5 Jul 2022


Scope-to-practice Barriers - American Nurses Association

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The Patient Protection and Affordable Care Act (ACA) has enabled many Americans to get access to health insurance coverages. This increasing number of people with access to health care services has provided a challenge to the existing primary care systems as a result of the increasing patient-care provider's ratio. The existing legislation and policies derail the prospects of using Nurse Practitioners (NP) as a solution to this problem by limiting the work-scope of the NPs. This article discusses the scope-of-practice barriers related to care provided by registered nurses and nurse practitioners and the recommendations for removing the scope-of-practice barriers (Hain & Fleck, 2014). 

Payer policies and health insurance mandates play an important role in determining the scope of the NPs practice. Stricter policies prevent the NPs from practising independently, as they will have to bill the services they provide through physicians to get reimbursements from the insurance providers. Most insurance providers and commercial health plan policies do not recognize NPs as independent primary care providers. The NPs are thus forced to be in practice as signatories or affiliates of hospitals, physicians or other care providing entities. Even in jurisdictions where the NPs are granted full practice authority, the failure of policy payers makes it impossible for them to practice because they fail to pay them directly or pay them lower than is expected (Hain & Fleck, 2014). 

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State practice and licensure policies vary from state to state. NP practice is regulated by the statutory licensing policies, which have an overall goal of full practice authority. The full practice authority requires that for licensure, the nurses have to meet some requirements including competent education and training, national certification, and accountability to the public and state board of nursing with regards to professional conduct and quality of care. However, only about a third or the states have practice and licensure for a full practice for the NPs. This conversely means that two-thirds of the United States do not permit the NPs to practice to the fullest extent of their education and training. The IOM report (2011) acknowledged that overly restrictive practice and licensure policies in some states is a serious barrier to primary care providers (Hain & Fleck, 2014). 

The belief that NPs undergo shorter and less rigorous training than a physician and they cannot, therefore, provide care at the same level as physicians impede effective NPs practice. The traditional model of health care provision emphasizes the physicians’ dominance over the healthcare team, and as a result, there is a minimum collaboration between the healthcare team. Failure to clearly outline the NPs role in the primary care system contributes to this belief and their undermining by both the physician, policymakers, and care seekers. Most physicians neither acknowledge the role NPs play in mitigating the shortage of primary care providers nor support the expansion of NPs roles. With the rapidly evolving healthcare landscape, it is imperative that the physicians and NPs effectively work together to achieve the best practice (Hain & Fleck, 2014). 

` Some barriers prevent nurses from providing continued care to their patients. The NPs may be privileged to prescribe medications and controlled substances to their patients, but they, however, may not follow up on their patients if the patients are hospitalized in acute care facilities. The barrier to admitting privileges reduces the quality of care provided to the patient. Also, job satisfaction is another barrier to the scope-of-practice. The NPs dissatisfied with their jobs will in most instances have difficulty in providing the required quality of care (Hain & Fleck, 2014). 

The extent of the implications of the scope-of-practice barriers has been documented in research and studies conducted across the nation. One study, for example, pointed out that in Massachusetts, new patients had to wait for an average of 39 days to see the physician. Furthermore, most of the physicians had been fully booked for the year and were no longer taking in new patients. The average primary care patient-doctor time is 15 minutes. The strained number of care providers forces the physicians to reduce the patient-doctor time to be able to attend to more patients. On face value, this has a positive effect as more patients will receive the primary care service. Reducing the patient-doctor time, however, does more harm than good. The probability of inconclusive diagnosis and consequently poor quality primary care. Studies have also shown that less interaction between the patient and the doctor leaves the patient frustrated. 

Contrary to the justification for ACA and increased coverage, the problem of access to health care may worsen with the increase in the number of people seeking primary services. Increasing coverage is a one-sided undertaking with no consideration for the prevailing health system and care providers. The restrictive policies and legislations bar the primary care providers, especially the NPs from fully applying their education and training in the on-field are delivery. Studies show that these restrictions have an equivalent effect of inadequate health care workforce primarily because more caregivers will be required to sufficiently provide care that would otherwise be provided by one or a few mandated NPs. This phenomenon is called the ‘spillover effect’. In most instances, the physician is tasked with the responsibility of following patients through from primary diagnosis, admission, discharge, and home prognosis monitoring. It should be noted that nurses are also trained in primary care provision and can perform the duties of the required standards. The nursing education and training coupled with the practical experience makes them apt to provide the primary care services on the same level as the physicians. If leveraged, the NPs services will positively shift the quality of care provided by reducing the over-reliance on physicians, thereby increasing the access of patients to primary care (Barbarito, 2016). 

Opposition to Removing the Scope-to-practice Barriers 

Questions about the competency of the advanced practice registered nurses (APRN) has been the main source of opposition and contention about removing of the scope-of-practice barriers and entrusting the NP with full practice authority. The IOM report pointed out that the American Nurses Association (AMA) listed that the disparity in clinical experience between the physicians and NPs was the main cause of concern in the debate. In 2014, New York State legislated the expansion of the roles and practice of NPs. This legislation was however challenged in court, where the complainant cited the AMA report. The complainant further cited a study conducted in 1999 which alleged that NPs might be economically inconsiderate by because they may need to perform more diagnostic tests to conclusively diagnose a case. In a 2012 report by the Physicians Foundation, the extent of the research acknowledged that NPs perform exceptionally within their areas of training and experience. This report was interpreted by a faction of physicians to mean that the NPs should be restricted to their area of training and expertise because they provide better service in those areas. 

Opposition among the NPs and physicians results in antitrust and unfair competition among the care providers. This has a negative effect on the quality, price, and availability of the primary care. Those against full practice authority for NPs argue that granting NPs the privilege to practice independently as physicians do will enhance competition and mistrust between the two groups of caregivers. The IOM report (2011) asserts that physicians and NPs and Physicians offer potentially substitute services. 

Impact of Leadership/Management Theory & QSEN Competencies Upon the Scope-to-practice Barriers 

The Quality and Safety Education for Nurses (QSEN) competencies provide the framework for the education, training and practice of NPs. Adherence to the QSEN ensures that the quality of service provided is as per the required professional and statutory standards. Juxtaposing the NPs primary care in accordance with the QSEN competencies and the primary care provided by the physicians shows that the care quality is on par, with minimum differences arising due to interpersonal variations. Studies have pointed out to equivalent patient outcomes from both the NPs and physicians primary care service. QSEN competencies are often used as quality check markers in the championing for removal of scope-of-practice barriers. Policy makers, other health provision entities and the public take into consideration the application of the QSEN competencies in the NP’s care provision (Boyer, 2016). 

Leadership nursing and management acts both as oversight for the NPs practice and mediator in policy decisions and legislation. Nursing leadership, in other words, bridges the relationship between the NPs and the policymakers. According to the American Nurses Association, nursing leaders have a responsibility to take part in executive decisions pertaining health care systems, represent their nursing staffs’ interests, create effective relationships between nursing staff and other healthcare entities and ensure that the NPs are practising in accordance to the set nursing guidelines. A failed leadership translates into poor adherence to the QSEN competencies and consequently poor primary service provision. However, if the nursing leadership is effective in discharging its roles, the QSEN competencies and guidelines will be adhered to, thereby justifying the need for the removal of the scope-of-practice barriers. 

Risk/Benefits Ratio 

Effective nursing leadership and adherence to the QSEN competencies begets more benefits than risks. The quality of primary service care is dependent on the competence of the caregiver, the integrity of the care, and the objective of the care given. These issues are addressed by the QSEN competencies and overseen by effective leadership. The overall effect is an improved quality of care. This adds more weight to the push for the removal of the scope-of-practice barriers and granting the NPs privilege of full practice authority. There is no evidence that points out to the risks of having effecting nursing leadership and adherence to QSEN competencies in relation to the quality of primary care. It may, however, be hypothesized that over-reliance on the leadership for quality care provision may be detrimental to the healthcare system. This is because an unprecedented collapse of the leadership framework may derail the quality of service, as well as impede the quest for removal of the scope-of-practice barriers. The urge to provide quality care should be intrinsic and not enforced to an individual by the leaders or policymakers. 

The ever-changing health system creates an increasing demand for sufficient, affordable and quality primary care. Following the enactment of ACA, more people have access to health insurance coverages. However, few measures have been put in place to ensure that the healthcare workforce meets the surging demand. Nurse practitioners are often inhibited by restrictive statutory laws, opposition by physicians and payer policies. Nurses leadership is responsible for ensuring that NPs adhere to the QSEN competencies, with the aim of ensuring the provision of quality service and justification for the removal of the scope-of-practice barriers. It is important for the policymakers to remove the restrictions and barriers that impede the full provision of care by NPs, to ease the availability to care. 


Hain, D., Fleck, L., (May 31, 2014) "Barriers to Nurse Practitioner Practice that Impact Healthcare Redesign"  OJIN: The Online Journal of Issues in Nursing  Vol. 19, No. 2, Manuscript 2. 

Boyer, E. (2016). Setting the Stage for a Leadership Framework.  Transforming Professional Practice: A Framework for Effective Leadership 1

Barbarito, A.J. (2016) Expanding the Scope of Practice for Advanced Practice Registered Nurses: A Legislative Call to Action 

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

Yee T, Boukus E, Cross D, Samuel D. (2013). Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies. National Institute for Healthcare Reform; NIHCR Research Brief No. 13. 

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