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States With Full Practice Authority for Nurse Practitioners Serve Marginalized Communities More Effectively

Analysis  |  By Carol Davis  
   January 27, 2023

In FPA states, the NP workforce tends to be more diverse and better racially and ethnically aligned with the state's overall population, a new West Virginia study says. 

Granting full practice authority (FPA) to nurse practitioners (NPs) is a “costless” way to help communities of color address healthcare access disparities, say authors of a new West Virginia University study.

More than half of US states have granted FPA, which is the authorization of NPs to evaluate patients, diagnose, order, and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing, rather than requiring them to hold a state-mandated contract with a physician as a condition of state licensure.

Though NPs of color are underrepresented in the workforce—less than 7% of NPs are Black, according to employment recruiter Zippia—states permitting FPA tend to have NP workforces that are more diverse and more racially and ethnically aligned with the state’s overall population, the study says.  

“We also found evidence that Black and Asian nurse practitioners serve more Black Medicare beneficiaries after receiving FPA,” according to study co-author Alicia Plemmons, a John Chambers College of Business and Economics assistant professor and coordinator for scope of practice research at the Knee Center for the Study of Occupational Regulation. “Full practice authority is a costless way of helping communities of color address healthcare access disparities.” 

Plemmons and Edward Timmons, service associate professor and director of the Knee Center, published their results in Policy, Politics and Nursing Practice.

The study addresses three healthcare industry concerns:

1. The worsening shortage of US primary care providers, particularly in marginalized communities.

2. The importance of enabling patients from communities of color to choose primary care providers who share their racial and ethnic background.

3. The debate over allowing nurse practitioners to exercise FPA.

“In every state, NPs may all meet with patients, but that’s where the similarities stop,” Plemmons says. “Some states require physician supervision for NPs, while others simply require collaboration agreements. Some limit NPs in diagnosing patients or developing treatment plans, others limit making specialist referrals or ordering imaging services. Probably the most contentious restriction is prescribing medication.” 

Reflecting patient demographics

The study compared the backgrounds of NPs, patients, and overall state populations nationwide, focusing on Black, Asian, and Hispanic communities and found that FPA states had higher concentrations of NPs from communities of color.   

Representation varied among different communities, according to the study, but the data for Black NPs and patients in FPA states stood out: Black NPs in FPA states served 2.8% more Black Medicare beneficiaries than Black NPs in non-FPA states.   

That’s significant because a nursing workforce that reflects its patient demographic makes healthcare more comfortable for every patient, several studies, including a Joint Commission report on cultural diversity, have shown.

But finding a doctor, especially a Black doctor, isn’t always easy, particularly in diverse, poor, or rural communities where doctors generally won’t work—but NPs will.

While most physicians will specialize in something more lucrative than primary care, 88% of NPs are certified in an area of primary care, and 70.3% of all NPs deliver primary care, according to the National Association of Nurse Practitioners (AANP).

Regardless, many states continue to limit NPs’ FPA, often on the basis of physician concerns about quality of care. The American Medical Association and other physician groups argue collaborations are needed for patient safety.

“Full practice authority is a costless way of helping communities of color address healthcare access disparities.”

Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.


More than half of the states have granted full practice authority.

Black and Asian nurse practitioners serve more Black Medicare beneficiaries after receiving FPA.

Many states limit NPs’ FPA, usually because of physicians’ concerns about quality of care.

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