Nursing Autonomy: Overview
Nursing autonomy refers to the legal ability of nurse practitioners (NPs) to practice independently, often without direct supervision from a physician. This concept has gained traction particularly in the context of increasing healthcare demands and a nationwide physician shortage, especially in underserved areas. As of 2023, several states have granted full practice authority to nurse practitioners, allowing them to evaluate patients, order tests, prescribe medications, and provide treatment independently. Proponents argue that this autonomy enhances access to affordable healthcare and alleviates burdens on physicians, while critics express concerns about the adequacy of NPs' training compared to physicians.
The history of nurse practitioners traces back to the 1960s when the first NP program was established to address the growing need for healthcare providers. Since then, the debate around their scope of practice has intensified, particularly during the COVID-19 pandemic when the healthcare system faced unprecedented strain. Despite the push for expanded autonomy, some states still require NPs to have collaborative agreements with physicians, and a few mandate direct supervision. As healthcare coverage expands, the conversation continues about finding a balance between leveraging the skills of nurse practitioners while ensuring patient safety and care quality.
Nursing Autonomy: Overview
Introduction
"Nurse practitioner" is a designation given to a particular type of highly trained nurse who has the legal autonomy to practice medicine without the supervision of a physician in certain cases. As of 2016, more than twenty states and Washington, DC, have medical practice and licensure laws that allow nurse practitioners to provide many of the same services as physicians, including evaluating patients, ordering medical tests and interpreting the results, writing prescriptions, and providing treatment, without requiring direct oversight by a physician.
Some policy makers and health care experts believe that increasing autonomy for nurse practitioners may help to relieve the growing physician shortage, especially among traditionally underserved populations. For example, the American Nurses Association and the American Association of Nurse Practitioners have argued that nurses need more autonomy in their daily practice. On the other hand, medical organizations such as the American Medical Association have expressed their support for limiting the autonomy of nurse practitioners, because nurses lack the same extended medical education and training of physicians. As more Americans become eligible for health insurance under the Patient Protection and Affordable Care Act of 2010 and the shortage of medical professionals becomes more acute, debate continues over how much autonomy to grant to nurse practitioners.
Understanding the Discussion
Collaborative agreement: An agreement required by some states to permit nurse practitioners to practice medicine without the direct oversight of a physician. These agreements generally require the nurse practitioner to pay a fee to the physician and to submit charts for review on a regular basis.
Full practice authority: Authorization for a nurse practitioner to practice medicine—within certain boundaries—without direct oversight or a required collaborative agreement with a physician.
Nurse practitioner (NP): Also called an advanced practice registered nurse (APRNs) or certified nurse practitioners (CNPs) in some states. Nurse practitioners attend nursing school, have a master's or doctorate degree, and have completed approximately five hundred to seven hundred hours of supervised clinical practice and have achieved national board certification and state NP licensure or registration.
Physician: A medical professional who attends medical school to receive a medical doctor (MD) or doctor of osteopathic medicine (DO) degree. Training usually requires about eleven years of academic study plus more than ten thousand hours of practical and clinical training, followed by certification exams. Physicians have full authority under the law to practice any type of medicine for which they are board certified.
History
In the years after World War II, the demand for medical care grew rapidly and eventually exceeded the supply of available physicians. Populations grew dramatically in urban areas, placing a strain on existing health care providers, and rural areas increasingly faced challenges due to inadequate medical facilities and providers. Because of the insufficient supply of medical professionals to meet the demand, the cost of health care increased significantly; this often left poorer populations underserved and unable to obtain adequate health care.
In an attempt to provide a solution to the shortage, Drs. Loretta Ford and Henry Silver started the first nurse practitioner (NP) program at the University of Colorado in 1965. The program's objective was to train additional medical professionals who could operate independently in clinical settings to perform routine care such as administer basic exams, diagnose and treat simple illnesses, and provide immunizations. Because NP programs are shorter and less expensive than the medical doctor (MD) programs that physicians complete, the intention was for nurse practitioners to provide more cost-effective care that could address patients' basic needs, thus freeing up physicians' time to treat patients with more complicated cases.
To become a nurse practitioner, one must first become a registered nurse (RN) by obtaining a bachelor's degree in nursing, completing practical training, and passing an RN licensing exam. Becoming a nurse practitioner further requires obtaining a graduate-level degree (master's or doctorate level) through an additional two to four years of study and practical training, as well as passing an additional certification exam. Similar to physicians, nurse practitioners can choose to specialize in particular areas of medicine, such as pediatrics, acute care, or psychiatry, although many remain in family heath or general practice.
In hospitals and other clinical settings, nurse practitioners are commonly tasked with supervising and managing RNs and licensed practical nurses (LPNs). However, they can also take a more active role in patient care independent of physician involvement due to their additional specialized training in diagnosing and treating various ailments. When practicing in private offices—either as part of a team with physicians or independently—nurse practitioners diagnose and treat minor illnesses.
The amount of autonomy a nurse practitioner has varies by state. As of 2015, twenty-one states and the District of Columbia grant nurse practitioners full practice authority, which allows them to treat patients independent of a physician. Permitted activities generally include diagnosing basic illnesses, ordering and interpreting tests, prescribing medication, and managing treatment. Of the remaining states, some require the nurse practitioner to have a collaborative agreement with a physician; this arrangement generally requires the nurse practitioner to consult with a physician before providing certain types of care and may also require that the nurse practitioner maintain and share particular types of medical records with a physician. However, several state legislatures have considered bills that seek to end this arrangement and allow nurse practitioners greater autonomy in practicing without such agreements—in part because they found that physicians were charging nurse practitioners significant monthly fees to sign such an agreement but not actually providing any significant collaborative relationship. Twelve states require direct supervision by a physician for a nurse practitioner to provide patient care. As of 2016, nurse practitioners have the authority to prescribe medication in all US states; however, their ability to prescribe certain controlled substances or to prescribe any medications without physician oversight varies by state.
The debate over how much autonomy to grant to nurse practitioners has existed since the inception of these programs. Those who support nurse practitioners' authority to practice without mandatory physician collaboration or supervision believe that autonomy allows better access to affordable, quality health care, especially for traditionally underserved populations. Supporters cite nurse practitioners' extensive education and clinical training as evidence of an adequate background to provide routine health care and believe greater autonomy would free up more highly trained physicians to handle more complex cases. By contrast, those who favor limiting nurse practitioners' autonomy to practice without mandatory physician supervision or collaboration believe that the training nurse practitioners receive, while extensive, is inadequate to replace the education and experience of a physician in diagnosing illnesses and prescribing medications.
Nursing Autonomy Today
During the COVID-19 pandemic in the early 2020s, the debate over nursing autonomy intensified as the number of patients needing care strained the resources of the entire health care system. As this need grew, some jurisdictions relaxed regulations that limited the scope of practice for advance practice nurses, such as nurse practitioners and clinical nurse specialists. By October 2023, the American Association of Nurse Practitioners reported that twenty-seven states, Guam, the Northern Mariana Islands, and Washington, DC, allowed nurse practitioners full practice, a model recommended by the National Academy of Medicine and the National Council of State Boards of Nursing.
The Bureau of Labor Statistics estimated that in 2023 there were more than 280,000 nurse practitioners in the United States. Nearly half worked in the offices of physicians, but a significant percentage also work in hospitals and outpatient care centers.
The issue of nurse practitioners and their autonomy to practice independently of physicians became even more significant with the passage of the Patient Protection and Affordable Care Act (ACA) in 2010. In 2024, the US Department of Health and Human Services reported that approximately 45 million Americans had gained health care coverage related to the ACA. Unfortunately, the American Medican Association reported in 2023 that an estimated 83 million people in the US live in geographic areas where there is a shortage of primary care physicians. This means that while more Americans now have the insurance coverage to obtain affordable health care, many lack the actual ability to do so because that care is unavailable due to a lack of health care professionals. Additionally, many rural areas suffer from an acute shortage of physicians to provide the care required by the population, and people may need to travel for hours to a larger city to obtain even the most basic medical care.
Some organizations, including the Kaiser Family Foundation, believe that greater autonomy for nurse practitioners may provide a solution to these problem; others believe that, although nurse practitioners provide a valuable service, the ACA should not be used as an excuse to substitute nurse practitioners for more highly trained physicians. The debate can become heated at times, particularly between doctors and nurses themselves: for example, in response to a bill in Florida that would allow nurse practitioners to prescribe controlled substances, Dr. Alan Harmon, then president of the Florida Medical Association, implied that allowing nurse practitioners this additional authority would exacerbate the nation's opioid addiction epidemic. Mary Chesney, a clinical professor at the University of Minnesota School of Nursing, responded that "to date, there isn't any study or evidence to support that nurse practitioners are any more likely than physicians to mis-prescribe narcotics."
These essays and any opinions, information, or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.
Bibliography
Aizenman, N. C. "Nurses Push for More Autonomy in Care." Washington Post, 23 Mar. 2013, www.washingtonpost.com/national/health-science/nurses-can-practice-without-physician-supervision-in-many-states/2013/03/24/98b241cc-8745-11e2-999e-5f8e0410cb9d‗story.html. Accessed 23 Sept. 2016.
"All about NPs." American Association of Nurse Practitioners, www.aanp.org/about/all-about-nps. Accessed 23 Sept. 2016.
"AMA President Sounds Alarm on National Physician Shortage." AMA, American Medical Association, 25 Oct. 2023, www.ama-assn.org/press-center/press-releases/ama-president-sounds-alarm-national-physician-shortage. Accessed 25 Apr. 2024.
Chen, Pauline. "The Gulf between Doctors and Nurse Practitioners." The New York Times, 27 June 2013, archive.nytimes.com/well.blogs.nytimes.com/2013/06/27/the-gulf-between-doctors-and-nurse-practitioners/. Accessed 23 Sept. 2016.
Dickson, Virgil. "Expanded Scope: Nurse Practitioners Making Inroads." Modern Healthcare, Crain Communications, 20 Feb. 2016, www.modernhealthcare.com/article/20160220/MAGAZINE/302209981/expanded-scope-nurse-practitioners-making-inroads. Accessed 23 Sept. 2016.
New England Journal of Medicine
Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Natl. Academies P, 2011.
"Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners." Occupational Outlook Handbook, Bureau of Labor Statistics, US Department of Labor, 13 Apr. 2018, www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm. Accessed 30 Apr. 2018.
"Occupational Employment and Wages, May 2023: 29-1171 Nurse Practitioners." U.S. Bureau of Labor Statistics, US Department of Labor, May 2023, www.bls.gov/oes/current/oes291171.htm. Accessed 25 Apr. 2024.
Pearce, Katie. "COVID-19 Ushers in Decades of Change for Nursing Profession." HUB, Johns Hopkins University, 19 Oct. 2020, hub.jhu.edu/2020/10/19/nursing-changes-covid-19/. Accessed 25 Apr. 2024.
"State Practice Environment." AANP, American Association of Nurse Practitioners, www.aanp.org/advocacy/state/state-practice-environment. Accessed 25 Apr. 2024.