencies, fellowships, and professional organizations. As part of an ongoing series on state practice authority, he’s worked with NP leaders, educators, and advocates from across the country to elevate policy discussions that empower NPs. His articles have featured interviews with the leadership of the American Association of Nurse Practitioners (AANP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and many other professional nursing associations.