Research and Reports

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The following sampling of documents provides information and data that support the removal of legislative barriers to APN scope of practice. If you have a specific question, please feel free to contact us at

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State Progress in Removing Barriers to Practice and Care

Since the publication of The Institute of Medicine Report, The Future of Nursing and the Campaign for Action began, nine states (South Dakota – 2017, Maryland-2015, Nebraska-2015, Minnesota–2014, Connecticut–2014, Nevada–2013, Rhode Island–2013, North Dakota–2011, and Vermont–2011) have removed statutory barriers that prevented nurse practitioners from providing care to the full extent of their education and training, helping to increase consumers’ access to care. This map shows all 22 states and the District of Columbia where consumers have full access to nurse practitioners, including where progress has been made since the Campaign began.

Map Definitions

Substantial improvement: States have made major legislative changes that bring nurse practitioners (NPs) close to full practice authority with small exceptions, such as still needing to contract to prescribe for controlled substances or being required to have an attestation agreement.

Incremental improvement: States have made minor legislative changes that have increased consumer access to care. Examples include increased signature authority (ability to sign forms such as handicap placards or POLST [Provider Orders for Life Sustaining Treatment]), and increased NP to MD ratios (increased numbers of NPs that a physician can contract with).


The turning tide of legislation coincides with the publication of reports, and journal articles that recommend states remove outdated barriers to APN (aka APRN or NP) practice and care. Such publications include:

  • The facts favoring the expansion of the scope of practice for Advanced Practice Registered Nurses are compelling, and momentum is entirely in favor of expansion. The ball is in the courts of the legislatures, however, and though change may occur incrementally, it continues to roll in favor of expansion. 
  • A legislature’s decision must be properly informed by objective study and careful consideration, by the opinions of both physicians and nurses, and by the concern for the overall health and welfare of state populations.
  • Assuring such access means that all willing primary and specialty care providers who are licensed in the state and available to provide this care, must be used to their full scope of practice in a statutory and regulatory environment that both recognizes and supports full practice and authorizes direct reimbursement for that care. 
  • To achieve the goal of maximizing access to health care through increased utilization of Advanced Practice Nurses (APNs), NJSNA seeks to eliminate the Joint Protocol from NJ APN statutes.
  • Concisely articulates the role PMH APNs in NJ play in improving consumer access to care and the state funded PMH APN positions which have been ongoing since 1999 provide the data to support this effort.

  • The document responds to the most commonly asked questions about NJ's Access to Health Care Bill and its impact on APN practice Mounting evidence supports removal of barriers to APN practice in an effort to improve access and quality of care while reducing the cost of healthcare for New Jersey residents. Thirteen of 21 New Jersey counties have a deficit of primary care physicians. 

Information For Legislators

Policy Analysis – Improving Access to Care for New Jersey May 2019

  • Mounting evidence supports removal of barriers to APN practice in an effort to improve access and quality of care while reducing the cost of healthcare for New Jersey residents. Thirteen of 21 New Jersey counties have a deficit of primary care physicians.

Reforming America's Healthcare System Through Choice and Competition

  • On December 3, 2018, the U.S. Department of Health and Human Services, Department of the Treasury, and the Department of Labor released a report entitled, "Reforming America's Healthcare System Through Coice and Competition".This White House Healthcare Report addresses Scope of Practice, Telehealth and Work Mobility. 

  • The report follows a Presidential Executive Order directing the Administration to examine ways that the U.S. health care system can better provide cost-effective, high-quality care by promoting choice and competition.

Health Policy Brief 

  • This is a good synopsis.

The Economic Burden and Practice Restrictions Associated with Collaborative Practice Agreements: A National Survey of Advanced Practice Registered Nurses

  • In this study, APRNs working in rural areas and APRN-managed private clinics were one and a half to six times more likely to be assessed Collaborative Practice Agreement fees often exceeding $6000 and up to $50,000 annually. 
  • Such unnecessary regulation risks diverting health services away from and increasing costs in traditionally underserved areas, contributing to inequities in care. 
  • It is incumbent on state legislatures to address these disparities and make their constituents access to high-quality care a priority. 
  • February 25, the U.S. Supreme Court ruled that a North Carolina dental regulatory board, made up mostly of dentists, does not have the authority to tell dental hygienists to stop offering teeth whitening services. 
  • The justices affirmed the FTC's previous stance that the dental board's actions constituted an illegal suppression of competition.
  • The ruling helps ensure state regulatory boards protect the best interests of patients by limiting unnecessary, anticompetitive restrictions that impede access to care, increase costs and exacerbate delays.

  • The Federal Trade Commission vigorously promotes competition in the health care industry through enforcement, study, and advocacy. 
  • Competition in health care markets benefits consumers by helping to control costs and prices, improve quality of care, promote innovative products, services, and service delivery models, and expand access to health.
  • A goal of competition law and policy is to foster quality competition, which also furthers health and safety objectives. 
  • to ignore competitive concerns in health policy can impede quality competition, raise prices, or
    diminish access to health care – all of which carry their own health and safety risks.
National Governors’ Association’s Report The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care

  • “Nurse practitioners could play a more prominent role in health care delivery and states should consider easing laws under which they practice, recommends a new report by the National Governors Association,” acknowledged Congressional Quarterly HealthBeat Associate Editor Jane Norman.
  • The NGA Report further states that, “to better meet the nation’s current and growing need for primary care providers, states may want to consider easing their scope of practice restrictions and modifying their reimbursement policies to encourage greater nurse practitioner involvement in the provision of primary care… Physician groups also may have financial concerns, but a recent analysis found no differences in physician earnings between states that have expanded scope-of-practice laws and those that do not.”

  • This document implores legislators to support access to healthcare for all consumers
  • This guide defines scope of practice based on education & training and suggests legislators base their regulatory decisions on facts surrounding the evidence

  • Per former PA Governor Edward Rendell, "the concept that access to healthcare would improve if state laws were changed to 'free nurse practitioners to do anything they are capable of doing.'
  • Lawmakers & health policy experts are looking to increase the utilization of NPs as an opportunity to improve healthcare delivery

  • NPs have demonstrated value to the healthcare workforce in both acute & primary care as well as in both the generalist & specialist roles
  • NP practice in many states is hampered by "outdated restrictions on a full range of professional services."
  • "Freeing APNs from the unnecessary constraints will 1) better enable Americans to receive affordable healthcare & 2) it will serve as a model for comprehensive reform of the regulatory framework by focusing on ability and competence rather than proprietary prerogatives."

Scope of Practice 

  • This important document supports the removal of scope-of-practice barriers 
  • Nurses should practice to the FULL extent of their education and training
  • Nurses should be FULL partners with physicians & other healthcare professionals in redesigning healthcare in the United States
  • This NEJM article supports the near certainty that nurses will be required to practice to their fullest capacity 
  • Fighting the expansion of NPs scope of practice is no longer a defensible strategy 
  • The challenge will be for all health care professionals to embrace these changes and come together to improve healthcare in the US
  • This document provides an overview of the NP workforce in the United States 89% of the NP population are trained in Primary Care & 75% of them are actively practicing
  • NPs are in a prime position to address the primary healthcare crisis in our country  


  • NP students have formal academic preparation in healthcare prior to entering their graduate NP program
  • NP students determine their patient population at the time of entry into their graduate program
  • NP education is competency based, NOT time based

Who Will Provide Primary Care and How Will They Be Trained?

  • Physicians, Nurse Practitioners & Physician Assistants must be trained in primary care to meet the increasing societal demands
  • A revamping of the educational training programs must include an increasingly diverse population of students, early exposure to primary care practices, and inter professional education.

Collaboration and Team Based

It's Time to Collaborate--not Compete--with NPs 

  • Susman, a physician, suggests that physicians engage in full partnership with APNs. 
  • Physicians should understand the differences within each others discipline and work together to develop models of patient care.
  • If physicians and APN join forces, they can develop innovative team care models achieving best health outcomes. 

  • NP Licensure needs to be consistent with the APRN Consensus Model and the NCSBN Model for Nurse Practitioner Act
  • Team-based care is a system approach NOT a licensure concept
  • Team-based care is a multidisciplinary, non-hierarchical collaborative and NOT a physician led collaborative 

  • Questions about team leadership often become entangled in professional “scope of practice” issues Arguments have arisen around “independent practice” versus team-based care and, where care is team-based, whether all team functions must be “physician-led,” and what this would imply for other health professionals with regard to care management decision making.
  • These questions seem much less problematic in the field than they are in the political arena. Among the teams nterviewed, notions of “independent practice” were not relevant because no one member of the team was seen as practicing alone, and leadership questions were not sources of conflict; rather, when leadership issues were raised they were portrayed as matters for open discussion that led to mutually agreeable solutions. 
  • Second, this relative lack of conflict might be because these teams use the term “leadership” in a nuanced way.

2012 RHRC NP Distribution
  • This study analyzed individual NPI records from the 2010 NPI data set to identify the urban and rural location in the United States of all APRNs, which includes nurse practitioners (NPs), certified registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), and clinical nurse specialists (CNSs).
  • Data was then compared to other national data sets to assess the extent in which the NPI data set represented the total number of APRNs in the United States.

Rand NP Workforce
  • The large projected increase in Nurse Practitioner supply is higher and more grounded than other forecasts and has several implications:
  • NPs will likely fulfill a substantial amount of future demand for care.
  • As the ratio of NPs to MDs will surely grow, there could be implications for quality of care and for the configuration of future care delivery system with a substantial body of research to show that the care will improve.

APNs; A Logical Choice 

  • It is estimated that 1.3 million NJ residents will need a primary care provider with the enactment of the ACA, While the number of family physicians in NJ decrease, the number of APNs have increased over 100% in ten years.
  • The number of residents in NJ needing mental health services (now more than ever after Super Storm Sandy) increase, while the wait time to see a psychiatrist is an average of 3 - 6 months, Psychiatric APNs have and will continue to address the growing need for mental health services. 

Quality of Care Outcomes

  • In this landmark JAMA article, outcomes for patients randomly assigned to physicians and NPs demonstrated NO significant differences in the patients' overall health.
  • In fact, for patients with hypertension, the diastolic value was statistically significant for the nurse practitioners' patients.

  • Quality care measures find that Nurse Managed Health Centers compare favorably with national benchmarks
  • Particularly high quality of care was demonstrated for chronic disease care management offered by NPs

Quality of NP Practice
  • The nurse practitioner role was created in 1965.  Research has consistently demonstrated the high quality of care provided by nurse practitioners
  • This text is a compilation of almost 20 article reviews demonstrating the quality of NP practice

  • 2009 healthcare reform was motivated by the pressing need to reduce the increasing spending on medical care, without compromising the quality of clinical services. 
  • This paper provides a combination of economic analysis and published literature reviews of how healthcare goals can be accomplished by increasing public access to independently licensed nurse practitioners (NP) to provide their wide range of services. 
  • NP services are consistently cited as providing care equal or better quality at lower cost than traditional comparable service delivery.

APRNs A Sytematic Review of the Literature

  • This systemic review (1990-2008) reinforced that NP patient outcomes are similar to and in some ways provide better care than by physicians
  • Use of Clinical Nurse Specialists in acute care settings showed reduction in length of stay and cost of care
  • Overall, APRN's provide effective, high-quality patient care and could help to improve patient access to care
  • In a comprehensive review of the literature, the results found no differences in healthcare outcomes, process of care, resource utilization or cost for services provided by NPs vs MDs
  • Patient satisfaction was found to be higher for nurse-led care
  • NPs provided longer consultations, more extensive patient education and recalled their patients more frequently than did their physician colleagues

Financial Issues and Malpractice 

  • Analysis of insurance claims data shows that the more rigid regulations increase the price of a well-child medical exam by 3 to 16 %. However, their analysis finds no evidence that the changes in regulatory policy are reflected in outcomes such as infant mortality rates or malpractice premiums. 
  • Results suggest that more restrictive state licensing practices are associated with changes in wages and employment patterns, and also increase the costs of routine medical care, but do not seem to influence health care quality.  
  • Presuming $10 per well child visit for 60 million visits per year in U.S, it can be estimated that by nationally relaxing NP regulations would save about $600 million/year for this one procedure. 

  • This article illustrates the negative financial impact that Managed Care Organizations in the United States have on the sustainability of Nurse Managed Health Centers across the country
  • By refusing to credential NPs as primary care providers, the MCOs restrict patient access to quality, competent and cost-effective healthcare provided by NPs
  • MCO plans that have made the biggest advances in NP credentialing practices are those in the commercial category, further supporting the economic value of increasing quality healthcare by increasing access to NP service delivery.

NSO Study: Malpractice Claims

  • Nurse practitioners with claims were MORE likely than nurse practitioners without claims to respond that their state regulations require direct physician supervision.
  • Nurse practitioners with claims have LESS prescriptive authority than those without claims.

  • For almost 4 decades, NPs have been reported to provide equivalent or improved medical care at a lower total cost than physicians
  • NP educational preparation costs 20-25% that of physician preparation
  • Full-time NP salaries across specialties averaged $90,200 whereas, primary care physician salaries ranged from $198,000 (family) to $205,000 (internal medicine), well more than double the NP average annual salary

  • This early text illustrated the costs and effectiveness of Nurse Practitioners
  • It reinforces that for well over 40 years, NP's have been vital members of the healthcare workforce

  • Among employed primary care physicians, expanded APRN scope of practice laws do not impact their earnings. 
  • In fact, wages for family and general physicians, general pediatricians, and surgeons rose at a slightly faster rate between 1999 and 2009 in states with more liberal scope of practice laws for APRNs than in states with restrictive laws.
  • Findings suggest MD wages are not adversely affected by changes in scope of practice barriers.

Physician Supporters

I   Medscape: Independent Nurse Practitioners and Physician Assistants: A Doc's View

  •    Practicing cardiac electrophysiology in Louisville, Kentucky, this author espouses a conservative approach to medical practice. 
  •    Type of degree has no bearing on the most important components of patient care and outcomes
  •    Organized Medicine has protected MDs by convincing the public and lawmakers to maintain their monopoly on healthcare. 
  •    Imagines a free market where outcomes rather than degrees matter.

F  Forbes: Sometimes The Best Medical Care Is Provided By Those Who Aren't M.D.s

  •    This quadruple board certified physician supports the dismantling of a whole system of licensing laws to allow all health professionals to render services for which they are trained independently of physicians not only expand access to health care and have the potential to decrease the cost of healthcare
  •    But also reflect a respect for the free market system. Addresses the "anti-competitive guild system" as couched in the rhetoric of "patient safety
What Do Faculty Physicians Know About Nurse Practitioner Practice?
  •    This study show that Physician Faculty knowledge about NP Scope of Practice and Education is limited. 
  •    Despite this, study shows that they have confidence and trust in NPs to deliver high quality care.

Free the Nurses
  •    Written by Associate Professor of Medicine; Director of Yale Internal Medicine Residency
  •    One answer to our health care crisis: Let nurse practitioners do primary care on the own The question that arises is what is so different about primary care that APRNs should be licensed to
    practice it independently?

A A Greater Role For Nurse Practitioners
  •    The question that arises is what is so different about primary care that APRNs should be licensed to practice it independently?
  •    Today's model of primary care makes it reasonable to assume that well-trained advanced practice registered nurses practicing independently could provide many facets of the care that primary care physicians are now doing. This could relieve the pressure on emergency rooms, which many patients who do not have primary care doctors use for their care.


NNational Council Medical Directors: The Psychiatric Shortage 

  •   The National Council Medical Director Institute published a 2017 white paper exploring the shortage of psychiatric providers.
  •   “One of the major paths to improving access and outcomes is to shift the focus of each of these professional groups to practice upto the level of their professional licensure.” 

 HRSA National Sample Survey of Nurse Practitioners

  •   Data from almost 13,000 respondents show that 76% of NPs in the workforce are trained in primary care and 48% of NPs in patient care provide primary care. 
  •  There is also evidence of increased proclivity to specialize in primary care among the most recent graduates, indicating that NPs will continue to play a critical role in improving access to primary care.

   Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses

  •   From the staff at the Federal Trade Commission (FTC), this policy paper focuses on proposed state-level changes to statutes and rules governing the “scope of practice” of Advanced Practice Registered Nurses (APRNs). 
  •   The paper notes the potential benefits of improved competition and cites research "suggesting that APRNs provide safe and effective care within the scope of their training, certification, and licensure." (FTC Press Release)

   The Mental Health Workforce: A Primer (pdf)

  •   From the Congressional Research Service, an analysis of "core mental health providers", which this report defines as advanced practice psychiatric nurses, psychiatrists, clinical psychologists, clinical social workers, and marriage and family therapists.

P Psychiatric Mental Health Nurse Practitioner Role Delineation Study (pdf)

  •   National Survey Results (2011) - From ANCC, a report pertaining to the practice of psychiatric-mental health nurse practitioners, based on the results of a 2011 national study of practice of PMH-NPs.

 Increased access to nurse practitioner care in rural Nebraska after removal of  required integrated practice agreement

  •   This report describes changes in access to primary health care in rural and  underserved areas of Nebraska after removal of the IPA barrier to practice. 
  •   The  report compares the number of primary care NPs working in medically  underserved areas before and after the legislation that ended the required IPA. 
  •   In addition, anecdotes will be  provided of NP and patient experiences in rural, NP-  owned practices in Nebraska after IPA requirements were e eliminated.

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