The Significance of Working to the Top of Practice Scope

You’ve completed years of training in classrooms and online, with the intent to make a positive impact on patients at risk for, or with, cardiovascular disease or stroke. You’ve passed exams, applied what you’ve learned through practicums, and continued to learn through webinars, lunch-and-learns, symposia, and other opportunities.   

Since starting in clinical practice, how might your experience differ from others with similar training and skills? Along with your specific job/role and place of employment, a great deal depends upon the state in which you practice.  

Sorting Through State Similarities and Differences

State laws and regulations can significantly impact nurse practitioners (NPs) and other health care providers (HCPs) such as Physician Assistants, Behavioral Health Providers, and Pharmacists. The American Association of Nurse Practitioners has developed an interactive map of the United States to illustrate the differences in what is authorized for an NP in each state. You can also find out more information about practice in your state on the AANP website, the National Conference of State Legislature’s research and training site ScopeOfPracticePolicy.org, and the State Law Chart of the American Medical Association. 

The model recommended1 by the National Academy of Medicine, and the National Council of State Boards of Nursing, advises that state practice and licensure laws permit all NPs to: 

  • Evaluate patients 
  • Diagnose, order, and interpret diagnostic tests 
  •  Initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing 

States where NPs have Full Practice authorization include Arizona, Colorado, Iowa, New York, and many others. 

Not all states follow this recommendation. Examples of states where Reduced Practice is in effect (as of April 11, 2022) include Alabama, Kansas, and Ohio, among others. By state law, a career-long regulated collaborative agreement with another HCP is required in order for an NP to provide patient care. The state may limit the setting of one or more elements of NP practice. 

The final type of state authorization is Restricted Practice. Some states will limit practice in one or more of these areas and may require supervision for the entirety of an individual’s career, delegation, or team management for the NP to provide patient care. Restrictive practice occurs in many states, including California, Florida, and Texas. 

Why Scope of Practice Matters 

Access to healthcare matters. From prenatal care and well-baby/mom check-ins to effectively administered immunization schedules and medication adherence, and from chronic disease management to availability of emergency medical services, the access you have to acquire care varies dramatically depending upon where you live, work, and play. 

When nurses are not able to work to the full scope of their training, it adds strain to an already over-taxed healthcare system, increases barriers to care for those most in need, and costs more. 

IssueScope of Practice Solution
Healthcare systems, and those employed in healthcare, have been under significant pressure to do more with less—and the recent pandemic has exacerbated the gaps with a surge in providers leaving the profession or retiring. To help control costs, there has been an increased focus on trying to determine the best ways to provide quality care efficiently.These are conditions for which NPs are well suited.2,3 While educational preparation of NPs generally costs 20-25% less than physician preparation,4 decades of research analyzing NP practice indicates NPs provide equivalent or improved medical care at a lower total cost compared to physicians.5,6
With regards to health equity, data demonstrates that a major contributor to inequity is the cost and lack of access for many individuals to obtain the medical care required,7 leading to increased risk of poor health outcomes.8,9NPs practicing at the top of their scope of licensure can contribute to availability of more providers in a system where people live, work, and play. This can directly impact health, longevity, and survival.
Inadequate health care resource availability can influence costs of care such as: a) by not having access to primary care, healthcare shifts to more expensive care in the emergency department, b) delays in visits to providers may lead to patients being ‘sicker’ when they are seen.An increased number of full-scope practicing NPs allows for additional access to care for individuals in rural, urban and suburban settings; making access to primary and preventive care more available; and reducing reliance on emergency care.

Additionally, the reimbursement rate for nurses is often less costly than other providers.

Advocacy Efforts for Scope of Practice 

Advocacy is a key factor in moving states towards having all nurse practitioners have the ability to practice at the fullest scope based on their education and training. There are currently over 325,000 nurse practitioners licensed in the US. Being able to harness the skills of these providers has the potential to improve access to care, and reduce health care costs.  

The first step is finding out what the status of practice legislation is in your state. If your state does not support full practice opportunities, actions you may take may include: 

  • Contacting your state nursing organizations and become involved.  
  • Finding out which of your representatives support full scope of practice.  
  • Participating in lobby days both at the state and national level.  
  • Working with patient advocacy groups, sharing the power in a common voice that can positively impact patient outcomes. 

What You Do Makes a Difference 

  • Demonstrate leadership no matter your role. Participate in—or lead—meetings or initiatives, and look for other opportunities to share your knowledge and skills with others. Consider volunteering with PCNA—and look for additional leadership training available later in 2022. 
  • Consider becoming involved in advocacy efforts. Check out PCNA’s Advocacy Center for additional details. 

References

  1. American Association of Nurse Practitioners. State Practice Environment. Updated April 11, 2022. Accessed 4/11/22.
  2. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Aff. 2010;29:893-899.
  3. Bedenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff. 2013;32:1881-1886.
  4. American Association of Nurse Practitioners. Nurse Practitioner Cost Effectiveness. 2013. . Accessed April 12, 2022.
  5. Kurtzman ET, Barnow BS. A comparison of nurse practitioners, physician assistants, and primary care physicians’ pattern of practice and quality of care in health centers. Med Care. 2017;55:61-622.
  6. Buerhaus P, Perloff J, Clarke S, et al. Quality of primary care provided to Medicare beneficiaries by physicians and nurse practitioners. Med Care. 2018:56:484-490.
  7. Call K, McAlpine D, Garcia C, et al. Barriers to care in an ethnically diverse publicly insured population: is health care reform enough? Med Care. 2014;52:720–27.
  8. National Association of Community Health Centers and the Robert Graham Center. Access denied: a look at America’s medically disenfranchised. (PFD) Washington (DC): National Association of Community Health Centers and the Robert Graham Center; 2007.
  9. Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611–20. doi:10.1016/j.puhe.2015.04.001

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