Nurse practitioner study eyes scope of practice, labor supply

Battles over scope-of-practice legislation occur routinely among licensed occupations operating in the same field.  For instance, the American Medical Association, citing patient safety, tends to oppose bills that would expand the authority of advanced practice registered nurses, including nurse practitioners. The AMA even has a campaign, #StopScopeCreep.

On the other side of this debate are the nurse practitioners, physician assistants and others who contend that enhanced autonomy does not compromise patient safety.

Into this debate enter Tianyan Luo, a post-doctoral researcher at the University of Florida, and Cesar Escalante, a professor at the University of Georgia. The duo released a working paper earlier this year that examines scope-of-practice laws governing nurse practitioners. Rather than focusing on patient safety, however, they address a less divisive aspect of patient care: the availability of caregivers.

What effect, they ask, do a state’s scope-of-practice laws have on the supply and behavior of nurse practitioners?  If more states allowed nurse practitioners to work and prescribe without the supervision of physicians, how would this affect they ways in which they practice, including their work settings and hours? Would nurse practitioners in more tightly regulated states, lured by the prospect of greater independence, move to more permissive states? Would expanding the scope of practice for nurse practitioners encourage more registered nurses to seek additional training in order to enjoy the same independence?

The answers to such questions are important, Luo and Escalante argue, because the nation has too few primary care physicians to meet the needs of its population, particularly in rural areas. That care gap can be narrowed by increasing the scope of practice for nurse practitioners. Their findings, they say, “can provide insight for policymakers in their decisions about how much practice and prescription autonomy to give to nurse practitioners.”

To answer such questions, the researchers used what they call “a quasi-natural experiment” involving the variety and timing of scope-of-practice laws among the states. As of 2019, 22 states had adopted laws allowing nurse practitioners to treat patients and prescribe drugs without the supervision or collaboration of physicians. By comparing nurse practitioner (and registered nurse) behavior in these states with their behavior in other states, their study concludes the following:

• Increased autonomy allows nurse practitioners to operate their own clinics and engage in consultation, potentially encouraging them to allocate time to administrative work at the expense of direct patient care. The net effect may still be positive, however, as access to primary medical care likely would increase, especially in underserved rural areas.
• Nurse practitioners in more restrictive states do not tend to relocate to full scope-of-practice states.
• The supply of nurse practitioners in full scope-of-practice states increases nonetheless because high-skilled registered nurses in those states are more likely to receive additional education in order to become nurse practitioners.
• Nurse practitioners who are allowed to practice independently are less likely to work in community health centers, which play an important role in delivering care to underserved populations. They’re more likely to work in ambulatory care agencies, which require acute nursing services. Ambulatory care agencies pay well, the study notes, and allow nurse practitioners in full scope-of-practice states to provide services akin to those of primary care physicians.

A couple of caveats.

First, as a working paper, “Improving Health Care Service Delivery by Relaxing Restrictions on Nurse Practitioners’ Professional Independence” had not been peer-reviewed at the time it was made available in February.

Second, Luo and Escalante are affiliated with The Center for Growth and Opportunity at Utah State University, which has made it available online. Though the center is nonpartisan, its policy preferences are libertarian. 

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