Should Nurse Practitioners Have Full Practice Authority?

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As of 2016, there were more than 220,000 nurse practitioners licensed to provide services in the USA. Out of these, close to 75% were focusing on two segments of practice: family services 55% and adult healthcare 17%.

Next three-largest segments of focus for Nurse Practitioners (NP) were acute care, primary care for children, and women’s health. Other segments included primary care of senior citizens, general nursing for senior citizens, mental health care for adults and families, and neonatal care.

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Reasons for Shortage of Nurses in the USA

The USA is likely to experience a shortage of qualified and experienced NPS in the future due to the following reasons.

The American baby boomer generation is reaching retirement, which means around 3 million individuals will reach retirement age every year for the next 20 years. This growing segment of retired population will require quality healthcare services, which will result in inevitable increase in demand for nurses.

The expanding eligibility of Medicare will also contribute to demand for nurse practitioners in the country. As of 2015, around 11,000 individuals were qualifying for Medicare every day. Three out of four NPs accept Medicare patients while 78 percent of NPs accept new Medicaid patients

Further, demographic data indicates that America is, as a nation, aging. By 2029, there will be more than 70 million Americans aged 65 or above. With a significant percentage of the population falling in the senior citizen category, more nurses were required for their health care and treatment.

Role of Practice Model for Nurses

Merely increasing the number of nurse practitioners without modifying their practice authority is unlikely to serve as a sustainable solution to the problem. There are three different regulatory models of practice applicable to NPs in America today.

Nurse practitioners in the United States of America don’t enjoy full practice authority in all states. Some states allow reduced practice while some other states permit restricted practice only

Full Practice

Some states permit full practice, which means licensed nurse practitioners can offer full extent of services to their patients. The biggest advantage of this model is better access to quality nursing care among the deprived section of the population. Full practice enables the nurse to provide comprehensive service with few or no artificial restrictions.

Patients can avoid multiple office visits, need not pay for compulsory collaboration with an external medical service provider, and are free from the hassles created by obsolete laws and cumbersome rules. Patients enjoy direct access to all the services offered by licensed nurse practitioners and enjoy the freedom of interacting with their preferred NP.

On the flip side, there is the risk of under-trained and under-qualified nurse practitioners offering full services to patients. Further, there are concerns that the existing education and training curriculum may not qualify NPs to provide full extent of care to patients.

To minimize this risk, states require NPs to qualify for recommendation from their National Council of State Boards of Nursing and the Institute of Medicine of the respective state. The State Board of Nursing functions as the sole licensing authority for such nurses.

The NPs are required to comply with all educational and licensing requirements, make sustained efforts to maintain their certification, comply with standards of care set by the State Board of Nursing, and consult with other experts as required.

Reduced Practice

While the full practice model offers complete freedom, the reduced practice model is a slightly restrictive model that requires nurses to coordinate and collaborate with an external medical expert.

Oversight of a fully qualified physician minimizes the risk of complications, and consequent liabilities, in the instance inadequately trained NPs prescribe wrong medications or provide inadequate medical care.

On the flip side, this model involves an increase in cost, reduction in efficiency, compliance with bureaucratic rules and procedures, and an inevitable and unavoidable reduction in accessibility of low-income population to quality healthcare.

Restricted Practice

The third model is the restricted practice model, which is similar to the reduced practice model, but with increased supervision and operation under the management of an external health export.

The biggest advantage of such a model remains the reduction in risk of NP liabilities. However, the disadvantages of the reduced practice model are exacerbated as the role of NPs in providing quality healthcare is significantly lower.

Identifying the Right Practice Model

Proponents of the full practice model point out that any artificial restriction on NPs will result in inevitable degradation of quality of care, increase in cost, and reduction in efficiency of the healthcare system as a whole.

Further, such supporters have opined that the link between medical education and quality of care is not as direct and clear cut as presumed when comparing services provided by nurses and physicians.

A comparison of education and training undergone by nurse practitioners and physicians does not reveal any significant mismatch. Generally, NPs complete a four-year undergraduate degree followed by a Masters program that may range from 1 ½ to 3 years without any mandatory residency requirement.

Physicians attend a four-year graduate school, obtain a four-year medical school degree, and complete minimum three years of residency.

Referring to more than a hundred studies, the American Association of Nurse Practitioners has pointed out not a single such study provides conclusive evidence that care and services provided by NPs are inferior to physicians. The outcome of services provided by NPs, in all the studies, is the same or, in some cases, even better than physicians.

Groups and Associations that have come out in support of the full practice model include The National Governors Association, The Bipartisan Policy Center, Institute of Medicine, and even the Federal Trade Commission. The latter supports full practice for its positive impact on promoting healthy competition in the American healthcare system, and for benefiting consumers in general.


There is a distinct possibility that artificial restrictions imposed on practice authority of NPs may be having a detrimental impact on their ability to provide quality care. In such a scenario, liberalizing the practice model and providing full authority may be the simplest and most elegant solution to improve quality, affordability, and accessibility of quality healthcare in America.