Nurse Practitioners Still Face Barriers In Most States; States East of The Mississippi Are Most Restrictive Only 5 States Grant Full Authority; Illinois And Hawaii Don't Recognize Nps

BUFFALO, N.Y. -- While nurse practitioners are considered part of the solution to physician shortages, many states still place restrictions on their practice, according to a study by researchers in the University at Buffalo School of Nursing.

The UB study is the first to paint a geographic picture of nurse-practitioner concentration and sketch out the barriers to practice which, if removed, could stimulate these primary-care providers to relocate in areas where they are needed most.

It showed that Illinois and Hawaii, the most restrictive of the 50 states, do not legally recognize nurse practitioners as a group.

The study found the U.S. had 33,178 nurse practitioners as of last spring. It also showed:

• Only 5.5 percent work in rural areas that historically have had a physician shortage.

• Only five states -- Alaska, Arizona, Montana, New Mexico and Wyoming -- grant nurse practitioners full authority to prescribe all medications, including controlled substances, with no additional directives or written protocols.

The analysis identified the 10 most-restrictive states to be Illinois, Hawaii, Wisconsin, Ohio, Alabama, Michigan, Massachusetts, Maine, Arkansas and Louisiana.

The 10 least-restrictive states were Wyoming, Arizona, Oregon, North Dakota, New Hampshire, Alaska, Washington, New Mexico, West Virginia, Montana and Iowa.

"Many studies have shown that nurse practitioners can provide quality care at substantially lower cost than physicians," said Patricia Burns, Ph.D., head of UB's nurse- practitioner program and director of the study.

"Thus, an argument can be made that nurse practitioners are cost-effective for improving access to health care, especially in rural regions and in other areas where there is a scarcity of physicians. However, the current legislative environment limits the effect nurse practitioners may have on the nation's health-care crisis."

The research was funded by the Federal Office of Rural Health Policy and conducted under the auspices of the New York Rural Health Research Center at UB.

To collect information on all nurse practitioners, the researchers had access to the licensing records of each state and the District of Columbia, which enabled them to pinpoint the location of each nurse practitioner by county.

Their analysis revealed major concentrations of nurse practitioners on the East and West Coasts, with a scarcity in the heartland.

California and New York had the most nurse practitioners -- 5,770 and 3,062, respectively -- while some western states had fewer than 100. Eighty-five percent were located in metropolitan areas, 9.5 percent worked in less populated surrounding townships and only 5.5 percent were located in underserved, rural areas.

To develop a profile of restrictiveness, researchers analyzed each state's laws regarding the practice of nurse practitioners. Restrictiveness was rated in nine categories: legal recognition, standards of practice, prescriptive authority, educational requirements, certification-examination requirements, continuing-education requirements, temporary practice, grandfather clause exempting nurse practitioners from new regulations and private-insurance reimbursement.

Prescriptive authority, legal recognition and standards of practice all determine the extent to which nurse practitioners can practice independently, Burns said.

"If nurse practitioners are required to practice within a structured physician relationship, independent practice is legally impossible," she stated. "If they are not able to practice independently, their usefulness in solving the shortage of primary health-care providers is limited."

Additional statistics showed that 41 of 50 states have a specific definition of nurse practitioner in their laws; 20 states allow nurse practitioners to be reimbursed directly by third-party insurers, and central and western states allow nurse practitioners more latitude than states east of the Mississippi.

A third phase of the study, currently under way, is a national survey of nurse practitioners to assess job satisfaction, scope of practice and barriers to practice. Researchers will compare responses from rural and urban participants. Information from all facets of the study will be made available to state and national health policy makers for their use in improving the delivery of health care to rural populations, Burns said.

Other members of the research team were: Thomas Nochajski, Ph.D., of the Research Institute on Addictions, and Edward Pristach, Ph.D., and Melissa Fingar, both of UB.