Why Nurse Practitioners Should Have Full Practice Authority in Every State

As the healthcare landscape continues to evolve, one of the most pressing debates centers around the role of nurse practitioners (NPs). These highly trained professionals are essential to the delivery of care in a variety of settings, but in many states, they are still subject to restrictive regulations that limit their ability to practice to the full extent of their education and training. It's time to change this.

What is Full Practice Authority?

According to The American Association of Nurse Practitioners (AANP), Full practice authority refers to the ability of nurse practitioners to evaluate patients, make diagnoses, interpret diagnostic tests, and initiate treatment plans, including prescribing medications, without the supervision, collaboration, or oversight of a physician. Currently, 28 states and the District of Columbia grant nurse practitioners full practice authority. However, in the remaining states, NPs are still required to work under supervisory or collaborative agreements with physicians, often limiting their autonomy and impeding their ability to deliver timely, quality care.

BLOG 3: THE STATUTORY AND REGULATORY MECHANISMS

HIERARCHY OF STATUTORY AND REGULATORY AUTHORITY

(Government Accountability Office, 2018)

Full Practice Authority (FPA) for Nurse Practitioners (NPs) is the ability for NPs to practice independently, without the need for supervisory, collaborative, or supervisory agreements with physicians. Full Practice Authority allows NPs to assess, diagnose, interpret diagnostic tests, and initiate treatment plans, including prescribing medications, based on their education and training. In the United States, FPA varies by state, and the statutory and regulatory mechanisms that govern this authority are complex, involving multiple legislative and regulatory bodies and processes. Statutory and regulatory laws play crucial roles in the policymaking process particularly in health policy according to Mecham (2020).

  

Statutory Mechanisms

Statutory laws are laws that are created by legislative bodies, such as Congress or state legislatures. These laws result from the formal legislative process and typically set out the broad framework or principles of health policies. How this relates to Full Practice Authority, statutory mechanisms primarily involve legislation (Meacham, 2020). The following are some key players within the United States regarding the creation of statutory laws.

The Federal Government

According to Policy Perspectives, additional scope of practice restrictions, such as physician supervision requirements, may hamper APRNs’ ability to provide primary care services that are well within the scope of their education and training. Policy Perspectives—Competition and the Regulation of Advanced Practice Nurses (March 2024)

Arizona Legislature

In Arizona, on April 21, 2017, SB1336, nurse anesthetists; prescribing authority; limitation; was signed by the governor (azbn.gov).  State legislatures pass laws that define the scope of practice for Nurse Practitioners. These regulations provide details on what NPs can and cannot do within their scope of practice. 

 

Regulatory Mechanisms 

Regulatory mechanisms refer to the systems and processes through which governments enforce laws and maintain order. These mechanisms are designed to ensure that power is exercised responsibly and that the rights and interests of citizens are protected (Meacham, 2020).

Regulatory Bodies that affect Full Practice Authority:

State Boards of Nursing

These boards regulate nursing practice and enforce the Nurse Practice Act. They are responsible for licensing NPs and setting standards for education, certification, and practice (NCSPN, 2023). NP licensure is regulated exclusively by the Arizona Board of Nursing, A.A.C. R4-506 (aanp.org).

Federal Influence

While FPA is primarily a state issue, federal policies can influence state decisions. For example, the Centers for Medicare & Medicaid Services (CMS) reimburses NPs directly for services, which supports FPA. The Veterans Health Administration (VHA) grants FPA to NPs within its system, regardless of state restrictions.

Conclusion

To accomplish policy change and secure Full Practice Authority for NPs, policy advocates must navigate a complex landscape of legislative and regulatory bodies, including state legislatures, boards of nursing, medical boards, and national organizations. The process involves drafting and advocating for legislation, lobbying lawmakers, gathering support from healthcare providers and patients, and engaging with regulatory bodies to ensure that Full Practice Authority is properly implemented. The goal is to create a legal and regulatory framework that allows nurse practitioners to practice to the full extent of their training and expertise, improving access to care, especially in underserved and rural areas.

 

 

References

aanp.org/advocacy/state/state-practice-environment/state-policy-fact-sheets/arizona-state-policy-fact-sheet 

Advisory Opinions & Position Statements | Board of Nursing 

Government Accountability Office. (2018). Regulatory guidance processes. /https://www.gao.gov/assets/gao-15-368.pdf

National Council of State Boards of Nursing (NCSBN). (2023). Consensus Model for APRN Regulation. Retrieved from https://www.ncsbn.org.

Meacham, M. R. (2020). Longest health policymaking in the United States (7th ed.).
Health Administration Press.

Policy Perspectives—Competition and the Regulation of Advanced Practice Nurses (March 2024)

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20 Feb 2025 20:56

The Birth of the Nurse Practitioner Role: The first nurse practitioner (NP) program was established in 1965 at the University of Colorado by Dr. Loretta C. Ford and Dr. Henry Silver. Their goal was to train registered nurses with advanced skills to provide primary and preventative care, addressing physician shortages and the need for accessible healthcare in underserved areas. Dr. Ford's vision combined nursing's focus on patient care with advanced clinical expertise, creating a new healthcare role capable of diagnosing, treating, and educating patients independently while collaborating with physicians (Berg, 2020). By 1970, the first group of nurse practitioners was trained in this innovative approach. As nurse practitioners (NPs) gained recognition, their services became increasingly in demand, especially in rural and underserved areas in the 1980s, where they provided primary care services like physical exams, tests, and prescriptions. In the 1990s, NPs expanded into hospitals, specialty clinics, and private practices, with many states granting them the authority to prescribe and perform clinical duties independently (aanp.org). Education for NPs advanced, with most programs requiring master's degrees by the late 1990s and the introduction of Doctor of Nursing Practice (DNP) programs in the early 2000s, raising the standard of education and expertise. (History of Nurse Practitioners in the United States - OAAPN).

Read more »

 

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Here’s Why Nurse Practitioners Should Have Full Practice Authority Nationwide:

  1. Addressing the Primary Care Shortage

The United States is facing a severe shortage of primary care physicians, with millions of Americans living in areas designated as Health Professional Shortage Areas (HPSAs). NPs are highly trained and capable of providing primary care services to these underserved populations. With full practice authority, NPs can take on a larger role in addressing this gap, reducing wait times, and improving access to care. Shortage Areas 

  1. Improving Access to Healthcare, Especially in Rural Areas

Rural communities are especially impacted by the shortage of healthcare providers. Many rural areas only have limited access to physicians, which often leads to longer travel times, delays in care, and poorer health outcomes. Nurse practitioners, when granted full practice authority, can help fill this void. They are trained to provide essential services like preventive care, health education, and chronic disease management, all of which are critical in improving the overall health of rural populations. Based on 2020 Census data, 20.3% of the population (62.8 million people) and 87.4% of the land area of the country to be rural. How We Define Rural | HRSA

  1. Cost-Effective Care

Studies show that NPs provide high-quality care that is often more cost-effective than that delivered by physicians. They tend to focus on preventive care, which can reduce hospitalizations and the need for expensive treatments. Additionally, NPs can operate in a broader range of settings, including retail clinics and urgent care centers, where they can provide low-cost alternatives to emergency room visits. Full practice authority would allow NPs to work to their full potential, providing high-quality, cost-effective care. Nurse Practitioner Cost Effectiveness

  4. Leveraging Advanced Education and Training

Nurse practitioners are not just nurses—they are advanced practice clinicians who undergo rigorous education and training. To become an NP, individuals typically hold a master’s or doctoral degree and undergo hundreds of hours of clinical training. Their expertise is on par with physicians for many aspects of primary and specialty care. In fact, numerous studies have demonstrated that NPs provide care that is comparable in quality to that of physicians, particularly in managing chronic conditions, providing preventive care, and treating acute illnesses.

 5. Support for the Healthcare Workforce

As more nurses advance to become NPs, the healthcare workforce will grow in numbers and expertise. Giving NPs full practice authority encourages more nurses to pursue advanced practice roles, thereby strengthening the healthcare system. By allowing NPs to practice to their full potential, we can create a more robust, resilient workforce that is better equipped to handle the increasing demands of the healthcare system (Yang et al., 2021)

  6. Data Supports Full Practice Authority

Research has consistently shown that NPs with full practice authority deliver care that is safe, effective, and cost-efficient. A 2022 systematic review found in the Journal of the American Association of Nurse Practitioners. found that states with full practice authority for NPs had better outcomes in terms of access to care, patient satisfaction, and cost-effectiveness (Barnett, Balkissoon, & Sandhu, 2022). Moreover, other studies have highlighted the lack of evidence supporting the argument that physician oversight results in better patient outcomes.

  7.  Aligning with National Standards

The American Association of Nurse Practitioners (AANP), the American Nurses Association (ANA), and other leading healthcare organizations support granting full practice authority to NPs in all states. National organizations, including the World Health Organization (WHO), also recognize the critical role of advanced practice nurses in expanding healthcare access and addressing global health needs. Aligning state policies with these standards ensures a more unified and efficient healthcare system.

Conclusion:

As the healthcare system faces increasing demand, nurse practitioners are an essential part of the solution. Empowering them with full practice authority in every state will increase access to high-quality, cost-effective care, address provider shortages, and improve patient outcomes. It’s time to fully embrace the potential of nurse practitioners and allow them to practice to the full extent of their education and training. This is not only in the best interest of NPs but also in the best interest of the millions of patients who need their services.

References:

Yang, B. K., Johantgen, M. E., Trinkoff, A. M., Idzik, S. R., Wince, J., & Tomlinson, C. (2021). State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review. Medical care research and review: MCRR, 78(3), 183–196.  https://doi.org/10.1177/1077558719901216 

Liu, C. F., Hebert, P. L., Douglas, J. H., Neely, E. L., Sulc, C. A., Reddy, A., Sales, A. E., & Wong, E. S. (2020). Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health services research, 55(2), 178–189. https://doi.org/10.1111/1475-6773.13246 

Barnett, M., Balkissoon, C., & Sandhu, J. (2022). The level of quality care nurse practitioners provide compared with their physician colleagues in the primary care setting: A systematic review. Journal of the American Association of Nurse Practitioners, 34(3), 457-464. DOI:10.1097/JXX.0000000000000660 Journal of the American Association of Nurse Practitioners

Delivering safe, good-quality care leading to high patient satisfaction: the benefits of advancing nursing roles in the Netherlands WHO

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Comments

MAGGIE M TALAMANTES
a month ago

Hello, I know you and I talked about this issue, and I am glad you chose this topic. I know too well that the hospital staff does not accept nurse practitioners. At least here at the Phoenix VA Hospital, Mental Health Nurse Practitioners are not welcome. I did a deep dive into why this might be and here is some information that I was able to gather which might expalon their
resistance
Cultural and Institutional Resistance –

Some VA hospitals have a long-standing preference for physician-led care and may be hesitant to change traditional models of care despite research showing MHNPs provide high-quality, cost-effective mental health services.

Scope of Practice Limitations –

Even when MHNPs are employed, they may face restrictions on their ability to prescribe certain medications, provide independent diagnoses, or lead treatment plans without physician oversight, depending on the facility.

Neil Patel
2 months ago

Hi Mara,

I share your interest in ensuring nurse practitioners have full practice authority within their scope of practice in the state they serve. I do believe there should be no restriction when practicing within the scope of the training APRNs receive. Thank you for sharing your experience with hospital credentialing. I haven’t gone through that process yet, but I understand it’s a complex and tedious one for all providers.

To add to Claudia’s point, I’m curious to learn more about your nurse practitioner training and the expectations of your role. I understand you work for an internal medicine group, which requires admitting, following, and discharge privileges. When you mention “following,” are you referring to managing internal medicine patients admitted as inpatients?

My training is in family and emergency practice, and per the latest advisory opinion from the AZ State Board of Nursing, inpatient internal medicine management would fall outside my scope of practice. However, I know acute care nurse practitioners often complete rotations in internal medicine and work alongside hospitalists, which qualifies them to manage inpatient cases. Additionally, I could see how a family nurse practitioner might work in specialties like gastroenterology or cardiology, co-managing patients as part of a consultative team.

I look forward to hearing more about your experiences and challenges. I’ve attached the advisory recommendation and FAQ for reference, as I’ve found it very informative.

There is also interest in dialogue in medicine regarding family medicine physicians who are considering working as hospitalists. Family medicine physicians complete a residency that focuses mostly on outpatient management with some inpatient exposure. due to the fact those positions are often filled by internal medicine-trained physicians who complete training primarily inpatient and outpatient.

Helpful links:
https://azbn.gov/sites/default/files/PS-Supervisory-Roles-APRN-Clinical-Settings.pdf

https://azbn.gov/sites/default/files/SOP-APRN-FAQs.pdf

https://www.aafp.org/about/policies/all/hospitalists-trainedfm.html

Claudia Warner
2 months ago

Hi Mara,
Thank you for bringing this issue to our attention. As you stated, advanced practice nurses (APRN) in Arizona can practice independently. I have encountered numerous nurse practitioners at the hospital visiting patients from various primary care and specialty provider groups. We need more providers to collaborate with us in the hospital environment to treat and discharge patients and relieve overcrowding.
Are there other examples of APRNs being denied hospital privileges? Is this a systemic issue in Arizona? I agree with you on creating a national standard and process for establishing acute care privileges for APRNs. Hopefully, this can also help standardize the quality of care APRNs provide.