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Nurse Practitioners' Quest for Full Practice Authority

The NP profession continues to make practice strides.

Nurse practitioners make up over 50% of primary care providers1, seeing to the health and wellbeing of patients daily, writing prescriptions when necessary and applying their learned skills to each appointment.

With the ever-increasing shortages of healthcare physicians and NPs filling in the gap, it would only make sense for NPs to be able to practice to the full scope of their abilities. Full practice authority (FPA), however, is not the standard in every state.

FPA is the collection of state practice and licensure laws allowing NPs to practice to the full scope of their education and certification, which includes seeing patients, ordering and interpreting diagnostic tests, prescribing medication, and managing patients' treatments. FPA removes the requirement for NPs to hold and maintain a relationship with a physician or facility as a condition of their practice. It's a concept that has been around since the beginning of the NP profession.

Instead of allowing NPs FPA, however, some states have reduced and restricted practice regulations on NPs.

"It's like having a driver's license but needing permission from someone in your neighborhood before you can drive," said Tay Kopanos, DNP, FNP, vice president of state government affairs at the American Association of Nurse Practitioners (AANP).

The Ongoing Campaign for Full Practice Authority
Despite the challenges, NPs have made significant strides toward FPA across the United States. By the end of 2016, 42% of the states in America had full practice legislation allowing NPs full and direct access to patients. Though no new states gained FPA last year, a total of 21 states and Washington, D.C., have FPA.

"State policy landscape is constantly changing," said Kopanos, who has been an NP for more than 15 years. "The need for states to provide quality health services, support affordable and sustainable healthcare, recruit and retain healthcare providers, and support the increasing number of older patients and individuals with chronic diseases will increasingly make states more receptive and interested in adopting FPA."

According to Kopanos, FPA is improving both healthcare and patients' access to healthcare. She said, "Since the 1980s, states with FPA have had a higher number of NPs working in rural and underserved areas. This trend continues today, and now we're even seeing that states with FPA attract more NPs to the state in general."

The healthcare needs of Americans have changed drastically over the years as our understanding of science and medicine grows and our methods of healing become more in-depth. The high demand for healthcare providers juxtaposed against the ever-increasing clinician shortage creates a gap in care. NPs are filling that gap thanks to full practice authority.

As states become receptive to the idea of FPA, two criteria must be met:

1) Legislators need to be educated on the services, outcomes, health models and benefits NPs provide; and

2) the strong, organized medical group opposition needs to be looked at with a critical eye.

Kopanos noted that the "medical hierarchy" that once existed does not reflect today's healthcare environment.

"The NP workforce has increased in number and is well equipped to meet the healthcare needs of our nation's patients," Kopanos added. "Decades of study have underscored the benefits of improved access, enhanced quality and cost improvement associated with NP care. A recent study found that-in states with FPA-patients have decreased hospitalizations, better overall health outcomes and can see some healthcare cost savings as a result."

Full Practice Authority for All APRNs
"Right now, full practice authority [for all APRNs] is patchwork," said Kopanos. Historically, the legislation regarding the four APRN roles evolved separately. "The good news is that more states are aligning for all four roles," Kopanos added, "and more states are adopting the national Consensus Model for all APRNs."

  • Clinical Nurse Specialists (CNSs)-CNSs, have FPA in 28 states. Of the remaining states, 13 recognize CNSs as APRNs but require a collaborative practice agreement with a physician.1
  • Certified Registered Nurse Anesthetists (CRNAs)-CRNAs have FPA in 27 states and Washington, D.C. Twenty states do not allow CRNAs to practice independently.2
  • Certified Nurse-midwives (CNMs)-CNMs have FPA in 25 states. Additionally, 19 states require CNMs to practice through a collaborative agreement with a physician.3

Continued Strides in 2016

Full practice authority isn't the only cause NPs are forging behind. 2016 proved to be an exciting year for the profession in many aspects. From hospitals and facilities adopting new policies to individual states updating their laws, the NP profession continued to grow. Some strides taken this past year included:

  • West Virginia removed the requirement for a collaborative agreement as a condition of NP practice.
  • West Virginia NPs also gained global signature authority.
  • NPs in Kentucky and Hawaii gained death certificate signature authority.
  • Wyoming and Idaho are the first two states to pass advanced practice nursing compact legislation, which is a state compact that allows NPs to practice with licensure from one state in another state.
  • Florida NPs gained authorization to prescribe controlled substances, becoming the 50th and final state to do so. This had been a 20-plus-year-long effort of advocacy.
  • The Department of Veterans Affairs (VA) proposed to give NPs full practice authority while working in the VA system, recognizing the benefits veterans could receive from NPs. No ruling has been made yet on this issue.

"States, policy makers and institutions continue to see the benefit of NP care," said Kopanos. "In addition, we are seeing hospitals adopt policies that provide NPs with voting positions on hospital boards, and we're seeing insurance companies increasingly offering patients the opportunity to elect an NP as their primary care provider, and new NP-owned and NP-managed clinics are opening."

Looking Forward to 2017
"States are gearing up for the 2017 state legislative session," Kopanos said. Over a dozen states are anticipated to be looking at licensure modernization in some capacity. Some are looking for signature recognition legislation. Others, like North Carolina and Massachusetts, will be advocating for FPA.

"Changing policy requires teamwork and cooperation," said Kopanos. "Being part of an association magnifies the NP voice and increases the chances for success. The best place to start is with education. Effective advocacy begins with knowledge of the issues, and then moves to sharing that knowledge with others."

NPs looking to join the cause and advocate for their state's FPA regulations should visit

Autumn Heisler is on staff at ADVANCEContact her at

1. National Association of Clinical Nurse Specialists. CNS Scope of Practice and Prescriptive Authority.

2. National Council of State Boards of Nursing. CRNA Independent Practice Map.

3. American College of Nurse-Midwives. Full Practice Authority.

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Actually, full practice authority for all NPs went through the VA on January 16, 2017 by the final rule. Well written article otherwise.

Gerald February 10, 2017


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