Nurse Practitioners' Primary Care Role for Rural Areas Hobbled by Practice Restrictions

NPs account for 1 in 4 medical healthcare providers in rural areas, but their potential to provide a full spectrum of primary care services can't be realized if states maintain practice restrictions.

Nurse practitioners are expected to play a critical role in alleviating the nation's rural healthcare workforce shortages, but some states continue to place hobbling restrictions on their scope of practice, a new study shows.

Researchers found that NPs comprise one-in-four of clinicians practicing in rural areas, a number that increased 43% from 2008-2016. Currently, of the 248,000 NPs in the country, about 87% are trained in primary care and more are in training.

However, study author Hilary Barnes said the increasing reliance on NPs to deliver a full spectrum of primary care services in rural areas is being hindered in some states by outmoded restrictions.  

In some states, such as Pennsylvania, "an NP has to maintain written agreements with a physician to practice and prescribe medication," said Barnes, an assistant professor in the College of Health Sciences’ School of Nursing at the University of Delaware.

"In the most extreme examples, the law states that an NP must talk about every patient with a physician. Or that the physician has to sign for prescriptions," Barnes said, in remarks accompanying the study.   

Barnes also described "mid-level" states, such as New Jersey, that provided latitude for NPs, but not autonomy.

"There's an in-between where an NP needs a collaborative agreement to prescribe medication," she said. "The provider can practice independently of a physician, but, without prescriptive authority, you are limited on the services that you can provide to patients."

In contrast, full-practice authority states, such as Delaware, allow NPs to practice primary care without supervision of a physician.  

States with fewer NP practice restriction also have more NPs providing primary care services to residents.

Barnes said the reason why is obvious.

"In the states with more restrictive laws, say you are a trained NP in a rural area who wants to practice primary care,” Barnes said. “Because there is no physician in town, you can't have a collaborative agreement. Therefore, you can't practice at the advanced practice level."

If the physician-collaborator moves away or retires, the NP loses the ability to practice.

Anecdotal evidence suggests that many NPs have to pay physicians to sign a collaborative agreement, Barnes said.

In addition, Barnes said, more restrictive laws don't improve care.

"All that they are really doing is putting up barriers to primary care. Removing the practice restrictions can really only be a benefit," she said.