Advanced practice nurses (APNs) are vital in providing comprehensive care to patients across various settings in the modern healthcare system. With advanced education and specialised training, APNs possess the expertise to deliver a wide range of healthcare services, including the diagnosis, treatment and management of acute and chronic illnesses. However, despite consistent national standards for nurse practitioner (NP) education, programme accreditation and board certification, state laws and legislative bodies authorise NP practice differently. This leads to various levels of practice authorisation across the nation, which causes significant challenges (American Association of Nurse Practitioners (AANP), 2023a).
The issue of APN autonomy is multifaceted and rooted in historical, regulatory and political factors that have shaped the healthcare system over time. While APNs are recognised as highly skilled healthcare professionals, their scope of practice remains constrained by outdated regulations and restrictive state laws, which vary widely across the country (Wheeler et al, 2022). The AANP supports the Consensus Model for advanced practice registered nurses and the adoption of full practice authority (FPA), which provides patients with complete and direct access to all the services that NPs are equipped to provide, improving access, streamlining care, decreasing costs and protecting patient choice (AANP, 2023a).
The lack of FPA for advanced practice registered nurses is due to several factors, including: practice authority restrictions; transition to practice requirements; federal regulations; and economic realities (Kleinpell et al, 2023). These barriers to full practice have created significant challenges for advanced practice nursing. With the shortage of physicians, patients in rural and underserved areas are more likely to be affected (AANP, 2023a). NPs that require supervision may be required to hire a physician. Physician supervision requirements can range from $500 to $1500 a month for a collaborator.
Practice authority
Practice authority variation exists by state, with some states allowing FPA and others restricting or reducing NPs' ability to practice. There are three levels of practice:
Full practice
State practice and licensure laws permit all NPs to evaluate patients, diagnose, order and interpret diagnostic tests, as well as initiate and manage treatments—including prescribing medications and controlled substances—under the exclusive licensure authority of the state board of nursing. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, and the National Council of State Boards of Nursing (AANP, 2023b).
Restricted practice
State practice and licensure laws reduce the ability of NPs to engage in at least one element of NP practice. State law requires a career-long regulated collaborative agreement with another health provider for the NP to provide patient care, or it limits the setting of one or more elements of NP practice (AANP, 2023b).
Reduced practice
State practice and licensure laws restrict the ability of NPs to engage in at least one element of NP practice. State law requires career-long supervision, delegation or team management by another health provider for the NP to provide patient care (AANP, 2023b). States that restrict or reduce NPs' ability to practice are more closely associated with higher chronic disease burden, primary care shortages, higher costs of care, and lower standing on national health rankings (AANP, 2023b).
Benefits of full practice
FPA for NPs has been shown to improve patient outcomes. NPs with FPA have been found to deliver care of comparable quality to that of physicians, consistently enhancing patient outcomes and delivering cost-effective care (AANP, 2023a). FPA allows NPs to practice independently and prescribe medications, which improves patients' access to primary care providers in health professional shortage areas (Kleinpell et al, 2023). In regions with FPA, NPs are more likely to reside in a health professional shortage area (HPSA) and have a higher mean probability of NP self-employment, which can lead to better patient outcomes and reduced healthcare costs (Kleinpell et al, 2023). Lastly, NPs with FPA are more likely to practice in rural and underserved areas, adhering to high quality and safety standards, leading to improved access to care, streamlined care, increased efficiency, decreased costs and protected patient choice (Peterson, 2017).
COVID-19 caused a rapid delivery system re-design; practice restrictions were temporarily or permanently removed for NP practice (O'Reilly-Jacob, 2022). The Coronavirus Aid, Relief, and Economic Security Act (2020) allowed NPs to order home health services, and the Centers for Medical and Medicaid temporarily waived physician supervision for Federally Qualified Health Centers and Rural Health Centers (Centers for Medicare and Medicaid Services, 2021). Some 22 state governors also temporarily waived physician supervision. The unprecedented regulatory changes during the COVID-19 pandemic reflect the World Health Organization (WHO) recommendation to allow nurses and nurse practitioners to function to the full extent of their education (WHO, 2020).
Aiken et al (2021) reported that having more nurse practitioners on staff can lead to higher patient satisfaction scores and better quality outcomes. Hospitals with more NPs had 21% fewer deaths after standard surgical procedures, shorter lengths of stays and 5% lower Medicare costs per patient (Aiken et al, 2021).
Arguments against FPA
The American Medical Association (AMA) primarily voices arguments against FPA for nurse practitioners (NPs), citing concerns about patient safety, lack of clinical experience and the potential for reduced quality of care in private practices (Cabbabe, 2016; Peterson, 2017). The AMA argues that gaps in training and lack of medical residency (NPs are required to have 500–1000 hours of clinical practice, compared to the physician's 10 000 hours) will threaten patient safety, and physicians claim that the lack of clinical experience renders NPs incapable of adequately caring for patients in private practices. A physician in the AMA stated that in Oregon, NPs have FPA; they reported to not see a shift to rural areas (AMA, 2020). In Stanford University's article: ‘Stanford medicine study challenges the AMA's fight against scope creep’, they cite the AMA comment: ‘allowing nonphysicians such as nurse practitioners (NPs) or physician assistants to diagnose and treat patients without any physician oversight is a step in the wrong direction’ (AMA, 2020).
Overall
However, studies have shown that NPs in advanced clinical roles in inpatient care are a valuable addition to registered nurse and interdisciplinary teams, and can lead to higher patient satisfaction scores, better quality outcomes and lower per-patient expenditures (AANP, 2023a). The decision to grant FPA to NPs remains a contentious issue, with arguments on both sides of the debate.