Examining variable nurse practitioner independence across jurisdictions: A case study of the United States

Nurse Practitioners have the potential to reduce primary care shortages for underserved populations. Yet, scopes of practice in some political jurisdictions (e.g. states, provinces) are more restrictive than others, and prevent Nurse Practitioners from working to the full extent of their training. The research is limited as to which intrastate or interstate characteristics contribute to understanding why scope of practice differences exist.

To estimate associations between intrastate/interstate characteristics and US state-level Nurse Practitioner Scope of Practice policy.

Retrospective study of state-level factors influencing Nurse Practitioner Scopes of Practice.

U.S. states from 2001 to 2015.

Our dependent variable is state-level Scope of Practice policy, indicating the extent to which Nurse Practitioners are autonomous in a state (Independent, Collaboration or Supervision). The intrastate characteristics that we include are numbers of Nurse Practitioners, Primary Care Physicians and rural hospitals per capita, state Board of Medicine governance and Nursing License Compact membership. We also measure the number of border-states that adopt specific policies in order to indicate the extent to which interstate characteristics influence focal states to adopt similar policies.

Among intrastate characteristics, we found that rural hospital concentrations (Odds Ratio=0.78; 95% Confidence Interval: 0.71-0.85) and Nursing License Compact membership (Odds Ratio=0.23; 95% Confidence Interval: 0.0-0.60) were associated with lower levels of restrictions, while Board of Medicine governance (Odds Ratio=27.36; 95% Confidence Interval: 5.75-130.20) was associated with increased levels of restrictions. Among interstate characteristics, higher numbers of border-states adopting Nursing License Compact membership (Odds Ratio=0.51; 95% Confidence Interval: 0.32-0.80) was associated with lower levels of restrictions.

Barriers to Nurse Practitioner independence are largely attributable to unfavorable governance arrangements and non-participation in reciprocal licensing networks. Achieving Nurse Practitioner independence will require cooperation between nursing, medicine and policy makers. We offer some suggestions as to where parties interested in seeing increased Nurse Practitioner independence should focus their efforts when attempting to remove restrictions on Nurse Practitioner practice.