Nurse practitioner scope of practice

Evidence Rating  
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  
Decision Makers
Date last updated

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.

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 to2, 3, 4, 5, 6, 7, 8, and sometimes better than, comparable care provided by physicians4, 6, 8, 92. On average, nurse practitioners’ patient satisfaction scores are similar to2 or higher than physicians’ scores7, 8, 94.

Overall, health status and outcomes for patients that receive routine care from NPs are equal to that of patients treated by physicians2, 3, 6, 7, 8, 10. NPs generally provide longer consults7, 8, more health advice7, and are more likely to take patient histories and discover history-related causes of health issues than physicians6.

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, 5, 11, 12, 13, 14, 15. NPs with expanded scope of practice have been shown to improve provider availability for injured workers using worker’s compensation benefits, particularly in rural areas16.

States that do not require physician oversight appear to have more NPs than states that require greater oversight17, 18. One study indicates higher numbers of primary care NPs in states with less oversight, particularly if NPs are paid the physician Medicaid reimbursement rate11. Primary care NPs12, 19 and family medicine NPs20 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 Medicare19 and Medicaid patients5, 11.

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 earnings21.

Equalizing NP and physician reimbursement rates is a suggested strategy to encourage full NP autonomy, as allowed within state laws11, 14; as of 2012, Medicare reimbursed independent NPs at 85% of the physician rate22

How could this strategy impact health disparities? This strategy is rated likely to decrease disparities.
Implementation Examples

As of March 2017, 22 states and Washington, D.C. allow nurse practitioners to diagnose, treat, and prescribe medications without physician involvement23. 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 system24

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 practitioners23, 25, 26

Implementation Resources

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.

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.

KFF-NP - KFF. Medicaid benefits: Nurse practitioner (NP) services.

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


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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 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.

3 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.

4 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).

5 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.

6 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.

7 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.

8 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.

9 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.

10 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.

11 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.

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

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

14 IOM-Nursing 2011 - Institute of Medicine (IOM). The future of nursing: Leading change, advancing health. Washington, D.C.: National Academies Press; 2011.

15 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.

16 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.

17 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.

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

19 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.

20 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.

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

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

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

24 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.

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

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