Set Them Free: NP Autonomy Advances in Virginia

More than 2 million Virginians live in areas where health professionals are scarce—part of why it can take about a month, on average, to find a new health care provider, according to the American Academy of Family Physicians. When wait times are long, people often don’t get medical attention until they’re very sick, which can ultimately make their care more difficult and costly.

But assistant professor Ashley Apple (BSN ’18, MSN ’20, DNP ‘21) is making a dent in that shortage. As commissioner of government relations for the Virginia Nurses Association, Apple successfully lobbied the Virginia General Assembly for legislation that makes it easier for nurse practitioners to establish and operate their own practices.

“One of the main reasons that nurse practitioner autonomy is so beneficial is because we know that it expands access to care, particularly in rural and underserved areas,” Apple said.

Autonomy “allows a frame of mind where you feel more empowered."

nurse practitioner Jimmy Howell (MSN, ’15, MSN-PMHNP/PNP ’21), who established a new practice, Mental Fitness Matters

Previously, nurse practitioners who wanted to set up their own clinics first had to spend five years working under a collaborative practice agreement with a physician. They paid a monthly fee—sometimes up to $1,000—to the collaborating doctor for their supervision.

Proponents of the five-year wait period to practice autonomously argue it provides nurse practitioners with more training and education, ensuring better outcomes for patients. In practice, however, the agreements’ effectiveness varies widely, and there still isn’t evidence it helps patients. Some nurse practitioners have active collaboration, while others hear from their collaborating doctors a handful of times per year.

“People think that we are doing the job of doctors, but with less education and training,” Apple, a family nurse practitioner herself, said. “But we’re not doing the job of doctors. We’re doing the job of nurse practitioners.”

In mid-2024, Apple, along with colleagues in the Virginia Nurses Association and the Virginia Council of Nurse Practitioners, lobbied to pass legislation that shortened the wait period for autonomous practice from five years to three. During the COVID-19 pandemic when clinician shortages were acute, Gov. Ralph Northam, a physician, issued an executive order shortening the transition to autonomy to two years. The order was extended for another year in 2021 but lapsed in 2022.

At five years, Virginia had one of the longest transitions to autonomy in the country. In 27 states, nurse practitioners can practice autonomously, and in most of those states, that begins as soon as they receive their licenses.

Nurse practitioner Jimmy Howell (COLL ’12, MSN ’15, MSN-PNP ’21, MSN-PMHNP ’22) pays $650 a month to a physician he rarely sees to run his Charlottesville pediatric psychotherapy clinic, Mental Fitness Matters. After rent for two offices (Howell’s wife, UVA nursing instructor Mary Howell (MSN ’15), also sees patients in their practice), it’s the single greatest expense to run his practice.

Howell worked in a pediatric clinic before opening a therapy practice a couple years ago and, at that point, spoke regularly with his collaborating physician about patients given that they were under the same roof. Now, he speaks with his collaborating physician about once a month.

“People think that we are doing the job of doctors, but with less education and training. But we’re not doing the job of doctors. We’re doing the job of nurse practitioners.”

assistant professor Ashley Apple, commissioner of government relations for the Virginia Nurses Association

And while the fee the Howells pay for the supervision is lower than what many other nurse practitioners fork over to run their own practices, which can be $1,000 a month or more, they look forward to earning autonomy after which they expect to save close to $16,000 per year. That opens “a wealth of opportunities,” Howell said.

They could expand to a larger building, offer art therapy and have three wheelchair-accessible offices, making it possible to bring in other providers and clients. That would be especially helpful as more young people across the country report symptoms of depression and anxiety. Already, the Howells have a full roster of pediatric patients seeking mental health care, and just earned accolades as Charlottesville’s “Best Mental Health Provider” from C-Ville Weekly.

Autonomy “allows a frame of mind where you feel more empowered,” Howell said. “I’m so appreciative of the work Ashley has done to push this envelope of autonomy.”

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