As of August 2016, 21 states and the District of Columbia have granted nurse practitioners (NPs) the ability to practice independently without physician oversight. Nurse practitioners across the country can prescribe medication (including controlled substances), sign death certificates, order physical therapy, and conduct telehealth visits (AANP).
Ample scientific research has demonstrated that nurse practitioners provide safe, high-quality, cost-effective care equal to that of physicians. For example, Nursing Economics (2011) published a systematic review of advanced practice nurse outcomes between 1990 and 2008, comparing nurse practitioner care with physician care and found no difference in patient satisfaction or patient health outcomes.
Numerous organizations including the Institute of Medicine, Federal Trade Commission, Robert Wood Johnson Foundation, and the American Association of Retired Persons support nurse practitioners. These organizations have independently reviewed research regarding the nurse practitioner profession, and have advocated for expanded practice. Furthermore, the American Association of Nurse Practitioners (AANP 2016) reported that malpractice rates among NPs are impressively low. Only 1.9 percent of NPs have been named as the primary defendant in a lawsuit.
Two terms often associated with nurse practitioners are “scope of practice” and “independent practice.” These terms refer to what nurse practitioners can and can’t do and they vary across states. These terms are similar and should be understood by nurse practitioners and other healthcare providers alike.
You’ll often hear the term “scope of practice” in relation to nurse practitioners. Scope of practice refers to the procedures, actions, and processes that a health care provider is legally permitted to perform or follow within the terms of their professional license. Scope of practice varies by state for each healthcare provider. Some states permit a liberal scope of practice for nurse practitioners, while others restrict nurse practitioners by requiring physicians to oversee what they do.
It’s important to note that although scope of practice for nurse practitioners varies by state, all nurse practitioners are educated to practice independently. Regardless of the state in which a nurse practitioner school is located, its NP students are trained to provide patient care without physician oversight.
The scope of practice varies significantly between nurse practitioners and registered nurses (RN). An RN is permitted to make a nursing diagnosis and implement a nursing treatment, which might include health education and case management. A nurse practitioner’s scope of practice, on the other hand, includes medical diagnosis and treatment, which might include prescription medication, diagnostic imaging, and counseling.
The scope of practice varies only slightly between a nurse practitioner and a physician in “full practice” regions, which are discussed in the section below. Often the biggest difference between the two is that physicians are permitted to make any medical diagnosis and prescribe any treatment, whereas nurse practitioners must remain within their medical specialty. The Institute of Medicine and the National Council of State Boards of Nursing (NCSBN) recommend this model with its relatively generous scope of NP responsibilities. By contrast, NPs in “restricted practice” areas have a relatively limited scope of practice compared to physicians and require more oversight (AANP Aug. 2016).
A detailed analysis comparing physician and nurse practitioner scope of practice can be found Chapter 2 of Dr. Carolyn Buppert’s Nurse Practitioner’s Business Practice and Legal Guide Fifth Edition. Also, detailed position papers on the NP state scope of practice, relative cost-effectiveness of services, and the quality of outcomes compared to doctors can be found on the AANP website.
In the context of medicine, independent practice refers to a nurse practitioner's ability to provide patient care without mandated oversight from a physician. A nurse practitioner who practices independently can assess, diagnose, and treat a patient without physician involvement. A nurse practitioner without independent practice rights must maintain a written, legal document signed by one or more physicians agreeing to particular conditions for practice.
The degree of nurse practitioner independence from physicians relies on state laws, which vary across the country. The AANP classifies each state by full practice (independent), reduced practice (partially independent), and restricted (non-independent):
Unfortunately, the scope of practice for nurse practitioners varies by state. As a result, the National Council of State Boards of Nursing has launched the Campaign for APRN Consensus, an initiative to assist states in equalizing their nurse practitioner laws. The term APRN refers to “advanced practice registered nurse,” which encompasses nurse practitioners, nurse midwives, nurse anesthetists, and clinical nurse specialists.
The Campaign aims to align state laws with the current, accepted model for nurse practitioner regulation, licensure, education, and certification. The goal of the Campaign is to help consumers, employers, and healthcare professionals to clearly understand the preparation and scope of practice of nurse practitioners.
Specifically, the Campaign encourages all states to adopt these rules:
Using the Campaign for Consensus as a guide, the nurse practitioner profession desires to attain independent practice in all 50 states. This process has been ongoing for decades now, with many victories and defeats. As mentioned above, 21 states and the District of Columbia have granted nurse practitioners independent practice. The battle, however, continues uphill. Nurse practitioners in California lost their fight for independent practice in mid-2016 when State Senator Ed Hernandez (D-West Covina) was forced to withdraw his bill which would have expanded the NP scope of practice. A similar initiative (SB 491) was defeated in 2013 (California Medical Association).
Regardless of your political persuasion or healthcare background, you can get involved in fighting for nurse practitioner rights and autonomy.
If you’re a nurse practitioner or nurse practitioner student, join and donate to the American Nurses Association (ANA), the American Association of Nurse Practitioners (AANP), and your local nurse practitioner organization. Right now there are over 680 bills in state legislatures across the United States. As a member of the AANP, you can follow, support, and access up-to-date information on all these bills in the State Legislation Tracking Center.
Nurse practitioners and others can contact their members of congress to cosponsor these three major bills: