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...

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…