Nurse Practitioner Scope of Practice Breakdown
As of July 2021, 23 states and the District of Columbia have granted nurse practitioners (NPs) the ability to practice independently. Nurse practitioners in these states can prescribe medication (including controlled substances), sign death certificates, order physical therapy, and conduct telehealth visits (AANP) without physician oversight.
Ample scientific research demonstrates that nurse practitioners provide safe, high-quality, and cost-effective care equal to that of physicians. For example, Oxford University Press published a systematic review of primary care outcomes in 2015 that found NPs provided equal or superior care compared to physicians. Similar conclusions were drawn in a systematic review on critical and emergency care, published by Human Resources for Health in 2017.
As of July 2021, 23 states and the District of Columbia have granted nurse practitioners (NPs) the ability to practice independently.
Numerous organizations support nurse practitioners, including the Institute of Medicine, Federal Trade Commission, Robert Wood Johnson Foundation, and the American Association of Retired Persons. These organizations have independently reviewed research regarding the nurse practitioner profession and have advocated for expanded practice.
A study published by Medical Research and Review in 2017 revealed that malpractice rates among NPs are relatively low. Only 1.1 to 1.4 per 1,000 NPs were listed in malpractice payment reports, compared to 11.2 to 19.0 per 1,000 physicians.
Two terms often associated with nurse practitioners are “scope of practice” and “independent practice.” These terms refer to what duties nurse practitioners can and cannot do, which varies across states.
What Is Scope of Practice?
Scope of practice refers to the procedures, actions, and processes that a healthcare provider is legally permitted to perform 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 supervise what they do.
Although the scope of practice for nurse practitioners varies by state, all nurse practitioners are trained to practice independently.
“Nurse practitioners (NPs) practice in nearly every healthcare setting including clinics, hospitals, Veterans Affairs and Indian Health Care facilities, emergency rooms, urgent care sites, private physician or NP practices (both managed and owned by NPs), nursing homes, schools, colleges, retail clinics, public health departments, nurse managed clinics, homeless clinics, and home health.
“NP practice includes, but is not limited to, assessment; ordering, performing, supervising and interpreting diagnostic and laboratory tests; making diagnoses; initiating and managing treatment including prescribing medication and non-pharmacologic treatments; coordinating care; counseling; and educating patients and their families and communities.”
“As licensed, independent practitioners, NPs practice autonomously and in coordination with healthcare professionals and other individuals. NPs provide a wide range of healthcare services including the diagnosis and management of acute, chronic, and complex health problems, health promotion, disease prevention, health education, and counseling to individuals, families, groups and communities. They may also serve as healthcare researchers, interdisciplinary consultants, and patient advocates.”
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 includes medical diagnosis and treatment, which might include prescription medication, diagnostic imaging, and counseling.
The scope of practice varies 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.
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.
What Is Nurse Practitioner Independent Practice?
In the context of medicine, independent practice, or full-practice authority, refers to a nurse practitioner’s ability to provide patient care without 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.
A nurse practitioner who practices independently can assess, diagnose, and treat a patient without physician involvement.
The degree of nurse practitioner independence relies on state laws, which vary across the country. The AANP classifies each state by full practice (independent), reduced practice (partially independent), and restricted (nonindependent):
- Full Practice
- “State practice and licensure laws permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.
- Reduced 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 in order for the NP to provide patient care, or it limits the setting of one or more elements of NP practice.”
- Restricted 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 in order for the NP to provide patient care.”
Campaign for Full Practice Authority Consensus
The scope of practice for nurse practitioners varies by state. As a result, the National Council of State Boards of Nursing launched the Campaign for APRN Consensus in 2008, 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 clearly understand the preparation and scope of practice of nurse practitioners.
Specifically, the Campaign for APRN Consensus encourages all states to adopt these rules:
- Recognition of four key roles: CNS, CNP, CRNA, CNM
- Recognition of the APRN title
- Licensure as an RN and as an APRN
- Graduate or postgraduate education from an accredited institution
- Board-issued certification in a medical specialty
- Independent practice
- Independent prescribing
The nurse practitioner profession desires to attain independent practice in all 50 states using the Campaign for Consensus as a guide. This process has been ongoing for decades now, with many victories and defeats. The battle, however, continues uphill.
Nurse practitioners in Louisiana lost their fight for independent practice in June 2021 when the state Senate failed to pass House Bill 495 before the close of the session. California State Senator Ed Hernandez (D-West Covina) was forced to withdraw a similar bill in mid-2016 when he was unable to garner enough votes for passage.
How Does Nurse Practitioner Authority Vary by State?
The ability of nurse practitioners to work to the full extent of their training and education is an issue that affects NPs nationwide. As documented in recent interviews with some of Michigan’s nurse practitioners and researchers, the fight for full practice authority (FPA) is crucial to help meet the growing demand for qualified providers (particularly in rural areas) and to keep costs down with safe, effective healthcare services.
While the VA, the AARP, the FTC, the Institute of Medicine, the Bipartisan Policy Center advocate for granting FPA to NPs, many physician organizations still oppose these efforts. As Dr. Denise Hershey of Michigan State University stated in her 2017 interview, “The biggest challenge in this fight is getting the physician groups to understand that we are not in competition with them.”
It is important to note that due to the tireless efforts of NP legislative advocacy, the state practice environments are continually evolving. This table examines the status of NP practice authority across U.S. states, including information about prescriptive authority and links to local boards of nursing and practice acts.
NP Practice Authority by State
NP Board of Nursing and Practice Act by State
District of Columbia
Frequently Asked Questions
NPs may engage in certain invasive procedures such as central line insertion or intubation. Physician supervision requirements vary by state. Nurse practitioners do not perform complex or specialized surgical procedures. There are 23 NP independent practice states as of July 2021. The District of Columbia also provides full authority to NPs. The majority of Southern states reduce or restrict the practice authority of nurse practitioners. Nurse practitioners who practice independently do not need physician approval or instructions, allowing them greater autonomy as care providers. NPs with full authority also save money by avoiding collaborating physician fees. While in many states licensed RNs can apply for “licensure by endorsement” reciprocity, the ability to work as an APRN across state lines is limited. With the COVID-19 pandemic, some states did allow for NPs to practice across state lines via telehealth and/or in person.The APRN Compact is working to change this.
What procedures can a nurse practitioner perform?
Which states are where NPs can practice independently?
What are the benefits of full practice authority for nurse practitioners?
Can nurse practitioners work in different states?
NPs may engage in certain invasive procedures such as central line insertion or intubation. Physician supervision requirements vary by state. Nurse practitioners do not perform complex or specialized surgical procedures.
There are 23 NP independent practice states as of July 2021. The District of Columbia also provides full authority to NPs. The majority of Southern states reduce or restrict the practice authority of nurse practitioners.
Nurse practitioners who practice independently do not need physician approval or instructions, allowing them greater autonomy as care providers. NPs with full authority also save money by avoiding collaborating physician fees.
While in many states licensed RNs can apply for “licensure by endorsement” reciprocity, the ability to work as an APRN across state lines is limited. With the COVID-19 pandemic, some states did allow for NPs to practice across state lines via telehealth and/or in person.The APRN Compact is working to change this.
Elizabeth M. Clarke, FNP, MSN, RN, MSSW
Elizabeth Clarke (Poon) is a board-certified family nurse practitioner. A native of Boston, MA, Clarke tired of the cold and snowy winters and moved to Coral Gables, FL in order to complete her undergraduate degree in nursing at the University of Miami. After working for several years in the UHealth and Jackson Memorial Medical systems in the cardiac and ER units, Clarke returned to the University of Miami to complete her master of science in nursing. Since completing her MSN degree, Clarke has worked providing primary and urgent care to pediatric populations.
She is a paid member of Red Ventures Education’s freelance review network.
Featured Image: Reza Estakhrian / The Image Bank / Getty Images
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