The Expanding Role of Nurse Practitioners: Challenges and Patient Care Impacts

The Scope of NP Practice Varies by State

In 2010, 17 states and the District of Columbia allowed full practice authority for NPs, while 33 states allowed for some level of “reduced” practice authority or required NP supervision in most instances.⁶ Eleven years later, those numbers have increased to 23 states (and the District of Columbia) in which NPs enjoy full practice authority and 16 states where NPs can practice independently after a transition-to-practice period, leaving 11 states with “restricted practice.”⁷ As of June 2021, the Delaware and Wisconsin legislatures are hearing bills to remove restrictions on NP practice.

NPs occupy a somewhat unique space in healthcare. As advanced practice registered nurses, their practice builds upon the competencies of registered nurses by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy.⁸ NPs evaluate and manage health conditions and responses to illness, and work in consultation and collaboration with (and, depending on the state, under the supervision of) other healthcare providers. For instance, in states like California, where the “practice of medicine” is defined to include “any system or mode of treating the sick or afflicted,” including diagnosing, treating, operating, or prescribing for “any ailment, blemish, deformity, disease, disfigurement, disorder, injury or other physical or mental condition,”⁹ the practice of NPs overlaps to a significant extent with the practice of medicine, and physician supervision has been required where such overlap exists.¹⁰ While, historically, the overlap between the practice of medicine and the practice of NPs has been a source of resistance to full practice authority for NPs,¹¹ data showing the impact of full NP practice authority on patient health outcomes demonstrates high-quality and safe patient outcomes.¹²

Full NP Practice Authority Improves Health Outcomes

The supply of NPs is greater and has grown faster in states with full practice authority¹³ — an especially important data point given that NPs are significantly more likely than physicians to treat underserved populations¹⁴ — and access to treatment for opioid use disorders is greater where NPs have full practice authority.¹⁵ In states where NPs have full practice authority, dual Medicaid-Medicare enrollees experience 31 percent fewer avoidable hospitalizations and 10 percent fewer hospital readmissions when compared with states where NP practice remained restricted.¹⁶ States that embraced full NP practice authority have experienced in the two years following expanded NP practice authority a 3.3 percent increase in the probability that adults had checkups in the past year; a 3.6 percent increase in the probability of having a usual source of care; a 4.8 percent increase in the probability of “always” being able to get an appointment when sick; and an 11.6 decrease in repeat emergency room visits for sensitive conditions.¹⁷

In addition to IOM and NAM, the Federal Trade Commission,¹⁸ the National Governors Association,¹⁹ and the American Enterprise Institute²⁰ all recommend that NPs have full practice authority. In making this recommendation, these organizations focus on the lack of evidence that mandated physician collaboration improves the quality of care; on the numerous studies finding that full NP practice authority expands access to care; and on the added administrative burdens for patients and the general population that mandated NP/physician collaboration entails.

Barriers to Full NP Practice Authority

Given the seemingly broad support for full NP practice authority, and the public health benefits such practice has been shown to deliver, what may be most surprising is that more than half of the states still do not allow NPs full practice authority. This likely is linked to certain challenges in implementation.

First, there is an inherent tension between NPs and physicians regarding who can “practice medicine” and in what contexts.²¹ Physicians may fear a loss of job security if NPs are able to practice medicine without supervision. However, as discussed above, even in states where NPs have full practice authority their practice remains limited by the scope of their education and experience. For example, an NP without surgical training or experience does not suddenly become authorized to perform surgery just because he or she practices in a state with full NP practice authority. Further, only eight percent of physicians entered a primary care residency in 2018, compared with more than 84 percent of NPs graduating from primary care programs,²² and the demand for primary care clinicians continues to outstrip the supply at ever-increasing rates.²³

Another challenge is that, although team-based care is universally agreed as the best practice in many situations,²⁴ confusion can arise as to who is the “leader” of the team. If an NP with full practice authority is the primary clinician for a patient, and the NP consults a physician for a complex situation involving the patient, does the physician then become the leader for that patient’s care? If not, will the physician be accepting of treating the NP as a peer with regard to managing the patient’s care? Physicians historically have been the de facto clinical leaders of care teams, but medical schools typically have not educated them on how to lead interprofessional teams.²⁵ One potential solution for this challenge may be in creating guidelines for interprofessional collaborative practice. For example, the Interprofessional Education Collaborative (IPEC), a collaborative of 21 national health professions associations, has created core competencies for interprofessional collaborative practice. ²⁶

One way to address some of these tensions and challenges may be for states to ensure that NPs and physicians are held to the same standards with regard to referrals, reporting, and other laws and regulations that serve to ensure quality of care. Yet, there may be good reasons not to subject NPs to such laws and regulations. For example, California’s ban on the corporate practice of medicine prohibits the employment of physicians in many contexts.²⁷ If the ban on the practice of medicine is extended to include NPs,²⁸ then healthcare providers that currently employ NPs may be faced with the unintended and highly burdensome task of trying to renegotiate all of their arrangements with NPs. This would seem to undermine the public health goals behind extending full practice authority to NPs.

Conclusion

The drive toward full practice authority for NPs across the United States has the potential to significantly lower the cost of care while increasing access, particularly for the most vulnerable in the population. Careful consideration of the many competing interests, challenges, and opportunities involved will help to ensure the greatest level of success in this endeavor.

Footnotes

1. P.L. 111-148, 124 Stat. 119 (Mar. 23, 2010).
2.  See https://www.healthcare.gov/where-can-i-read-the-affordable-care-act/.
3.  Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health, The National Academies Press (2011)
4.  Supervision of NPs, where it is required, takes different forms, depending on the state. For example, in California NPs are supervised to the extent their practice overlaps with the practice of medicine via “standardized procedures,” which are protocols developed collaboratively among the NP, the supervising physician, and the health system, setting out when and how an NP should perform a specified procedure or course of treatment, and under what type of supervision. California does not require in-person supervision of NPs. See Cal. Bus. & Prof. Code § 2835.7, 2836.1; 16 Cal. Code Reg. § 1485.
5.  NAM‘s 2021 report recognized some progress toward full NP practice authority since 2010 and advocated for continued work toward this goal.
6.  Brom, H.M., Salsberry, P.J., &  Graham, M.C., “Leveraging health care reform to accelerate nurse practitioner full practice authority,” Journal of the American Association of Nurse Practitioners, 30(3), 120-130.
7.  See https://storage.aanp.org/www/documents/advocacy/State-Practice-Environment.pdf.
8.  See https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf.
9.  Cal. Bus. & Prof. Code § 2052(a).
10.  See California Board or Registered Nursing General Information: Nurse Practitioner Practice (“The NP does not have an additional scope of practice beyond the usual RN scope and must rely on standardized procedures for authorization to perform overlapping medical functions (CCR Section 1485).”), rev. Apr. 2011.
11.  For example, two key organizations representing physicians — the American Medical Association (AMA) and the California Medical Association — opposed California’s proposed expansion of NP practice authority. The AMA argued that “Patients, especially those with chronic conditions, want and expect their medical care to be directed by a physician. . . . AB 890 . . .  threatens that option by allowing NPs to replace doctors in underserved communities.”  O’Reilly, K.B., Independent practice for NPs fails to solve rural access problems (Aug. 17, 2020).
12.  See https://www.chcf.org/publication/californias-nurse-practitioners/.
13.  Reagan, P.B. &  Salsberry, P.J., The Effects of State-Level Scope-of-Practice Regulations on the Number and Growth of Nurse Practitioners,” Nursing Outlook 6 no. 1 at 392–99 (2013).
14.  Spetz, J., et al., 2017 Survey of Nurse Practitioners and Certified Nurse-Midwives, Healthforce Center at UCSF (April 2018). See alsoCalifornia Physicians: Who They Are, How They Practice, California Health Care Foundation (2017).
15.  Spetz, J., Toretsky, C., Chapman, S., Phoenix, B., & Tierney, M., Nurse practitioner and physician assistant waivers to prescribe buprenorphine and state scope of practice restrictions, JAMA, 321 (14) at 1407-08 (2019).
16.  Oliver, G., et al., Impact of Nurse Practitioners on Health Outcomes of Medicare and Medicaid Patients, Nursing Outlook 62 no. 6 at 440–47 (2014).
17.  Traczynski, J. &  Udalova, V., Nurse Practitioner Independence, Health Care Utilization, and Health Outcomes, Journal of Health Economics 58 at 90–109 (2018).
18.  Gilman, D.J. &  Koslov, T.I., Competition and the regulation of advanced practice nurses, Federal Trade Commission (2014).
19.  See https://www.nga.org/wp-content/uploads/2019/08/1212NursePractitionersPaper.pdf.
20.  See https://www.aei.org/research-products/report/nurse-practitioners-a-solution-to-americas-primary-care-crisis/.
21.  See, for example, n. 9, above.
22.  See https://www.healthaffairs.org/do/10.1377/hblog20181211.872778/full/. Possible reasons for physicians not entering primary care fields such as internal medicine, family medicine, and general pediatrics include lower income compared with specialists, particularly when balanced with high debt from medical school; medical schools overtly or covertly encouraging medical students to pursue specialty practice; the regular heavy paperwork burden borne by primary care providers; and the struggle to balance providing comprehensive patient care with externally-imposed time limits on patient visits (e.g., the average primary care physician visit is only 15 minutes long). See Knight, V., American Medical Students Less Likely to Choose to Become Primary Care Doctors, Kaiser Health News (July 3, 2019). See also Schimpff, S.C., Why primary care is in crisis – and how to fix it, Medical Economics (Feb. 7, 2020)
23.  Spetz, J., Coffman, J., &  Geyn, I., California’s Primary Care Workforce: Forecasted Supply, Demand, and Pipeline of Trainees, 2016-2030, Healthforce Center at UCSF (Aug. 15, 2017).
24.  See https://www.aha.org/system/files/media/file/2020/09/value-initiative-issue-brief-team-based-care-creates-value.pdf.
25.  Van Dyke, M., Redefining the Physician’s Role as Care Team Leader, American Hospital Association Trustee Services (n.d.)
26.  Interprofessional Education Collaborative, Core Competencies for Interprofessional Collaborative Practice (2016)
27.  See Cal. Bus. & Prof. Code §§ 2052, 2400.
28.  See Cal. Bus. & Prof. Code §§ 2837.103(b), 2837.104(g).