Nurse Practitioner Full Practice Authority: A Policy Analysis

Introduction

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 been a growing consensus among health care providers that nurse practitioners possess the education, training, and expertise 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 half of the states, the District of Columbia, and the U.S. Department of Veterans Affairs have granted nurse practitioners full practice authority. This means 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 within prescribed limits in their practice — an issue that forms the focus of this policy analysis.

Identification and Definition of the Problem

The problem is that nurse practitioners in many states currently do not work under their own independent practice authority, despite a growing body of evidence concerning the cost-effectiveness of this alternative and its general efficacy in achieving optimal clinical outcomes. According to 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 would free up more time for primary care physicians to treat more complex conditions and would improve accessibility to primary health care services for a 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 placed in primary care settings, with nearly half (49.2%) specializing in family care (Kraus & DuBois, 2017). According to Kraus and DuBois (2017), expanding full practice authority to all nurse practitioners makes good medical and business sense for several reasons. As they note, "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, research to date indicates that although the types of malpractice suits against nurse practitioners are similar in type to those experienced by physicians, nurse practitioners have substantially lower malpractice rates, and there is no indication that full practice authority for nurse practitioners causes any corresponding increase in physician liability (Kraus & DuBois, 2017). 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 grant nurse practitioners full practice authority has severely constrained progress on this issue.

Background Surrounding the Problem

Despite the growing body of evidence supporting full practice authority for nurse practitioners, more than half of U.S. 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, providing 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 remote regions of the country.

Notwithstanding these trends and the corresponding body of evidence demonstrating the effectiveness of the full practice authority model, advanced practice nurses can gain or lose several important practice privileges simply by moving across a state border. The reluctance of holdout states — and those 29 states that impose onerous compliance measures for limited autonomy — is all the more difficult to understand in an era when evidence-based practices are widely recognized as the preferred approach to health care delivery. 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 burdensome, and physicians need only be available by telephone or email to satisfy these stipulations (Where can nurse practitioners practice, 2016).

The foregoing jurisdictional differences make clear that nurse practitioner autonomy exists along a continuum affected by numerous variables, including the specific elements of autonomous practice that are permitted. A recent study by Park, Athey, Pericak, Pulcini, and Greene (2018) found that nurse practitioners experienced enhanced autonomy in daily practice in jurisdictions where they enjoyed prescriptive independence. A noteworthy finding 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).

Park et al. (2018) also identified other organizational and structural barriers that affected the level of day-to-day practice autonomy among nurse practitioners, suggesting that factors beyond state-specific scope of practice laws influence nurse practitioner autonomy irrespective of controlling legislation. They 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 universal adoption of the full practice authority model involves the perspectives of physicians — a barrier that exists in a number of other countries as well. 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 called for even greater autonomy. 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 resistant to change — though this constraint has also been widely recognized by proponents of full practice authority. Pritchard (2017) emphasizes that "The nurse-doctor relationship needs to be re-evaluated in light of the expanding role of nurses into areas that traditionally had been considered a doctor's role" (p. 31). The reluctance of some physicians to cede practice authority to other practitioners is also understandable given the time and expense involved in acquiring that authority, and this reluctance is reflected in the scope-of-practice continuum described above.

In some cases, physicians have only grudgingly accepted greater but still highly limited autonomy for nurse practitioners. Unlike other professions, however, this reluctance is attributable less to so-called "turf battles" than to a perceived threat to their traditional positions atop the health care hierarchy — particularly when it comes to prescribing medications. 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). Prescriptive authority for nurse practitioners appears to be a particularly sensitive issue for many physicians, as if this authority represented the last bastion of their former exclusive domain (Pritchard, 2017).

Beyond these jurisdictional differences, there are numerous significant variations among state-specific prescriptive authority laws (Pritchard, 2017). This blurring of professional roles between physicians and nurse practitioners has adversely affected their working relationship, demanding closer scrutiny to identify ways to overcome it. As Pritchard 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 physician-nurse practitioner relationship as a barrier to universal authorization of full practice authority. A descriptive study by Maylone, Ranieri, Griffin, McNulty, and Fitzpatrick (2010) evaluated the current status of nurse practitioner perceptions concerning the quality of their relationships with physician colleagues and their corresponding levels of autonomy in day-to-day practice. The study analyzed 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 — modified by Maylone et al. (2010) for an advanced practice nursing context.

Based on the results of these two survey instruments, Maylone et al. (2010) concluded that although nurse practitioner respondents rated both their 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 and implement initiatives specifically addressing this barrier to the adoption of full practice authority (Maylone et al., 2010).

Conclusion

The research showed that granting full practice authority to nurse practitioners produces a number of significant benefits, including reduced costs, increased patient satisfaction, and improved clinical outcomes. Although a number of states have already granted nurse practitioners 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 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 as a factor that adversely affects physician acceptance rates. In the final analysis, it is reasonable to conclude that unless and until this significant barrier can be addressed directly, there will continue to be disparities in the scope of practice authorized by various jurisdictions in the United States — to the detriment of the tens of millions of stakeholders involved.

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