Nurse practitioner autonomy and scope of practice

Today, health care in the United States is characterized by growing demand combined with skyrocketing costs and critical shortages of qualified health care practitioners. In response to these challenges, there has also been a growing consensus among health care providers that nurse practitioners possess the education, training and expertise that are required to provide high quality medical services for a wide array of disorders. In fact, some studies have indicated that nurse practitioners can treat fully 90% of the typical conditions that have historically been treated by primary care physicians with higher rates of patient satisfaction and compliance with treatment regimens. Nevertheless, fewer than one-half of the states, the District of Columbia and the U.S. Department of Veterans Affairs only have granted nurse practitioners full practice authority, meaning that tens of millions of health care consumers across the country are being denied the full range of benefits that can be achieved when nurse practitioners enjoy full autonomy with prescribed limits in their practice, an issue the forms the focus of this policy analysis as discussed further below.
Identification/definition of the problem/issue
The problem is that nurse practitioners in some states currently do not work under their own practice despite the growing body of evidence concerning the cost effectiveness of this alternative and its general efficacy in achieving optimal clinical outcomes. For instance, according to the advocates at one major nursing organization, “With nurse practitioner autonomy being legislated in an increasing number of states, nurse practitioners are able to fill gaps in preventative care and keep Americans healthier” (Carlson, 2017). In addition, increased nurse practitioner autonomy will free up more time for primary care physicians to treat more difficult conditions and increase accessibility to primary health care services for greater number of patients, especially in rural regions of the country.
These trends have been matched by declining physician interest in providing primary care services while the number of nurse practitioners in primary care settings has increased significantly in recent years, climbing from just 30,000 in 1990 to 140,000 in 2010 (Kraus & DuBois, 2017). Furthermore, the vast majority of these newly added nurse practitioners have been in primary care settings, with nearly half (49.2%) specializing in family care (Kraus & DuBois, 2017). According to Kraus and DuBois (2017), the expansion of full practice authority to all nurse practitioners just makes good medical and business sense for a number of reasons. For instance, Kraus and DuBois note that, “The nurse practitioner workforce can be expanded with less training time than that for physicians. Some data indicate that nurse practitioners can provide about 90 % of primary care services commonly provided by physicians, with at least comparable outcomes and at lower cost” (p. 284).
Moreover, the research to date indicates that although the types of malpractice suits against nurse practitioners are similar in type to those experienced by physicians, they have substantially lower malpractice rates and there is no indication that full practice authority for nurse practitioners causes any corresponding increase to physician liability (Kraus & DuBois, 2017). In addition, Kraus and DuBois also point out that, “Many physicians agree that nurse practitioners are a great addition to a clinic, because they ‘can pay for themselves’ and reduce physician workload” (2017, p. 284). Nevertheless, the reluctance on the part of many physicians and other stakeholders to granting nurse practitioners full practice authority has severely constrained the process, and the background surrounding this urgent problem is discussed further below.
Background surrounding the problem
In spite of the growing body of evidence supporting full practice authority for nurse practitioners, more than half of the states have still not granted this authority and the scope of practice in other states varies significantly (Where can nurse practitioners practice without physician supervision, 2016). At present, 21 states and the District of Columbia have approved full practice authority for nurse practitioners in their jurisdiction, and this level of autonomy provides them with the authority to assess, diagnose, interpret diagnostic tests, and prescribe medications independent of direct physician supervision (Where can nurse practitioners practice, 2016). Not surprisingly, states with especially large rural areas such as Alaska, Washington and Oregon, were among the first to approve full practice authority for nurse practitioners nearly 30 years ago in order to improve accessibility to health care services in these remote regions of the country
Notwithstanding these trends and the corresponding body of evidence that has been amassed concerning the effectiveness of the full practice authority model for nurse practitioners in improving patient care and reducing costs, advanced practice nurses can gain or lose several important privileges simply by moving across a state border. The reluctance of the holdout states and those states that require onerous compliance measures for limited autonomy in 29 states is all the more difficult to understand during an era when evidence-based practices are widely recognized as the preferred approach to health care delivery. For example, according to one nursing organization, “While the practice guidelines for these levels are slightly different depending on location, all require nurse practitioners to have either a signed collaboration agreement with a physician or direct oversight from a physician” (Where can nurse practitioners practice, 2016, para. 5). In some cases, however, these requirements are less onerous and physicians need only be available by telephone or email to satisfy these stipulations (Where can nurse practitioners practice, 2016).
The foregoing jurisdictional differences in the scope of nurse practitioner practice authority make it clear that autonomy exists along a continuum that is affected by a number of variables, including the various elements of autonomous practice that are allowed. In this regard, a recent study by Park, Athey, Pericak, Pulcini and Greene (2018) found that nurse practitioners experienced enhanced autonomy in their daily practice in those jurisdictions where they enjoyed prescriptive independence. A noteworthy finding by Park et al. (2018) was that, “There were only small and largely insignificant differences in day-to-day practice autonomy between nurse practitioners in fully restricted states and those in states with independent practice but restricted prescription authority” (p. 66).
In addition, Park et al. (2018) also identified other organizational and structural barriers that affected the level of day-to-day practice autonomy among nurse practitioners. These findings suggest that other factors besides state-specific scope of practice laws influence the autonomy level of nurse practitioners irrespective of controlling legislation. Based on their research, Park and his associates conclude that, “Removing barriers at all levels that potentially prevent nurse practitioners from practicing to the full extent of their education and training is critical not only to increase primary care capacity but also to make [them] more efficient and effective providers” (2018, p. 66).
Yet another potential barrier to the universal adoption of the full practice authority model in the United States involves the influential perspectives of physicians, a barrier that exists in a number of other countries as well. For instance, a meta-analysis of 36 studies conducted in seven different countries by Andregård and Jangland (2015 found that physicians tend to view nurse practitioners as dependent on their ongoing guidance while some nurse practitioners considered their role as autonomous and others calling for greater autonomy in their practice. In this regard, Andregård and Jangland (2015) report that, “The nurse practitioners described their role as an independent one, with support from physicians only in more complex patient cases—and many asked for more autonomy [while] physicians mostly described the nurse practitioner role as dependent and in need of supervision” (p. 8).
Given the longstanding nature of the dependent relationship between physicians and advanced practice nurses, these barriers are especially intractable to change, but this constraint has also been widely recognized by proponents of full practice authority for nurse practitioners. For instance, Pritchard (2017) emphasizes that, “The nurse-doctor relationship needs to be re?evaluated in light of the expanding role of nurse`s into areas that traditionally had been considered a doctor`s role” (p. 31). The reluctance of some physicians to cede any of their practice authority to other practitioners is also understandable given the amount of time and expense that were involved in acquiring this authority, and this reluctance is reflected on the above-mentioned scope continuum.
Indeed, in some cases, physicians have only grudgingly accepted greater but still highly limited autonomy for nurse practitioners. Unlike other professions, however, this reluctance is not so much attributable to so-called “turf battles” as it is to a perceived threat to their traditional lofty positions atop the health care pillar, especially when it comes to writing prescriptions for any category of drugs. As Pritchard (2017) points out, “While the medical profession has been willing to relinquish some control to nurses in areas such as wound or incontinence care because these aspects do not threaten their authority, position or power. The issue of non?medical prescribing remains for some in the medical profession a topic of concern” (p. 31). In fact, prescriptive authority for nurse practitioners appears to be a particularly acute sore point with many physicians as if this authority represented the last bastion on their former glory days as the only professionals who were entitled (Pritchard, 2017).
Moreover, beyond the other jurisdictional differences that exist concerning the scope of full practice authority for nurse practitioners, there are numerous significant differences between state-specific prescriptive authority laws (Pritchard, 2017). This blurring of the professional roles between physicians and nurse practitioners has adversely affected the physician-nurse practitioner relationship to the point where this barrier demands closer scrutiny in order to identify ways to overcome it. As Prichard concludes, “As nurses take on more responsibility such as prescribing medication the old traditional view of this relationship is no longer viable, if we are to maximize patient health care in the 21st century” (2017, p. 31).
Other researchers concur with this assessment of the strained relationship between nurse practitioners and physicians as a barrier to universal authorization of full practice authority for all nurse practitioners. For instance, the purpose of a descriptive study by Maylone, Ranieri, Griffin, McNulty and Fitzpatrick (2010) was evaluate the current status of nurse practitioner perceptions concerning the quality of their relationships with physician colleagues as well as their corresponding levels of autonomy in their day-to-day practice. Based on their analysis of a survey of a convenience sample of 99 nurse practitioners enrolled at a national clinical conference using the 30-item Dempster Practice Behavior Scale and the 19-item Collaborative Practice Scale, both of which have demonstrated validity and reliability. These two survey instruments were specially modified by Maylone et al. (2010) for an advanced practice nurse context.
Based on the results that emerged from the administration of these two survey instruments, Maylone et al. (2010) concluded that although the nurse practitioner respondents rated the perceptions of autonomy and the quality of their collaborative practice with physicians as high, there was no corresponding correlation between these two variables. These findings further underscore the need for a timely reassessment of the physician-nurse practitioner relationship in order to develop a better understanding so that initiatives can be implemented to specifically address this barrier to the adoption of full practice authority for nurse practitioners across the country (Maylone et al., 2010). Taken together, it is clear that there are a wide array of factors involved in the debate concerning the authorization of full practice authority for nurse practitioners, but there are also some social, economic, ethical, political, and legal factors involved that must be taken into account as discussed below.
Identify any social, economic, ethical, political, and legal factors as appropriate
Against a backdrop characterized by rapidly rising costs and increasing health care practitioner shortages, it is little wonder that nurse practitioners have faced a seemingly uphill battle to climb another notch on the full practice authority continuum. While many of the barriers have been identified, there remains a paucity of timely and relevant research concerning the specific issues that have constrained the adoption of full practice authority for all nurse practitioners in the United States. More to the point, these types of barriers remain firmly in place despite the growing need for high quality health care services, a need that nurse practitioners have been shown to be able to fill. In this regard, Poghosyan and Liu (2016) point out that:
The nurse practitioner workforce represents a substantial supply of primary care providers able to contribute to meeting a growing demand for care. However, controversy exists regarding the expanding role of nurse practitioner in primary care in terms of challenging the teamwork between nurse practitioners and physicians. To date [however] no empirical evidence exists regarding how to promote teamwork in primary care between NPs and physicians. (p. 771)
Arguments in support of the need for additional research, though, are countered by the body of evidence that has been accumulated that supports the granting of full practice authority to nurse practitioners as well as the increasingly urgent nature of the health care situation in the United States today. For example, Kraus and DuBois (2017) make the point that the requirements of the Affordable Care Act have added further fuel to the heated debate over full practice authority for nurse practitioners and the degree of autonomy they should be afforded in their day-to-day practice. One area that does appear to be in need of further study, though, concerns the potential effects of full practice authority for nurse practitioners on physician attitudes about these advanced practice nurses. As Kraus and DuBois stress, “Such discussions in the media and among professional organizations may insinuate that changes to the laws governing nurse practitioner practice will engender acrimony between practicing physicians and nurse practitioners” (2017, p. 284).
As noted above, nurse practitioners in the United States can gain – or lose – various elements of autonomy in their day-to-day practice simply by moving across a state border. As depicted graphically in Figure 1 below, the following states (besides the District of Columbia) currently provide full practice authority for nurse practitioners:
· Alaska;
· Arizona;
· Colorado;
· Connecticut;
· Hawaii;
· Idaho;
· Iowa;
· Maine;
· Maryland;
· Minnesota;
· Montana;
· Nebraska;
· Nevada;
· New Hampshire;
· New Mexico;
· North Dakota;
· Oregon;
· Rhode Island;
· Vermont;
· Washington; and,
· Wyoming (Where can nurse practitioners practice, 2016).

Figure 1. Nurse Practitioner Scope of Practice by State as of March 1, 2017
Source: https://s3-us-west-1.amazonaws.com/nurseorg-prod-media/images/blog/2017/03/01/ 2017_NP_Practice_Authority_map.png
This disparity in full practice authority for nurse practitioners has assumed new importance and relevance for practitioners and consumers alike as a result of the provisions of the Affordable Care Act combined with increased demand for primary health care services and these issues are discussed further below.
Why is this health policy issue important to the profession of nursing?
The universal adoption of full practice authority for all nurse practitioners represents an important milestone in the professionalization of advanced practice nursing (Carlson, 2017). For example, according to Carlson (2017), “With legislative sessions currently taking place in many states around the U.S., bills related to nurse practitioners and their nursing scope of practice have been in the news” (para. 5). This attention has been given further impetus by the granting of full practice autonomy to all nurse practitioners in January 2017 by the U.S. Department of Veterans Affairs. While this approval represented a significant milestone and provided additional support in achieving universal full practice scope authority for nurse practitioners, the fact that nurse practitioners working in these federal facilities may enjoy greater scope authority compared to their counterparts working in other health care settings just down the street means that these fundamental differences must be addressed at the earliest opportunity in order to solidify their expanded role in the early 21st century.
What are the desired outcomes related to this health policy issue?
The overarching desired outcome related to this health policy issues is universal autonomy for nurse practitioners in their day-to-day practice in all U.S. jurisdictions.
How will this policy change healthcare/nursing?
Achieving the foregoing desired outcome will introduce across-the-board cost savings in primary health care settings, including the hefty fees that nurse practitioners must currently pay in order to receive the requisite physician supervision for their jurisdiction (Carlson, 2017). In addition, the reduced monitoring and enforcing of nurse practitioner supervision by physicians will also save states significant resources while increasing the availability of primary care services to a wider range of patients (Carlson, 2017).
How can this health policy be evaluated when implemented?
Fortunately, an enormous amount of benchmark data has been compiled over the past 30 years concerning the effectiveness of full practice authority for nurse practitioners, and the scholarship in this area has increased significantly in recent years as well. Some of the salient benchmarks that can be used to routinely evaluate new full authority practice models include patient satisfaction levels, malpractice suit rates, comparative costs, and clinical outcomes such as the need for emergency care or hospitalization following treatment by nurse practitioners within a specified period of time (e.g., 1 or 2 weeks).
How are the profession of nursing and nurses involved in shaping or revising this policy issue?
A number of major nursing national health care organizations have been involved in revising the current disparities in practice authority among the various states. For instance, the National Council for State Boards of Nursing and the Institute of Medicine recommended the adoption of the full practice model for nurse practitioners in 2010 (Where can nurse practitioners practice, 2016). Likewise, the American Association of Nurse Practitioners also strongly supports the full practice authority model for nurse practitioners developed by the National Council of State Boards of Nursing (Full practice authority, 2017).
Identification of the stakeholders of this problem/issue
The primary stakeholders in this issue include most especially the more than 140,000 nurse practitioners and more than one million physicians in the United States today (Statistics and facts on U.S. physicians, 2018). Because this issue affects virtually all health care consumers, other stakeholders include the 326 million citizens of the United States, including most especially those residing in rural regions of the country where accessibility to primary care physicians is limited. For example, a study by Spetz, Skillman, Holly and Andrilla (2017) found that accessibility to primary care in rural areas can be alleviated in significant part by the addition of nurse practitioners with full practice authority. Based on the results of their analysis of the 2012 National Sample Survey of nurse practitioners, Spetz et al. (2017) concluded that, “To meet rural primary care needs, states should support rural nurse practitioner practice, in concert with support for rural physician practice” (p. 227).
Conclusion
The research showed that granting full practice authority to nurse practitioners produces a number of numerous benefits, including reduced costs and increased patient satisfaction and improved clinical outcomes. Although a number of states have already granted nurse practitioners will full practice authority, others continue to either restrict their scope of practice or impose onerous compliance requirements on these health care professionals. There has been significant movement in recent years, though, to identify the precise barriers to universal adoption of full practice authority for nurse practitioners, and many researchers cite the strained relationship between physicians and nurse practitioners that adversely affects acceptance rates among physicians. In the final analysis, it is reasonable to conclude that unless and until this significant barrier can be addressed head-on, there will continue to be disparities in the scope of practice authorized by various jurisdiction in the United States to the detriment of the tens of millions of stakeholders that are involved.





References
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