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Ranking State NP Regulation: Practice Environment and Consumer ...

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This study measured and ranked the regulatory environment for nurse practitioner (NP) practice and consumer health care choice in each of the 50 states and the District of Columbia (DC). An expert panel examined the state rules and regulations in three dimensions: (1) the environment affecting consumer access to NPs as providers, (2) the environment affecting reimbursement and NP patients' access to related health care services, and (3) the environment affecting NP patients' access to prescription medications. Scores in each of these domains were calculated for each state and DC, which were then ranked by the composite scores of the three domains. Findings suggest that wide variations exist in state regulation of NP practice, indicating the strong likelihood that, in some states, NPs cannot reach their full capacity to meet patients' needs. This wide variation also suggests that regulations for NP practice are not evidence based, have no patient-safety foundation,and appear arbitrary.
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Content Preview
NP PRACTICE
Ranking State NP Regulation:
Practice Environment and
Consumer Healthcare Choice
Nancy Rudner Lugo, DrPH, NP;
Eileen T. O’Grady, PhD, RN, NP;
Donna R. Hodnicki, PhD, APRN,BC, FNP, FAAN; and
Charlene M. Hanson, EdD, RN,CS, FNP, FAAN
This study measured and ranked
the regulatory environment for
nurse practitioner (NP) practice
and consumer healthcare choice
in each of the 50 states and the
District of Columbia (DC). An
expert panel examined the state
rules and regulations in three
dimensions: (1) the environment
affecting consumer access to NPs
as providers, (2) the environ-
ment affecting reimbursement
and NP patients’ access to relat-
ed healthcare services, and (3)
the environment affecting NP
patients’ access to prescription
medications. Scores in each of
these domains were calculated
for each state and DC, which
were then ranked by the compos-
ite scores of the three domains.
Findings suggest that wide vari-

suggests that regulations for NP
their state’s or district’s standing
ations exist in state regulation of
practice are not evidence based,
relative to the rest of the nation
NP practice, indicating the
have no patient-safety founda-
and to propel reform for mod-
strong likelihood that, in some
tion, and appear arbitrary. The
ernizing nurse practice acts to
states, NPs cannot reach their
study results can be used as an
align with improved consumer
full capacity to meet patients’
advocacy tool for NPs working
choice and evidence-based patient-
needs. This wide variation also
with policy makers to identify
safety principles.
8 I THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS APRIL 2007 VOL. 11 NO. 4

Overview
In order to develop a frame-
environment and the supply of
The dense regulatory patchwork
work to understand the diversity
these providers in each state.13 The
for NP practice described in the
of regulations governing NP prac-
authors’ practice environment
Institute of Medicine’s (IOM’s)
tice, the authors evaluated the 50
scoring system consisted of three
2001 report, Crossing the Quality
states and DC in terms of (1) the
primary measures: legal status,
Chasm: A New Health System for the
multiple components of NP regu-
reimbursement, and prescribing.
21st Century,1 persists in 2007.
lation, (2) the practice environ-
The authors found wide variation
With national statistics indicating
ment, and (3) the effect of each
among states in both practice envi-
an increasing shortage of both
state’s regulation on patients’
ronment scores and practitioner/
nurses and primary care physi-
access to NPs and related services.
population ratios. Favorable envi-
cians, state regulation continues to
These findings highlight the states
ronments were associated with a
that are in the greatest need of sig-
restrict the full scope of practice
greater supply of these providers.
nificant revision in regulation or
for NPs.2,3 Extensive research vali-
Many voices have called for
legislation to improve the context
uniform NP regulation across the
dates that the care NPs provide is
in which patients receive health
states and DC. Cooper et al
safe, cost-effective, and needed.2-6
care from NPs. In this way, the
reviewed “state practice preroga-
Despite these findings, state
entire nation can achieve the goal
tives” for autonomy, scope of prac-
regulation still erects barriers to
of facilitating patients’ access to
tice, and prescriptive authority for
the full scope of care that NPs can
continuous, timely, and efficient
10 professions, including the NP
provide. Regulation of NP practice
care and services.
profession.14 These authors found a
exists on a continuum ranging
wide range in regulatory oversight
from exceedingly restrictive lan-
Review of the Literature
and scope of practice, and posited
guage requiring supervision by
Many papers have been written
that such variation could further
healthcare professionals from
over the years assessing the diversi-
fragment the US healthcare system,
another discipline to language
ty of state regulation on NP prac-
leaving more regions without ade-
allowing unimpeded autonomous
tice and its impact on health
quate healthcare providers.
practice within the scope of the
services.7-12 Since 1989, The Pearson
Safriet examined how unneces-
profession. Much of the regulation
Report© has provided an annual
sary restriction of non-physician
governing NPs appears to lack an
descriptive, detailed compendium
providers affects access and quality
evidence base. For example, in one
of state rules and regulations
of care.15 Safriet, along with the
state, NPs are required to “intern”
affecting NP practice. The 2007
Pew Health Professions Commis-
with a physician or dentist, where-
version of The Pearson Report
sion,11 emphasized the need for
as in other states, NPs with nation-
(http://www.webnp.net/ajnp.html)
regulation to be evidence based,
al certification established by the
concludes that although some
consistent, and protective of
NP profession can practice auton-
progress has been made in this
patients instead of being directed
omously. Variability of the regula-
regard, significant state reforms are
toward serving the economic inter-
tion is such that some states
still needed. Since 1999, the total
ests of physicians. Regulations that
require permission from a health-
number of NPs in the United
are “barriers serve no useful pur-
care professional from another
States has increased by 83%, from
pose and contribute to our health-
discipline for NPs to prescribe
76,306 to 139,520, whereas regu-
care problems by preventing the
more than 7 days of medication,
lations remain varied regarding
full deployment of competent and
other states mandate an on-site
prescriptive authority, physician
cost effective providers who can
physician 10% of the time, and
involvement, ability to dispense
meet the needs of a substantial
still other states mandate a physi-
medication samples, and ordering
number of consumers.”15
cian’s order for physical therapy.
of diagnostic tests and physical
Wing, O’Grady, and Langelier
These highly variable practice
therapy for patients.
assessed changes in the legal prac-
environments are not based on
Sekscenski and colleagues eval-
tice environment of NPs from
evidence and continue to hamper
uated state practice environments
1992 to 2000.16 An NP Pro-
the ability of NPs to provide their
for NPs, physician assistants, and
fessional Practice Index was built
full scope of care while impeding
certified nurse midwives, as well as
on Sekscenski’s earlier work, and
patient access and safety.
the relationship between practice
used the same categories of legal
VOL. 11 NO. 4 APRIL 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS I 9

NP PRACTICE
authority, reimbursement, and pre-
To date, no studies have shown
about the 50 states and DC that
scriptive authority. The authors
an adverse effect on consumers
might help in the creation of a
found that although NPs had
when care is delivered by an NP. In
coherent national regulatory frame-
increased in number and, in many
fact, the opposite is true—many
work for NPs. To facilitate this
states, had expanded their scope of
studies have shown the favorable
effort, the study presents a ranking
practice between 1992 and 2000,
effects on healthcare outcomes
of the multiple components of NP
they were still greatly underutilized
when care is delivered by NPs.4,6,17-19
state regulation and compares prac-
because of variable regulatory lim-
The National Council of State
tice environments for NPs across
its on autonomy, entry into prac-
Boards of Nursing (NCSBN)
the 50 states and DC.
tice, reimbursement, and scope of
Advanced Practice Advisory Panel
Method—An expert panel of
practice relative to their skill and
is developing a vision paper, The
four doctorally prepared NP
potential contribution.
Future Regulation of Advanced
researchers conducted a secondary
The IOM report, Crossing the
Practice Nursing. This vision paper
analysis of the regulatory environ-
Quality Chasm,1 acknowledged that
articulates a regulatory model,
ment data contained in The Pearson
state practice acts that limit non-
developed in collaboration with
Report 2007, which reflects state
physician providers, e-health, and
other stakeholders, that will set a
and DC regulations as of
multidisciplinary teams act as a bar-
standard for APN regulation and
December 1, 2006. The Pearson
rier to innovative health care—inno-
credentialing across the states. The
Report data provide summary
vations that can enhance care for
NCSBN posits that regulation of
descriptions on the regulatory and
patients across settings and over
NPs must be based on the “funda-
practice environments of all 50
time. Crossing the Quality Chasm rec-
mental principle of protection of
states and DC. The researchers
ommends greater coordination and
the health, safety, and welfare of
identified key components of NP
communication among profession-
the public.” The NCSBN recom-
regulation, based on the NCSBN
al boards both within and across
mends that state boards of nursing
vision paper and previous studies
states as the patchwork of advanced
have sole authority over APNs, and
of state regulation of NPs.
practice nursing (APN) regulation is
that APNs’ practice must be inde-
Content analysis of the data
resolved over time. The report also
pendent, with no supervision
explored 12 specific measures of
recommends that regulators create
requirements by healthcare pro-
each state’s or district’s regulatory
an infrastructure to support evi-
viders from other disciplines. No
environment that affect patients’
dence-based practice, facilitate the
evidence indicates that onerous
access, care, and safety. The 12 spe-
use of information technology, align
requirements for NP practice
cific measures were conceptually
payment incentives with quality ini-
such as supervisory or collabora-
configured into three dimensions
tiatives (eg, payment for group
tive agreements enhance patient
of the regulatory environment
patient visits), and prepare the
health, safety, or welfare. As geo-
(Table 1). The first dimension,
workforce to better serve patients in
graphic boundaries between states
Environment Affecting Consumers’
a world of expanding knowledge
become obsolete with advances
Access to NP Providers, is defined as
and rapid change. The report stresses
such as e-health and multi-state
the environment that regulates and
that if innovative programs are to
employers, there exists a signifi-
authorizes NP to provide health
flourish, regulatory environments
cant need for NP licensure to
care to the public. This dimension
will need to foster innovation in
evolve toward an interstate com-
is composed of three measures:
organizational arrangements, work
pact (mutual recognition). This
(1) NP governance solely by the
relationships, and use of technology.
compact will improve access to
state board of nursing (BoN) or
The 21st-century healthcare system
qualified NPs. However, in order
shared with another profession,
described in Crossing the Quality
for the compact to become a real-
(2) NP requirements for entry into
Chasm cannot be achieved in the
ity,
the enormous variation
practice, and (3) professional
current environment of regulation
between the state practice acts gov-
autonomy for NP practice. The sec-
and oversight. The report summa-
erning NPs must be eliminated.12
ond dimension, the Environment
rizes the current patchwork of regu-
Affecting Reimbursement and NPs’
latory frameworks as inconsistent,
The Study
Patients’ Access to Related Health-
contradictory, duplicative, outdated,
Purpose—The study was con-
care Services, is defined as the envi-
and counter to best practices.
ducted to provide quantified data
ronment that allows NPs to be
14 I THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS APRIL 2007 VOL. 11 NO. 4

reimbursed for services rendered
The third dimension, Environment
identified as the prescriber on all
and to order needed testing and
Affecting NPs’ Patients’ Access to
prescription bottles, and (4) to
related services. The five measures
Prescription Medications, describes
receive and dispense drug samples.
that comprise this dimension are
the environment that allows NPs
These three dimensions reflect the
NPs’ abilities (1) to practice in an
to write prescriptions for medica-
extent to which state regulations
environment free of onerous
tions and provide drug samples.
(1) allow the nation’s almost
requirements that are not evidence
The four measures comprising this
140,000 NPs to provide care
based, (2) to obtain hospital privi-
dimension are NPs’ abilities (1) to
according to their level of educa-
leges, (3) to order laboratory test-
write for appropriate amounts of
tion, competence, and experience;
ing or physical therapy, (4) to be
legend or controlled drugs, (2) to
(2) allow these same NPs to prac-
named as primary care providers
write prescriptions without in-
tice within the context of basic
(PCPs), and (5) to receive reim-
volvement of providers from
patient safety principles and con-
bursement for services rendered.
another discipline, (3) to be clearly
sumer choice; and (3) ensure that
TABLE 1
STATE REGULATORY ENVIRONMENT DIMENSIONS AND MEASURES AFFECTING NP PRACTICE
Environment Affecting Consumers’ Access to NP Providers—30 points
Governance of NP profession (10 pts)
Board of Nursing has sole state authority over NPs
Entry into practice (10 pts)
Requirements to enter into NP practice facilitate availability of safe,
professional y qualified NPs and are not excessive
Professional autonomy (10 pts)
Scope of practice is congruent with NPs’ education and professional
ability; practice is not encumbered by members of any other profession
Environment Affecting Reimbursement and NPs’ Patients’ Access to Related Healthcare Services—40 points
No onerous, unreasonable
Practice environment is free of onerous requirements imposed on NPs;
requirements (10 pts)
NPs have authority to diagnose and treat without cumbersome oversight
requirements, which can raise the cost of care (eg, required practice
hours, practice agreements, limiting protocols, chart review, frequent
filing of col aborative agreement)
Hospital privileges (4 pts)
State has no legislative prohibitions against NP hospital privileges
Access to diagnostic and
State has unencumbered laboratory testing, diagnostic testing, and
other services (9 pts)
physical therapy policies for patients of NPs
Primary care providers (7 pts)
State authorizes NPs to be recognized as primary care providers
Payment (10 pts)
Legislative language permits NP reimbursement by 3rd party or HMO
Environment Affecting NPs’ Patients’ Access to Prescription Medications—30 points
Prescriptive authority (8 pts)
NPs’ prescribing is within scope of expertise unfettered by other
professions (eg, protocols, practice agreements)
Prescriptions (10 pts)
NPs’ patients have ful access to prescriptions
NP name on bottle (7 pts)
Patients’ prescription medication bottle is required to have NP’s name
Receiving and dispensing samples (5 pts)
NPs are authorized to receive and dispense pharmaceutical samples for
patients
NP = nurse practitioner; HMO = health maintenance organization.
VOL. 11 NO. 4 APRIL 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS I 15

NP PRACTICE
TABLE 2
CONSUMER CHOICE RANKINGS OF STATE NP REGULATION, 2006
Rank
State
Legal
NP Patients’
NP Patients’
State*
Ranking Category
Capacity
Access to
Access to
Score
Services
Prescriptions
Maximum points
30
40
30
100
1
ARIZONA
30
40
30
100
Grade A: State is exemplary for
2
WASHINGTON
30
40
28
98
patient choice
3
WYOMING
30
37
30
97
4
DISTRICT OF COLUMBIA
30
35
30
95
5
NEW HAMPSHIRE
30
40
25
95
6
MONTANA
27
37
30
93
7
OREGON
27
36
30
92
8
NEW MEXICO
27
40
25
91
9
CONNECTICUT
24
37
27
88
Grade B: State partial y supports
10
RHODE ISLAND
24
37
27
88
patient choice
11
UTAH
19
40
27
87
12
IOWA
24
37
25
86
13
ALASKA
21
37
27
85
14
NEW YORK
21
37
27
85
15
IDAHO
25
35
22
82
16
NEW JERSEY
19
37
25
81
17
KENTUCKY
21
37
22
80
18
WEST VIRGINIA
24
33
21
79
Grade C: State confines patient
19
PENNSYLVANIA
24
31
22
78
choice
20
DELAWARE
16
37
25
77
21
WISCONSIN
24
28
25
77
22
VERMONT
24
28
25
77
23
NORTH DAKOTA
22
30
25
76
24
CALIFORNIA
18
32
25
75
25
MINNESOTA
17
33
25
75
26
TENNESSEE
17
33
25
75
27
KANSAS
21
30
22
73
28
NEVADA
17
29
27
73
29
MAINE
18
33
22
72
30
OHIO
18
33
20
71
31
ARKANSAS
19
25
24
68
Grade D: State restricts patient
32
COLORADO
21
30
18
68
choice
33
INDIANA
13
30
22
65
34
MISSISSIPPI
17
26
22
65
35
TEXAS
18
28
19
65
36
SOUTH DAKOTA
14
27
22
63
37
OKLAHOMA
24
20
19
63
38
LOUISIANA
18
25
19
62
39
NEBRASKA
10
23
27
61
40
VIRGINIA
17
28
15
60
41
SOUTH CAROLINA
14
26
19
59
Grade F: State severely restricts
42
MARYLAND
13
24
20
57
patient choice
43
NORTH CAROLINA
13
25
19
57
44
MICHIGAN
22
24
12
57
45
MASSACHUSETTS
17
24
15
56
46
HAWAII
13
33
9
55
47
ILLINOIS
11
25
19
55
48
GEORGIA
12
26
16
53
49
FLORIDA
13
20
16
49
50
MISSOURI
13
18
5
36
51
ALABAMA
17
13
5
35
Average
20
31
22
73
Standard Deviation
5
6
6
15
*Composite state score may not be the exact sum of the three dimension scores (legal capacity, NP patients’ access to services, NP patients’ access to
prescriptions) because of rounding.
16 I THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS APRIL 2007 VOL. 11 NO. 4

patients of NPs have access to
in that state. In 23 states, gover-
still be restrictive. For example, in
needed services and prescriptions.
nance of the profession is shared by
Oklahoma, the state BoN regulates
Each of the 12 measures was
the BoN and another non-nursing
the profession, but the state scores
assigned a weighted numerical
entity, typically the Board of
relatively low in measures of
score by each of the four experts.
Medicine. Requirements for entry
patients’ access to NP services and
Next, concordance on the weight
into practice vary widely. New
prescriptions.
was reached on each measure.
Hampshire, like 4 other states and
Environment Affecting Reim-
Content analysis of the data was
DC, requires that NPs be nationally
bursement and NPs’ Patients’ Access
completed in three steps. In step 1,
certified by their profession and
to Related Healthcare Services. Once
data on each state and DC were
does not place other restrictions on
an NP has met state requirements
individually evaluated by each
entry into practice. By contrast,
for practice, the scope and authority
researcher. In step 2, the researchers
Maine requires recent NP gradu-
to practice varies across a continu-
formed pairs to reach consensus on
ates to practice under physician
um from independence to a
the study data. In step 3, the four
supervision for the first 2 years.
requirement for follow-up or on-
researchers as a group came to con-
Practicing NPs’ professional
site supervision for selected popula-
cordance on all state data and rank-
autonomy also varies greatly. In 9
tions. In Missouri, when an NP sees
ings. These three steps provided
states (Arizona, Idaho, Montana,
a new patient or a patient with
reliability to the study findings.
New Hampshire, New Mexico,
major changes in diagnosis or treat-
States were ranked by the total
Oregon, Washington, and Wyo-
ment plan, a physician must see the
overall score that was determined
ming) and DC, NPs’ scope of
patient within 2 weeks after the NP
by the individual scores on the
practice is congruent with NP edu-
contact. Texas requires a physician
three dimensions. Higher-ranked
cational preparation and profes-
to review 10% of the charts of
states have the most favorable
sional ability, and is independent
patients seen by NPs in medically
environment for NP practice and
of or in collaboration with, not
underserved and alternative practice
consumer choice, whereas lower-
controlled by, another profession.
sites; however, no review is required
ranked states restrict NP practice
By contrast, other states require spe-
in the more affluent, mainstream
and patient access to safe and effec-
cific written relationships between
settings. In many states, NPs’ ability
tive care by NPs.
NPs and members of other profes-
to order laboratory tests for patients
Results—Table 2 provides sub-
sions; these relationships range
is limited to those tests spelled out
scores, composite scores, and rank-
from general collaboration to
in a written protocol or collabora-
ing of the states. Rankings ranged
more specific protocols or written
tive agreement. Some states do not
from 38 to 100 (maximum, 100
collaborative agreements, with or
permit NPs to prescribe physical
points). Composite scores were
without direct on-site supervision.
therapy. Other states require that a
divided into deciles and assigned
Predominately rural South Dakota
physician be on-site a certain per-
letter grades to reflect the regulatory
requires direct on-site personal
centage of the time, be within a lim-
environment for patient choice and
contact between the NP and col-
ited geographic radius, and co-sign
access. States with lower total scores
laborating physician for 10% of the
charts. Some states require frequent
showed variation among the three
time. South Carolina requires that
revisions of detailed collaborative
dimensions. For example, in Hawaii,
a supervising physician or dentist
agreements. These varied require-
South Carolina, and Nevada, the
be readily available for consulta-
ments have not been shown to
legal
environment
governing
tion. A few states authorize podia-
improve quality of care but, rather,
patient access to NPs, including NP
trists and optometrists to serve in
to raise the cost of care and impede
entry into practice, is relatively
the role of supervisor to NPs.
patient access to health care.
restrictive, although once NPs in
South Carolina arbitrarily requires
Environment Affecting NPs’
these states are in practice, patients’
increased scrutiny of applications
Patients’ Access to Prescription Medi-
access to services and prescriptions
when more than 3 NPs practice
cations. State regulatory approach-
is less limited.
with 1 physician or if the NP prac-
es to NP prescribing range from no
Environment Affecting Con-
tice site is more than 45 miles from
authorization for prescribing (in
sumers’ Access to NP Providers. In
the supervising physician’s site. It is
Georgia, 2006 legislation passed
28 states and DC, the NP profes-
noteworthy that even when the
which recognized NPs as pre-
sion is governed solely by the BoN
BoN is the sole authority, a state can
scribers, but the rules have not
VOL. 11 NO. 4 APRIL 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS I 17

NP PRACTICE
been approved at the time of this
among themselves, making it
states, they propose removing bar-
writing) to unencumbered pre-
extremely difficult for analysts to
riers to NP practice.
scriptive authority (Arizona, DC,
develop a ranking rubric.
Policy issues can be moved to
Montana, Oregon, Washington,
the top of the policy agenda when
and Wyoming). NPs in 47 states
Implications of the Findings
highly relevant research is pub-
can prescribe controlled sub-
These findings are important to
lished under the right political cir-
stances, although some states limit
practicing NPs, as well as to educa-
cumstances. State and national NP
the quantities prescribed or place
tors, certifiers, and regulators who
associations, as well as grassroots
other restrictions on NPs’ prescrib-
license and credential the NPs. In
NPs, could use these findings to
ing. In 4 states (Alabama, Florida,
essence, this ranking could be used
encourage change strategies. Each
Hawaii, and Missouri), NPs’ ability
as a tool to move outdated nurse
state policymaker could be given a
to prescribe is limited to legend
practice acts onto the political
copy of the ranking table depicting
drugs (no controlled substances),
agenda. With current shortages of
where his or her state stands in rela-
with or without restrictions. In 42
nurses and PCPs, a window of
tion to the others, with a letter from
states, the NP prescriber’s name
opportunity may be opening to
the state NP association listing spe-
must be on all medication bottles,
look at the barriers that are present
cific items that need to be changed
whereas in 6 states, regulation does
in state legislation and regulations
to work toward an nurse practice
not permit the prescribing NP’s
that are impeding consumer access
act that reflects modern practice.
name to be on the label. This latter
to healthcare services. NPs are
Higher-ranking
states
should
situation creates a patient safety
viable providers of safe, cost-effi-
receive recognition for their for-
violation because neither the phar-
cient health care. Changes in health
ward thinking and leadership advo-
macist nor the patient can easily
policy and legislative reforms can
cacy, whereas lower-ranking states
access or identify the prescriber.
be instituted. Examples of possible
could be given a specific list of con-
solutions in terms of state reform
cerns that must be addressed and
Limitations of the Study
measures and favorable political
conditions that must be modern-
These study findings are empirical-
circumstances are noted in the
ized. Individual NPs could engage
ly supported. Limitations of this
Crossing the Quality Chasm Report,
the public by writing letters to
research are associated with the
which recommends reform and
newspaper editors and by alerting
analysis of secondary data and the
pay-for-performance
initiatives.
the media in their state to their
high degree of intra- and interstate
Findings of the present study could
state’s rankings. NPs can also edu-
variation in NP regulation. The
serve as a powerful advocacy tool to
cate persons in the media about
researchers had early and exclusive
strengthen the regulatory environ-
how NP practice affects their com-
access to 2006 data collected for
ment to provide consumer access to
munity and how regulatory barriers
The Pearson Report 2007. The
qualified NPs at a time when access
harm patients.
Pearson Report data collection pro-
to healthcare providers is becoming
Further research could use the
cess relied on several different
more limited.
elements of the NCSBN vision
methods. Data were gathered
This analysis of state regulation
paper to measure and rank the
from reviews of state legislation,
underscores the need for policy-
progress of state reform for NP
reviews of state rules and regula-
makers and legislators to under-
practice. Annual rankings could
tion, interviews with personnel
stand that these restrictions on
assist NP organizations in exerting
from state boards of nursing, and
consumer choice are not based on
continuous pressure on state poli-
interviews with state nursing lead-
patient-safety concerns or on evi-
cymakers to align their state nurse
ers. The varied sources of data
dence. Some state lawmakers have
practice acts with the NCSBN
could result in variable accuracy
recognized the favorable impact of
model to improve and standardize
across states, depending on the
NPs on health care and have devel-
the regulatory environment. Until
level of expertise of the responder.
oped policies to increase the num-
states use an evidence-based
Lack of an a priori system used to
ber of NPs available to meet their
approach to regulating NP prac-
rank the data collected poses
state’s healthcare needs. For exam-
tice, an interstate compact for NP
another limitation. Finally, the 51
ple, as governors of California and
licensure will be elusive and NP
nurse practice acts lack any coher-
Pennsylvania develop plans to
regulation will be based on the
ent framework or congruence
expand access to care in their
whims and political leveraging of
18 I THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS APRIL 2007 VOL. 11 NO. 4

interest groups rather than on
approach to regulation of NP prac-
Acknowledgments
patients’ needs or safety.
tice. The states and DC approach NP
The authors thank Dr Linda J.
However, opportunities for pol-
regulation on a continuum ranging
Pearson for her 19-year commit-
icy change can be realized only if
from independent practice to strict
ment to collecting data across the
NP organizations display a high
oversight by the medical profession
states on NP issues, for providing
degree of political competence.
and in some cases other professions.
pre-publication state data to our
Policymakers do not typically read
In order for NPs to meet the needs
research team, and for her guid-
nursing and NP journals. It is criti-
of patients and of the healthcare sys-
ance and wisdom before, during,
cal that NPs and nurse leaders
tem, they must unapologetically
and after this study; Louise Young,
communicate these findings in are-
seek regulatory environments that
NP Communications Publisher,
nas where policy is being devel-
foster innovation and protect the
for her early support of this
oped. Table 3, Translating Research
public. This patchwork of regula-
research; Drs Mary Wakefield and
to Policymakers, provides strategies
tions impedes NP practice and nar-
Julie Sochalski for their conceptual
for disseminating this information. rows the scope of practice for which
guidance; and other colleagues
NPs must demand change in
they are educationally prepared and
who generously reviewed our
the state regulatory environments
professionally certified. Clear and
methodology, gave constructive
because this dense and varied land-
focused NP leadership is required
feedback, and allowed us to test
scape of laws can be harmful to
to reframe the regulatory patch-
our ideas.
patients.
Calls for regulatory
work across the United States into
This full report, all Tables, and
reform need to be focused on solu-
a sound, evidence-based, coherent
The Pearson Report 2007 can be
tions to the larger problems faced
vision, with a strong patient safety
downloaded from the NP Com-
by the state and on consumer
orientation, expressed in the
munications website: http://www.
access to safe, cost-efficient care
NCSBN vision paper. I
webnp.net/ajnp.html
that can be provided, at least in
part, by NPs. As health care is
The authors are editors and columnists
References
increasingly
delivered
within
for NP Communications, publisher of
1.
Institute of Medicine, Committee on
national corporate structures, and
The American Journal for Nurse
Quality of Healthcare in America. Crossing
as telehealth grows, these outdat-
Practitioners and NP World News.
the Quality Chasm: A New Health System for
ed, arbitrary, overly complicated,
They saw a need for a ranking of state
the 21st Century. Washington, DC: National
and confusing regulations across
regulations described in The Pearson
Academy Press; 2001.
states must evolve as geographic
2.
US Department of Health and Human
Report to depict the patchwork of laws
Services. Healthy People 2010: Understanding
boundaries become obsolete.
and rules governing NP practice.
and improving health. Washington, DC: US
Modernizing state nurse practice
Nancy Rudner Lugo, from the 49th
Government Printing Office; 2000.
acts can result in improved patient
state according to this ranking, is the
3.
National Center for Health Statistics.
safety in multiple ways. Patient
president of NR Consulting, Inc, and
Health, United States, 2006. Hyattsville, Md:
safety is enhanced when NPs can
a faculty member at the University of
National Center for Health Statistics; 2006.
order an appropriate course of
4.
Brown SA, Grimes, DE. A meta-analysis
Central Florida in Orlando. Eileen T.
of nurse practitioners and nurse midwives in
medication for a presenting prob-
O’Grady, who writes about NP and
primary care. Nurs Res. 1995;44(6):332-339.
lem. Safety is improved when the
health policy issues, resides in the
5.
Horrocks S, Anderson E, Salisbury C.
NP prescriber’s name is easily iden-
state of Virginia, which ranks 40th.
Systemic reviews of whether nurse practition-
tifiable to both patient and phar-
Donna R. Hodnicki is a professor of
ers working in primary care can provide
macist on the medication label.
nursing and MSN Program director
equivalent care to doctors. BMJ. 2002;
Patient outcomes are improved
324(7341):819-823.
at Georgia Southern University in
6.
Mundinger MO, Kane RL, Lenz ER, et al.
when NPs are able to order timely,
Statesboro, Georgia, a state that ranks
Primary care outcomes in patients treated by
necessary tests and services on
48th. Charlene M. Hanson, who also
nurse practitioners or physicians: a random-
behalf of their patients.
hails from the 48th state, is professor
ized trial. JAMA. 2000;283:59-68.
emerita
at
Georgia
Southern
7.
Hanson CM, ed. Regulation and creden-
Conclusion
University. The authors state that they
tialing of advanced practice nurses. Adv Pract
Nurs Q.
1998;4(3).
The findings of this study of the 50
do not have a financial interest in or
8.
Hanson CM. Regulatory issues will lead
states and DC clearly present the
other relationship with any commer-
advanced practice nursing challenges into
effects of the current arbitrary
cial entity named in this article.
the new millennium. Adv Pract Nurs Q.
VOL. 11 NO. 4 APRIL 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS I 23

NP PRACTICE
1998;4(3):iii-iv.
https://www.ncsbn.org/NurseLicensureCom
2005;9(2):25-39.
9.
Hodnicki D. Advanced practice certifica-
pactFAQ.pdf
17. Lenz E, Mundinger MO, Kane R, et al.
tion: where do we go from here? Adv Pract
13. Sekscenski E, Sansom S, Bazell C, et al.
Primary care outcomes in patients treated by
Nurs Q. 1998;4(3):34-43.
State practice environments and the supply
nurse practitioners or physicians: two year fol-
10. Pearson L. The Pearson Report. Am J
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18. Lambing AY, Adams DL, Fox DH, et al.
11. Pew Health Professional Commission.
14. Cooper R, Henderson T, Dietrich C.
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12. National Council of State Boards of
15. Safriet B. Impediments to progress in
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TABLE 3
TRANSLATING RESEARCH TO POLICYMAKERS
I
Link research to specifics of the state.
– Show example: “State X has an uninsured rate (and/or cite state health indicators) of Y% and a broken
Medicaid budget, yet a highly restrictive state practice act for NPs; with improved regulation, NPs can be a big
part of the solution.”
– Make highly specific recommendations for regulatory change that wil benefit patients and payors. Link changes
to improved patient access and quality.
I
Encourage NP professional organizations to provide leadership.
– Focus governmental affairs and policy priorities toward modernizing state nurse practice acts.
– Organize state and local nursing and NP groups to develop policy solidarity by developing a strong, cohesive
policy message and strategy.
I
Educate the public.
– Write letters to newspaper editors depicting the state ranking and what the state legislature must do to
modernize regulation.
– Alert regional media to inform the public about the ranking and how restrictive NP regulation can harm patients
by limiting access to qualified healthcare providers.
– Invite the media to “fol ow an NP” for a day to generate public interest stories.
I
Inform policymakers about research findings.
– Create awards and recognition strategies for forward-thinking states, congratulating them for supporting NP
practice and patient access to qualified safe healthcare providers.
– Summarize and distribute relevant research, including your state’s ranking, with a customized, highly specific
action list (1-2 pages) for your state legislators.
I
Include reference to the National Council of State Boards of Nursing (NCSBN) vision paper for the future of
APN regulation.
– Develop model language for state legislatures to work toward in states that impose restrictions on NP practice.
– Invite policymakers to visit NPs in clinics.
I
Refer to the nurse practice acts in the higher-scoring states and the NCSBN vision paper.
24 I THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS APRIL 2007 VOL. 11 NO. 4

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