The scope of nurse practitioner (NP) practice is regulated by the state government. Currently, 21 states and Washington, D.C have passed legislation allowing nurse practitioners full practice authority. This permits NPs in these states to independently diagnose, make treatment decisions, order and interpret diagnostic tests, and prescribe medications without the oversight of a physician. Research unequivocally supports the safety, effectiveness and quality of the care provided by nurse practitioners as a safe alternate to physician care (Horrocks et al. 2002, Mundinger et al. 2000). Furthermore, this model for nurse practitioner care is endorsed by the groundbreaking 2010 Institute of Medicine report titled, The Future of Nursing: Leading Change, Advancing Health. This document comprehensively analyzed ways to expand access to quality care for persons in the United States and supports NPs practicing to the full extent of their license and education. This movement is gaining momentum as NPs have made great strides in lobbying for full practice authority.

A recent article in the New York Times, “Doctoring without the Doctor” tells the story of a nurse practitioner in rural Nebraska who, upon graduation, was unable to practice in her field because she was unable to find a collaborating physician to work with for a reasonable cost and within a reasonable distance. The article goes on to describe the recent legislation in Nebraska, which, in April 2015, became the 20th state to pass legislation allowing nurse practitioners to practice without a collaborating physician. While the overall tone of the article was supportive and brought to light the issues of access to healthcare in rural America, the title insinuates an effort for NPs to take on duties and responsibilities that they were not trained to perform (i.e. providing the services of a doctor with no doctor). In reality, the legislation has little to do with the nurse practitioner practicing without “the Doctor;” the impetus for full practice authority lies in a goal to eliminate barriers to healthcare access rooted in old, outdated laws and regulatory barriers that prevent nurse practitioners from practicing to the full degree and providing the full scope of services for which we were educated for. Furthermore, nurse practitioners do not wish to eliminate collegial collaboration with physicians or any members of the healthcare team. We all understand that true quality care takes a team of healthcare providers from multiple disciplines. Nurse practitioners are not lobbying to “doctor” without a “doctor” as the title implies. In essence, the NP movement to expand legislation to support scope of practice will provide increased patient access to proven high quality care,expanding the healthcare work force to allow access to care in geographic regions where patients have limited access to quality care. 

As nurses, we must continue to support legislation and promote our profession, as well as continue to educate the public on misconceptions about the profession. There were over 400 comments in response to the New York Times article. Reading through them brings to light an abundance of support from the public and healthcare community, but, unfortunately, also highlights continued misconceptions of the public and healthcare providers on the role and scope of NP practice in the U.S., as well as misconceptions as to the goal of full practice authority. One comment from a physician is as follows, “I may be biased, but I am yet to encounter a nurse practitioner with the competence, (I believe) intelligence and with the sense of responsibility of my physician.” Another physician writes, “If NPs want independent practice, so be it. Just make them get their own malpractice insurance and not be tied in any way to any physician, supervising or not. Take full responsibility and liability for all their own medical decisions and see how it plays out. It's only fair.”(Tavernase, 2015). These type of comments shade the topic to appear as a turf battle, when in reality, the majority of NPs and physicians work together seamlessly in our healthcare system. 

The American Association of Nurse Practitioners (AANP) has been a main supporter of removing barriers to NP practice. In an issues brief they summarize the goals best as to “remove barriers and obsolete legislation and regulations that do not recognize NPs’ advanced education and clinical preparation to furnish the full range of services that they are licensed to provide.” 

Recently, the Pennsylvania Coalition of Nurse Practitioners (PCNP) organized a lobby day in support of a house and senate bill to support full practice authority. PCNP has dedicated significant time and effort to ensure PA laws are udated. To date, PA has yet to pass this legislation. What types of struggles have you encountered in your state for full practice authority? Do you have full practice authority in your state and if so, has there been any noticeable changes in your day to day practice? Have the physicians, patients, and other nurses in your life supported this work? Please share your thoughts in the comment below.

References: 
AANP Issues Brief: Remove Barriers to Nurse Practitioners’ Ability To Practice.Retrieved from: 
http://www.aanp.org/images/documents/federal-legislation/issuebriefs/Issue%20Brief%20-%20Removing%20Barriers.pdf

Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011

Horrocks, S., Anderson, E. & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ, 324, 819

Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A. M., Tsai, W., Cleary, P.D., Friedewald, W.T., Siu, A.L. &Shelanski, M.L. (2000). Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial. The Journal of the American Medical Association. 283(1), 59-68

Tavernise, S. (2015). Doctoring, without the doctor. New York Times. May 25, 2015.Retreived from: http://www.nytimes.com/2015/05/26/health/rural-nebraska-offers-stark-view-of-nursing-autonomy-debate.html

Megan Doble, MSN, RN, CRNP