The relationship between state regulations and nurse practitioner practice

Access to primary health care remains a problem for many Americans. Effective utilization of nurse practitioners (NPs) may help to alleviate this problem. While there is research demonstrating that states with more liberal regulations governing NPs have higher proportions of NPs, there is very little research which shows how state regulations influence the practice of NPs within states. This study examines the association between state regulatory environment (SRE) and NP practice arrangements within states. Data were derived from a national survey of NPs conducted in 1994 (N = 1378). SRE was measured using a previously developed 100-point scoring system. For physician comparison, generalists from the 1994 National Ambulatory Medical Care Survey (NAMCS) of office-based practices were used. NP practice was examined in two ways: the location of the practice (where NPs worked) and practice patterns (how NPs worked). A positive association was found between state regulation of NPs and where NPs work—a more restrictive SRE was associated with more NPs working in Health Professional Shortage Areas (HPSAs) and working with more Medicaid and minority patients. However, even in the most liberal states, the proportion of NPs working with Medicaid and minority patients and in HPSAs was greater than the proportion of physicians working with these populations. In contrast, there was no association between SRE and NP practice patterns. NPs working in states requiring MD supervision were no more likely to have a physician onsite than NPs employed in states without this requirement. In addition, most of the NPs working in states without prescriptive authority reported that they prescribe medications. However, nearly all of these NPs prescribe medications with physician collaboration, suggesting that physicians are assisting NPs in negotiating the regulatory system to provide medications for their patients. States with liberal regulations have higher proportions of NPs. Within states, restrictive regulations are associated with an increased proportion of NPs working in underserved areas. Yet, in all states, NPs work with these populations at higher rates than physicians. It would appear, therefore, that NPs working in liberal states have access to a variety of employment opportunities while in restrictive states, opportunities for NPs are limited to working more with underserved populations. While research demonstrates an association between SRE and NP practice location, state policies governing NPs appear to play less of a role in the practice patterns of NPs than previously thought. This raises questions about the purpose of such regulations and supports current recommendations to regulate professionals based on demonstrated competencies and to standardize state requirements. Consequently, efforts to improve the geographic distribution of health professionals may be better focused on provider training rather than altering regulations which affect entire professions