Chapter 4.  Nurse Practitioners

This chapter summarizes the original practice environment index for NPs developed by Sekscenski et al, the 2000 update of this index, and the new professional practice index developed in this study for NPs for the fifty States plus the District of Columbia. It includes the following subsections:

• Introduction
• The Original Practice Environment Index for NPs
• The New Professional Practice Index for NPs
• Discussion

Detailed criteria and scoring sheets for the three professional practice indices for NPs for the 50 States and the District of Columbia can be found in Appendices C and E.

Nurse practitioners (NPs) are registered nurses (RNs) with advanced academic and clinical experience which enables them to diagnose and manage acute, episodic and chronic illness, either independently or as part of a health care team. NPs provide some care once offered only by physicians, and in most States they have the ability independently to prescribe medications.

As of 2000, all States and the District of Columbia had statutes or regulations governing the qualification and professional practice for NPs. Most jurisdictions required NPs to pass one of a number different general or specialty-specific certifying exams. [NCSBN, 1998] Laws in most States allow NPs to provide patient services independently in collaboration with a physician.

Their clinical knowledge and experience as RNs, coupled with their advanced clinical training, enables NPs to work with patients on a wide range of clinical tasks. NP practice blurs the discipline boundaries between nursing and medicine so their services can both substitute for and complement the care of physicians. This ability to work across the spectrum of care delivery sites and manage patients in both hospital and ambulatory care settings has found acceptance in a growing number of settings and specialties. On the other hand, because the number of NPs is much smaller than the number of physicians, they are currently used in only a fraction of the sites where physicians work.

An important long-term question is whether NPs will continue their penetration of the health care system. If they do, they could play a dramatically larger role in the health care system of the future. The roles of NPs are continuing to evolve in the health care system, however, and the future is not entirely clear. Recommendations by the recent AHA-sponsored Commission on Workforce for Hospitals and Health Systems [2002] suggests that NPs could play greater roles in the staffing of hospital care teams. If penetration of NPs continues in different medical and surgical specialties, there will clearly be a significant growth of the NP profession. The current attention to patient safety and health care quality suggests that NPs will be integral to future health care delivery across the U.S.

The original NP practice environment index developed by Sekscenski et al for 1992 was based on three broad criteria and point allocations reflecting the then present practice environment for the profession. The broad criteria and point allocations used in creating the index were Legal Status (Maximum Score  = 20);  Reimbursement (Maximum Score = 40); and Prescriptive Authority (Maximum Score = 40). The detailed point allocations for the original index for NPs in 2000 are presented in Table C-1 in Appendix C.

The original professional practice index scores for NPs for the 50 States based on the criteria in Appendix C are summarized in Table 4-1. The scores show a definite trend toward broader professional practice across the fifty States and the District of Columbia between 1992 and 2000. The increases in the index scores indicate greater professionalization, socialization, and standardization of professional practice for NPs over the last decade.

To better reflect the subtle differences that often exist in professional practice across the 50 States, a new index was developed as part of this study that incorporates more criteria and more variability in the scores assigned. The new professional practice index more accurately reflects the practice environments of NPs across the U.S. Most States scored lower on the new index than on the original index for 2000, indicating that the expectations/possibilities about professional practice for NPs had increased since 1992.

The broad scoring criteria for the new NP Professional Practice Index are the same as for the original index, but the point allocations are different. The three criteria are: Legal Status (Maximum Score  = 35);  Reimbursement (Maximum Score = 35); and Prescriptive Authority (Maximum Score = 30). The detailed point allocations for the new index for NPs for each of the 50 States are presented in Appendix E.

The new professional practice index scores for NPs for the fifty States and the District of Columbia resulting from the application of these criteria are presented in Table 4-1. A qualitative overlay to the new professional practice index scores has been provided to identify States that provide Excellent, Favorable, Acceptable, Limiting,  or Restrictive practice environments for NPs. These terms and categories are not hard-and-fast. They are provided only to help readers to characterize the general practice environments in different States. The terms and ratings generally conform to characterizations of the practice environments in States by knowledgeable NPs.

The scores on the original NP practice environment index reveal a trend toward greater practice opportunities for NPs across the fifty States and the District of Columbia between 1992 and 2000. The scores indicate the trend towards greater professionalization, socialization, and standardization of the NP profession over the last decade. Additional analyses of the index scores are described and summarized in Chapter 7.

Table 4-1 shows that most States scored lower on the new index than on the original 2000 index. This is an indication of the impact of the changing health care delivery system which places greater demands and requirements on health professionals in both clinical practice and practice management. The lower scores also reflect the greater efficiency of the new index in capturing nuances in practice options. For example, the prescriptive authority component of the original index had only a three-point scale for prescriptive authority, with 40 points for “full authority”, 0 points for no authority, and an incompletely defined 1 to 39 points for “partial authority”. The prescriptive authority component of the new index on the other hand has seven parts, the largest of which is a graduated scale for type of authority that assigns 1 point for legend drugs only, 3 points for Schedule V drugs, 6 points for Schedule IV and V drugs, 9 points for Schedule III to V drugs, and 12 points for Schedule II to V drugs. Thus, the new index provides a better basis for identifying differences in professional practice options for NPs in different States in 2000 than does the original index.

As is true with many such indices, the true differences that underlie small differences in the scores are generally very small. Thus, states that are close on any of the indices are not significantly different in their professional practice.

Comparisons of individual NP professional practice scores on a State-by-State basis should be made with caution. The scores reflect general, not particular, conditions in the State regulatory environments. Comparing one State with another on the original practice environment index may not fully reflect similarities or differences in actual practice patterns. The index is a good basis for assessing trends toward broader practice environments, but it does not capture or reveal detailed variations in State environments.