County Health Rankings & Roadmaps, A Healthier Nation, County by County

The County Health Rankings models and measures

Our Approach

The County Health Rankings model of population health

What can I do?

Action Center

Explore guides and tools for improving health.

What Works for Health

Explore programs and policies that work!

What can I learn from others?

Reports

Key findings from the last four years of County Health Rankings and other national reports.

County-by-County Blog

Project updates, commentaries, events and news about health across the nation from the County Health Rankings & Roadmaps team.

Nurse practitioner scope of practice

Evidence Rating

Scientifically Supported

Health Factors

Nurse practitioners (NPs) have graduate-level nursing education and must complete national board certification exams. NP scope of practice is regulated by state-level Nurse Practice Acts and Boards of Nursing and varies by state, ranging from requirements to collaborate with or be supervised by physicians to autonomy to provide care to the full scope of NP training and skills without physician oversight (e.g., independent practice and prescription authority). NPs frequently specialize in primary care, acute care, or mental health care ().

Expected Beneficial Outcomes (Rated)

  • Improved quality of care

  • Increased patient satisfaction

Other Potential Beneficial Outcomes

  • Increased access to care

Evidence of Effectiveness

There is strong evidence that nurse practitioners (NPs) provide high quality routine care that is equivalent to (, Cochrane-Kuethe 2013, Newhouse 2011, , AHRQ-O’Grady 2004, Cochrane-Laurant 2004, Horrocks 2002), and sometimes better than, comparable care provided by physicians (Martinez-Gonzalez 2014, Newhouse 2011, AHRQ-O’Grady 2004, Horrocks 2002). On average, nurse practitioners’ patient satisfaction scores are similar to () or higher than physicians’ scores (Martinez-Gonzalez 2014Newhouse 2011, Cochrane-Laurant 2004, Horrocks 2002).

Overall, health status and outcomes for patients that receive routine care from NPs are equal to that of patients treated by physicians (, , Cochrane-Kuethe 2013, AHRQ-O’Grady 2004, Cochrane-Laurant 2004, Horrocks 2002). NPs generally provide longer consults (Cochrane-Laurant 2004, Horrocks 2002), more health advice (Cochrane-Laurant 2004), and are more likely to take patient histories and discover history-related causes of health issues than physicians (AHRQ-O’Grady 2004).

Standardizing NP scope of practice laws to support full NP autonomy, within the scope of NP training, may increase the availability of primary care providers (, , , , , IOM-Nursing 2010, ). NPs with expanded scope of practice have been shown to improve provider availability for injured workers using worker’s compensation benefits, particularly in rural areas ().

States that do not require physician oversight appear to have more NPs than states that require greater oversight (, Perry 2012). One study indicates higher numbers of primary care NPs in states with less oversight, particularly if NPs are paid the physician Medicaid reimbursement rate (). Primary care NPs (, ) and family medicine NPs () are more likely to practice in rural or health professional shortage areas (HPSAs) than NPs with other specialties or physicians. Primary care NPs also care for a greater portion of Medicare () and Medicaid patients (, ).

Models suggest that removing restrictions on NP scope of practice could reduce health care costs (). A study that compares states with full scope of practice regulations to states with more restrictions indicates that expanded NP scope of practice laws do not affect physician earnings (Pittman 2012).

Equalizing NP and physician reimbursement rates is a suggested strategy to encourage full NP autonomy, as allowed within state laws (, IOM-Nursing 2010); as of 2012, Medicare reimbursed independent NPs at 85% of the physician rate (Cassidy 2013). 

Impact on Disparities

Likely to decrease disparities

Implementation Examples

As of March 2017, 22 states and Washington DC allow nurse practitioners to diagnose, treat, and prescribe medications without physician involvement (Campaign for Action). New Hampshire expanded the scope of practice of psychiatric mental health nurse practitioners (PMHNPs) in 2015, following extensive collaboration among PMHNPs, physician leaders, and policy makers focused on improving care within the state mental health system (de Nesnera 2016). 

National organizations such as Campaign for Action, the National Governors Association, and the Federal Trade Commission have efforts underway in support of expanded scope of practice for nurse practitioners (Campaign for Action, NGA-NP 2012, FTC-Gilman 2014). 

Implementation Resources

Clavelle 2012 - Clavelle JT. Implementing Institute of Medicine Future of Nursing recommendations: A model for transforming nurse practitioner privileges. Journal of Nursing Administration. 2012;42(9):404–7.

APRN Consensus toolkit - National Council of State Boards of Nursing (NCSBN). Advanced Practice Registered Nurse (APRN) consensus model toolkit.

Barton-NP - Barton Associates. Interactive nurse practitioner (NP) scope of practice law guide.

AANP - American Association of Nurse Practitioners (AANP). State practice environment. State regulatory map.

KFF-NP - Kaiser Family Foundation (KFF). Medicaid benefits: Nurse practitioner (NP) services, by state. 2012.

Citations - Evidence

* Journal subscription may be required for access.

Cochrane-Laurant 2004 - Laurant M, Reeves D, Hermens R, et al. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Review. 2004;(4):CD001271.

Cassidy 2013 - Cassidy A. Health policy brief: Nurse practitioners and primary care (updated). Health Affairs; May 15, 2013.

Horrocks 2002 - Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324(7341):819–23.

IOM-Nursing 2010 - Institute of Medicine (IOM). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press; 2010.

Naylor 2010* - Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Affairs. 2010;29(5):893–9.

Newhouse 2011 - Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing Economics. 2011;29(5).

AHRQ-O’Grady 2004 - O’Grady ET. Chapter 43. Advanced practice registered nurses: The Impact on patient safety and quality. In: Nurse Practitioner World News and the American Journal for Nurse Practitioners; 2004.

Sears 2008* - Sears JM, Wickizer TM, Franklin GM, Cheadle AD, Berkowitz B. Expanding the role of nurse practitioners: Effects on rural access to care for injured workers. Journal of Rural Health. 2008;24(2):171–8.

Cochrane-Kuethe 2013 - Kuethe MC, Vaessen-Verberne AAPH, Elbers RG, Van Aalderen WMC. Nurse versus physician-led care for the management of asthma. Cochrane Database of Systematic Reviews. 2013;(2):CD009296.

Martinez-Gonzalez 2014 - Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: A systematic review and meta-analysis. BMC Health Services Research. 2014;14:214.

Graves 2016b* - Graves JA, Mishra P, Dittus RS, et al. Role of geography and nurse practitioner scope-of-practice in efforts to expand primary care system capacity. Medical Care. 2016;54(1):81–89.

Xue 2016* - Xue Y, Ye Z, Brewer C, Spetz J. Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review. Nursing Outlook. 2016;64(1):71–85.

Reagan 2013* - Reagan PB, Salsberry PJ. The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners. Nursing Outlook. 2013;61(6):392-399.

DesRoches 2013* - DesRoches CM, Gaudet J, Perloff J, et al. Using Medicare data to assess nurse practitioner-provided care. Nursing Outlook. 2013;61(6):400–407.

Stanik-Hutt 2013* - Stanik-Hutt J, Newhouse RP, White KM, et al. The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners. 2013;9(8):492–500.e13.

Oliver 2014* - Oliver GM, Pennington L, Revelle S, Rantz M. Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nursing Outlook. 2014;62(6):440–447.

Buerhaus 2015* - Buerhaus PI, DesRoches CM, Dittus R, Donelan K. Practice characteristics of primary care nurse practitioners and physicians. Nursing Outlook. 2015;63(2):144–153.

Spetz 2016* - Spetz J, Skillman SM, Andrilla CHA. Nurse practitioner autonomy and satisfaction in rural settings. Medical Care Research and Review. 1077558716629584.

Barnes 2016* - Barnes H, Maier CB, Altares Sarik D, et al. Effects of regulation and payment policies on nurse practitioners’ clinical practices. Medical Care Research and Review. 1077558716649109.

Pittman 2012 - Pittman P, Williams B. Physician wages in states with expanded APRN scope of practice. Nursing Research and Practice. 2012;2012:671974.

Odell 2013* - Odell E, Kippenbrock T, Buron W, Narcisse MR. Gaps in the primary care of rural and underserved populations: The impact of nurse practitioners in four Mississippi Delta states. Journal of the American Association of Nurse Practitioners. 2013;25(12):659–666.

Perry 2012 - Perry JJ. State-granted practice authority: Do nurse practitioners vote with their feet? Nursing Research and Practice. 2012;2012:482178.

Citations - Implementation Examples

* Journal subscription may be required for access.

de Nesnera 2016 - de Nesnera A, Allen DE. Expanding the role of psychiatric mental health nurse practitioners in a state psychiatric system: The New Hampshire experience. Psychiatric Services. 2016;67(5):482–484.

NGA-NP 2012 - National Governors Association (NGA). The role of nurse practitioners (NP) in meeting increasing demand for primary care. Washington, DC. 2012.

FTC-Gilman 2014 - Gilman DJ, Koslov TI, Feinstein DL, et al. Policy perspectives: Competition and the regulation of advanced practice nurses. Washington, DC: Federal Trade Commission (FTC); 2014.

Campaign for Action - Campaign for Action. Improving access to care. Center to Champion Nursing in America. AARP Foundation. Robert Wood Johnson Foundation.

Date Last Updated

Mar 16, 2017