Wyoming has a population of 583 000 with a median household income of $60 938. There are 46 Healthcare Provider Shortage Areas (HPSAs) for primary care services.1 There are 450 nurse practitioners (NPs) in the state.2 To meet the need for primary care services across the state, this state, like many others, need more providers, including NPs. As President of the American Association of Nurse Practitioners, I met with an NP who practiced in a small rural town. Most of her patients work on large farms and ranches. Not only does she provide vital primary care services, this NP is frequently consulted by clinics in surrounding areas to provide management of complex diabetes patients. Interestingly, because the Centers for Medicare & Medicaid Services does not allow NPs to order therapeutic shoes for her patients with diabetes, she must refer her patients to a physician hundreds of miles away to obtain an order for these shoes. Going weeks and months without therapeutic shoes while waiting to see a physician can be detrimental for a patient with diabetes, leading to injuries, poor healing wounds, and even amputations. As I visited with Wyoming NPs, I was humbled by the vast care they provided to the many remote and rural ranching communities across the state. Wyoming is known as a "Full Practice Authority (FPA)" state, meaning the NPs in this state have the licensure authority to practice to the full extent of their education and training. This licensure authority is crucial to be able to provide direct access to NP care services across Wyoming.

I then returned to my home state of Tennessee. Tennessee has a population of 6 597 000 with a median household income of $48 708. Tennessee has 133 primary care HPSAs.1 Thirty percent of the state's residents are uninsured.3 Tennessee is listed among the bottom 10 of all states in terms of healthcare outcome measures.4 Tennessee is known as a "restricted practice" state for NPs, meaning NPs do not have the licensure authority to practice to the full extent of their education and training. Tennessee requires a career-long contract with a physician and requires the physician to visit the NP on-site and review 20% of the NP's patient charts each month.5 Because of these restrictions, some NPs are financially unable to provide care in rural areas due to the cost of the physician contracts, whereas other NPs are unable to provide care in rural areas because they cannot find a physician to sign this contract and perform the visits and patient chart reviews. I've thought a lot about what it would mean to Tennesseans if they had full and direct access to NP care within their own community.

As an associate dean of clinical and community partnerships with Vanderbilt University School of Nursing (VUSN), I work with NPs who practice in community clinics. We have collaborating physicians who perform our visits and chart reviews. However, we refer to physicians, specialists, and specialty services such as oncology care regularly, because this is part of our scope of practice and falls within our education and training. The clinics serve underserved communities across greater Nashville, Tennessee, area. The NPs are also VUSN faculty, meaning they educate and train NP students as well as work as clinicians. Dr Courtney Pitts directs the Family Nurse Practitioner Education Program at VUSN. When we begin to explore what it means to practice to the full extent of education and training, I often refer to Dr Pitts to speak to the depth of education required.

Dr Pitts, like NP program directors nationally, oversees the program's population-focused curriculum that includes didactic and clinical experiences and its respective competencies. At the heart of NP programs, as well as other advanced practice RN (APRN) programs, is the APRN core. The APRN core, advanced physiology/pathophysiology, advanced pharmacology, and advanced health assessment, are required graduate-level courses as outlined by the APRN Consensus model.6 This regulatory model clearly articulates APRN preparation for practice by addressing licensure, accreditation, certification, and education. More specifically, NP programs are expected to be in alignment with national standards (eg, National Task Force (NTF)).7 The standards provide guidance related to required didactic courses (eg, ARPN core, NP role, and population-specific courses), clinical hours to be completed during the program, and core competencies. In addition, NP program curricula may align with the American Association of Colleges of Nursing Essentials: Core Competencies for Nursing Education as well as the National Organization of Nurse Practitioner Faculties core competencies to ensure that NP students have met entry-level competencies for their respective specialty and are practice-ready upon graduation.8,9 Collectively, these documents provide structure to NP education and contribute to the clinical knowledge and skill development of NP students who will continue to be able to provide culturally appropriate, autonomous care to an aging nation with increasing chronic, complex healthcare needs.

There are over 355 000 NPs across the United States; 89% are educated and trained to practice in primary care.1 Twenty-six states and the District of Columbia are known as FPA states. Over 1 billion people choose to see NPs for their healthcare each year. If NPs were able to practice to the full extent of their education and training in every state, the United States would realize greater access to primary care services. Currently, over 98 million people across the United States lack access to primary care.1 Full and direct access to NPs would provide a massive step forward in nationwide access to vitally needed primary care services. Helping to support the required policy changes in each state should be a priority for nurse leaders who have a responsibility in ensuring healthcare access for all.

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