Nurse practitioner scope of practice
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 care1. NPs must have a bachelor’s degree in nursing, a current registered nurse (RN) license, receive an additional degree from a nationally accredited graduate NP program, and pass a national NP board certification exam2.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved quality of care
Increased patient satisfaction
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Increased access to care
What does the research say about effectiveness?
There is strong evidence that nurse practitioners (NPs) provide high quality routine care that is equivalent to3, 4, 5, 6, 7, 8, 9, and sometimes better than, comparable care provided by physicians3, 5, 7, 9, 10. On average, nurse practitioners’ patient satisfaction scores are similar to3 or higher than physicians’ scores5, 8, 9, 10.
Quality and health. Overall, health status and outcomes for patients that receive routine care from NPs are equal to that of patients treated by physicians3, 4, 7, 8, 9, 11. NPs generally provide longer consults8, 9, more health advice8, and are more likely to take patient histories and discover history-related causes of health issues than physicians7.
Expanding scope of practice laws for NPs may reduce health care amenable deaths, particularly in rural areas12. States with regulations authorizing NPs’ full scope of practice appear to have greater NP involvement in accountable care organizations (ACOs), which is associated with fewer hospital readmissions and improved preventive care13. States that allow NPs greater independence in practice may see improvements in children’s health outcomes, particularly for children from families with lower incomes and among older children14. Expanded scope of practice has also been shown to improve access to pediatric care in nonrural areas15.
Provider availability. Standardizing NP scope of practice laws to support full NP autonomy, within the scope of NP training, may increase the availability of primary care providers1, 6, 16, 17, 18, 19, 20 and overall capacity of the workforce21. States with NPs practicing to the full extent of their abilities score higher in population health ratings, suggesting that full scope of practice NPs may reduce primary care shortages and improve population health22. NPs with expanded scope of practice have been shown to improve provider availability for injured workers using worker’s compensation benefits, particularly in rural areas23. In states that grant NPs full practice authority, diabetic patients appear to access care faster, avoid more expensive treatments later, and experience these benefits regardless of if they live in an urban or rural area24. Women living in medically underserved areas in states with restricted scope of practice for NPs may be more likely to be diagnosed with late-stage cervical cancer than women in states with full scope of practice for NPs, suggesting that expanding scope of practice for NPs may increase timely access to care for underserved women by filling health care shortages25.
States that do not require physician oversight appear to have more NPs than states that require greater oversight26, 27. One study indicates higher numbers of primary care NPs in states with less oversight, particularly if NPs are paid the physician Medicaid reimbursement rate17. Primary care NPs18, 28 and family medicine NPs29 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 Medicare28 and Medicaid patients6, 17.
Costs. Models suggest that removing restrictions on NP scope of practice could reduce health care costs1. 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 earnings14, 30. A Massachusetts-based study suggests that while health care utilization has increased following the state’s NP scope of practice expansion, the cost of care provided by NPs is less than that of physicians and patients are more likely to access care sooner, avoiding more costly care later on31. Equalizing NP and physician reimbursement rates is a suggested strategy to encourage full NP autonomy, as allowed within state laws17, 20; as of 2026, Medicare reimburses independent NPs at 85% of the physician rate32.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: supported by some evidence.
There is some evidence that expanding scope of practice laws for nurse practitioners (NPs) has the potential to decrease disparities in access to care between individuals in rural or underserved areas1, 31, 37, 38, 39 and those in areas with large numbers of health care providers.
Expanded practice autonomy and reduced restrictions on types of care increases the primary care capacity of NPs1. In states with fewer restrictions on NP scope of practice, health care utilization appears to be greater, particularly for underserved and rural populations37. Expanding NPs’ ability to prescribe medications has been shown to reduce disparities in access to office-based health care between rural and urban communities38. Massachusetts granted full practice authority to NPs, significantly increasing access to care for residents of underserved and rural areas, as well as members of vulnerable populations31. Expanded scope of practice for NPs may also support increases in access to mental health care in underserved rural areas39. Following scope of practice expansions, NPs have been shown to provide additional emergency medical services in rural areas40.
NPs are more likely than primary care physicians to practice in rural communities and areas with more vulnerable populations, such as minority groups and families with lower incomes; within states with laws whose scope of practice restrictions require NPs to work with a physician, communities are more likely to suffer from disparities in access to care1. States with fewer restrictions on NPs’ scope of practice appear to have more NPs providing care in rural and medically underserved areas1, 37, including providing primary care18. Rural NPs may experience greater clinical autonomy compared to urban NPs41 and provide care to the full extent of their ability18. NPs in states with full scope of practice laws can have their own outpatient practices, maintain their own patient panels, and may be more likely to offer primary care, especially for rural and underserved populations16.
Even with expanded NP scope of practice, additional investment will be needed in rural areas to match the care available in urban and suburban areas15. Structural barriers in rural areas such as workforce turnover, insurance reimbursement challenges, and limits to clinic infrastructure persist, making access to care difficult, even with expanded scope of practice for NPs18.
Experts suggest that standardizing NP scope of practice laws to support full autonomy within the scope of their training may increase the availability of primary care providers1, 6, 14, particularly in rural areas42.
What is the relevant historical background?
The nurse practitioner (NP) role was created in 1965 at the University of Colorado as a way to increase access to health care, particularly in areas experiencing health care shortages14, 31, 43, 44. The first NP training program focused on primary care for children from families with lower incomes from both urban and rural areas31; this new role was required to practice under the supervision of a physician40.
In the 1970s, states began to regulate the NP role beyond that of registered nurses (RNs); while this offered additional support and legitimacy for the role, it posed difficulties for NPs, patients, and health care organizations in following scope of practice regulations2. Multiple organizations were established, including the National Association of Pediatric Nurse Practitioners (NAPNAP), the American Nurses Association’s (ANA) Council of Primary Care Nurse Practitioners44 and the American Academy of Nurse Practitioners (AANP) to help promote the legitimacy of the role45.
Even though there are national standards for NP education, program accreditation, and board certification, the scope of care NPs can provide continues to be determined by individual state’s rules and scope of practice regulations2, 14, 40. States have been slowly expanding scope of practice laws for NPs to counteract the primary care provider shortage, particularly after the Affordable Care Act (ACA) was passed in 201014, and by 2020 22 states had granted NPs full scope of practice authority14.
As of 2025, 43 million people live in rural areas with a shortage of primary care providers and over a third of rural adults visited emergency rooms for care that could have been provided by a primary care practitioner46. Physician shortages are expected to worsen47, with an anticipated primary care physician shortage of 54,000-133,000 by 203014 that will be felt particularly in rural areas46. Certain health care services provided by NPs can help alleviate shortages as demand for health care increases47. HRSA projections suggest that there will be surpluses of NPs by 203848.
Equity Considerations
- Who experiences worse health outcomes in your community? Who does not have access to primary care or is experiencing delayed care due to primary care shortages? What is being done to ensure everyone has access to primary care?
- How can your community raise public awareness of nurse practitioners as a workforce that can increase access to health care, particularly primary care for those in HPSAs? How can community voices champion legally expanding scope of practice at the state level?
Implementation Examples
As of December 2023, 27 states, Washington, D.C., and two territories allow nurse practitioners (NPs) to diagnose, treat, and prescribe medications without physician involvement33; in 2023, Utah became the 27th state to adopt full practice authority for NPs34. U.S. Nursing Regulatory Bodies regulate standards of nursing care, issue nursing licenses, and set nursing scope of practice, which apply to all types of NPs, through Nurse Practice Acts (NPAs)35; the NPA for each U.S. state and territory is available through the National Council of State Boards of Nursing (NCSBN)36.
Implementation Resources
‡ Resources with a focus on equity.
NCSBN-NPA - National Council of State Boards of Nursing (NCSBN). (2026). Find your Nurse Practice Act (NPA). Retrieved October 19, 2026.
Barton-NP - Barton Associates. Interactive nurse practitioner (NP) scope of practice law guide.
KFF-NP - KFF. Medicaid benefits: Nurse practitioner (NP) services.
AANP-State practice 2026 - American Association of Nurse Practitioners (AANP). (2026). State practice environment: State regulatory map. Retrieved October 12, 2026.
AANP-Full practice authority 2025 - American Association of Nurse Practitioners (AANP). (2025). Issues at a glance: Full practice authority. Retrieved September 15, 2026.
Footnotes
* Journal subscription may be required for access.
1 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.
2 AANP-Full practice authority 2025 - American Association of Nurse Practitioners (AANP). (2025). Issues at a glance: Full practice authority. Retrieved September 15, 2026.
3 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.
4 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.
5 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).
6 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.
7 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.
8 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.
9 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.
10 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.
11 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.
12 McMichael 2023 - McMichael, B. J. (2023). Supply-side health policy: The impact of scope-of-practice laws on mortality. Journal of Public Economics, 222, 104901.
13 Huang 2021c - Huang, N., Raji, M., Lin, Y., Chou, L., & Kuo, Y. (2021). Nurse practitioner involvement in Medicare accountable care organizations. American Journal of Medical Quality, 36 (3), 171-179.
14 Bhai 2024 - Bhai, M., & Mitchell, D. T. (2024). The effects of occupational licensing reform for nurse practitioners on children's health. Southern Economic Journal, 91(1), 62–91.
15 Fitzpatrick 2026 - Fitzpatrick, J. J., Mehlman, M., Plemmons, A., Duffy, E. G., Gerlick, J. A., Davis, S., Votruba, M., & Norful, A. A. (2026). The impact of nurse practitioner full practice authority on pediatric care experiences: A national secondary data analysis. Journal of Pediatric Health Care, 40(2), 251–257.
16 Zwilling 2021 - Zwilling, J., Fiandt, K., & Ahmed, R. (2021). Comparison of rural and urban utilization of nurse practitioners in states with full practice authority. The Journal for Nurse Practitioners, 17(4), 386–393.
17 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.
18 Spetz 2017 - Spetz J, Skillman SM, Andrilla CHA. Nurse practitioner autonomy and satisfaction in rural settings. Medical Care Research and Review. 1077558716629584.
19 Naylor 2010 - Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Affairs. 2010;29(5):893–9.
20 IOM-Nursing 2011 - Institute of Medicine (IOM). The future of nursing: Leading change, advancing health. Washington, D.C.: National Academies Press; 2011.
21 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.
22 Dunbar-Jacob 2025 - Dunbar-Jacob, J., & Rohay, J. M. (2025). State health and the level of practice authority for nurse practitioners. Nursing Outlook, 73(1), 102319.
23 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.
24 Wallace 2025 - Wallace, A., Bhai, M., & Hughes, D. R. (2025). The effects of nurse practitioner scope of practice laws on diabetic health care costs. Contemporary Economic Policy, 43(1), 93–115.
25 Smith-Gagen 2019 - Smith-Gagen, J., White, L. L., Santos, A., Hasty, S. M., Tung, W.-C., & Lu, M. (2019). Scope-of-practice laws and expanded health services: The case of underserved women and advanced cervical cancer diagnoses. Journal of Epidemiology and Community Health, 73(3), 278–284.
26 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.
27 Perry 2012 - Perry JJ. State-granted practice authority: Do nurse practitioners vote with their feet? Nursing Research and Practice. 2012;2012:482178.
28 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.
29 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.
30 Pittman 2012 - Pittman P, Williams B. Physician wages in states with expanded APRN scope of practice. Nursing Research and Practice. 2012;2012:671974.
31 Cuccovia 2022 - Cuccovia, B. A., Heelan-Fancher, L., & Aronowitz, T. (2021). A policy analysis of nurse practitioner scope of practice in Massachusetts. Journal of the American Association of Nurse Practitioners, 34(2), 410–417.
32 CMS-APRNs 2026 - Centers for Medicare & Medicaid Services (CMS). (2023, May 13). Advanced Practice Registered Nurses (APRNs). Retrieved October 19, 2026.
33 AANP-State practice 2026 - American Association of Nurse Practitioners (AANP). (2026). State practice environment: State regulatory map. Retrieved October 12, 2026.
34 AANP-Utah 2023 - American Association of Nurse Practitioners (AANP). (2023, March 16). Utah’s new law will improve patients’ health care access. Retrieved October 12, 2026.
35 NCSBN-NRBs - National Council of State Boards of Nursing (NCSBN). (2026). About U.S. Nursing Regulatory Bodies (NRBs). Retrieved October 19, 2026.
36 NCSBN-NPA - National Council of State Boards of Nursing (NCSBN). (2026). Find your Nurse Practice Act (NPA). Retrieved October 19, 2026.
37 Geller 2021a - Geller, D. E., & Swan, B. A. (2021). Recent evidence of nurse practitioner outcomes in a variety of care settings. Journal of the American Association of Nurse Practitioners, 33(10),
38 Guo 2024 - Guo, J., Kilby, A. E., & Marks, M. S. (2024). The impact of scope-of-practice restrictions on access to medical care. Journal of Health Economics, 94, 102844.
39 Finley 2020 - Finley, B. A. (2020). Psychiatric mental health nurse practitioners meeting rural mental health challenges. Journal of the American Psychiatric Nurses Association, 26(1), 97–101.
40 McMichael 2025 - McMichael, B. J. (2025). Scope‐of‐practice laws and the practice patterns of nurse practitioners and physician assistants. Contemporary Economic Policy, 43(1), 9–30.
41 Neprash 2021 - Neprash, H. T., Smith, L. B., Sheridan, B., Moscovice, I., Prasad, S., & Kozhimannil, K. (2021). Nurse practitioner autonomy and complexity of care in rural primary care. Medical Care Research and Review, 78(6), 684–692.
42 RHIhub Rural HC workforce - Rural Health Information Hub (RHIhub). (2026). Rural healthcare workforce. Accessed August 28, 2026.
43 ANJ-Dunlap 2024 - Dunlap, J. D. (2024). Nurse practitioners: Past, present, and future. American Nurse Journal (ANJ), American Nurses Association. Retrieved October 12, 2026.
44 AANP-Timeline - American Association of Nurse Practitioners (AANP). (2026). Historical timeline. Retrieved October 12, 2026.
45 AANP-About - American Association of Nurse Practitioners (AANP). (2026). About the American Association of Nurse Practitioners® (AANP): Your national nurse practitioner (NP) community. Retrieved October 12, 2026.
46 CWF-Rural primary care - Commonwealth Fund (CWF). (2025). The state of rural primary care in the United States [Issue Brief]. Accessed August 28, 2026.
47 NCHWA-Physician workforce - National Center for Health Workforce Analysis (NCHWA). (2024). Physician Workforce: Projections, 2022-2037. Health Resources and Services Administration (HRSA). Retrieved October 12, 2026.
48 HRSA PC Workforce - Bureau of Health Workforce (2025, December). State of the primary care workforce, 2025. Health Resources and Service Administration (HRSA). Accessed August 27, 2026.
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