The United States is facing a health care provider shortage,

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1 An Assessment of Physician Supervision of Nurse Practitioners Nancy Rudner, DrPH, NP, and Ying Mai Kung, DNP, NP In 21 states, nurse practitioners (NPs) have full practice authority; they are licensed to practice and prescribe without physician oversight. The other 29 states require some level of physician supervision. The authors used an anonymous, online survey to determine the patterns of physician supervision of NPs in Florida and the relationships between physician supervision, practice setting, and NP characteristics. Physician supervision was measured by three factors: the percentage of time the physician is on site, the percentage of medical records reviewed, and the percentage of patients requiring consultations. The relationships among these factors and NP characteristics (sex, race, education, experience) and practice setting were examined. NPs with more experience and those with doctorate degrees worked without a physician on site more often, had fewer patient records reviewed, and were required to consult on fewer patients than those with less experience or without a doctorate. However, some NPs with no experience had no physician oversight, whereas some NPs with more than 20 years of experience had extensive oversight. Males were more likely to practice without a physician on site and had fewer records reviewed. Keywords: Full practice authority, nurse practitioner, nursing regulation, physician supervision, scope of practice The United States is facing a health care provider shortage, especially in primary care (Buerhaus, DesRoches, Dittus, & Donelan, 2015). Nurse practitioners (NPs) can meet the need for more primary care clinicians, but restricted practice authority limits their ability (Yee, Boukus, Cross, & Divya, 2013; Federal Trade Commission, 2014; Kuo, Loresto, Round, & Goodwin, 2013). NPs with master s or doctorate degrees provide primary, specialty, and acute care, with a given advanced practice role and a population focus area (National Council of State Boards of Nursing [NCSBN], 2008). The majority are trained in primary care (Yee et al., 2013). As shown in Figure 1 and Figure 2, in 21 states and Washington, DC, NPs have full practice authority: they are licensed to practice and prescribe without supervision by another professional. In 29 states, however, NPs are required to practice or prescribe medications with some level of physician oversight (NCSBN, 2016a, 2016b). This physician supervision is worded as a collaborative agreement or supervision in different states. Regardless of the wording, oversight requires the involvement of another profession. An NP cannot practice without a formal arrangement with a physician, or in some states, another professional, such as a dentist. Multiple organizations including the Institute of Medicine, the National Governors Association, and the NCSBN have called for NPs to practice to the full extent of their education and training, removing supervisory or collaborative agreement limitations (Institute of Medicine, 2011; National Governors Association, 2012; NCSBN, 2008). Full-practice authority for NPs is seen as an avenue to increase health care access and innovation without compromising quality in health care. Research supports these positions. Full-practice authority is linked to a larger supply of NPs (Reagan & Salsberry, 2013), greater access to care (Stange, 2014), and fewer avoidable hospitalizations and hospital readmissions (Oliver, Pennington, Revelle, & Rantz, 2014). NPs in states with full practice and prescribing authority are more likely to practice in primary care (Westat, 2015), in rural areas (Buerhaus et al., 2015), and with Medicaid patients (Buerhaus et al., 2015). Full-practice authority for NPs is also associated with lower ambulatory care costs (Perloff, DesRoches, & Buerhaus, 2016). Multiple analyses have found NPs provide high-quality care (Stanik-Hutt et al., 2013; Swan, Ferguson, Chang, Larson, & Smaldone, 2015). Both the Institute of Medicine and the National Governors Association reports recognize that states requirements for NPs to be supervised by another profession have no foundation in evidence (Institute of Medicine, 2011; National Governors Association, 2012). Nonetheless, the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP) maintain that the NP should function only under physician supervision (AAFP, 2013, 2014; AAP, 2013, 2016). AAFP advises physicians to review the NP s work and records on a continuing basis to ensure that appropriate directions are given and understood (AAFP, 2014). The AAFP does not provides evidence 22 Journal of Nursing Regulation

2 to support the organization s position but calls for ongoing supervision and record reviews (AAFP, 2013). AAP declares that the pediatrician should be the leader of the care team and that NPs should work under the pediatrician. But, it neither provides evidence for this stance nor specifies what that supervision should look like (American Academy of Pediatrics, 2013, 2016). Like more than half the states, Florida requires physician supervision over NP practice. Florida NPs are required to have a written collaborative agreement with a physician or dentist on file, with the board of nursing (BON) containing protocols outlining which conditions, procedures, and medications the NP is permitted to manage. The Florida Administrative Code Rule 64b8-35 mandates that NPs shall only perform medical acts of diagnosis, treatment, and operation pursuant to a protocol between the [NP] and a Florida licensed physician, osteopathic physician, or dentist. The degree and method of supervision, determined by the [NP] and the physician or dentist, shall be specifically identified in the written protocol and shall be appropriate for prudent health care providers under similar circumstances. The regulations do not provide specificity on the nature of the supervisory relationship (Florida Administrative Code, 2016). The NP supervision and protocol regulations have not changed significantly since they were written in An Examination of Physician Oversight This descriptive study used an anonymous, online survey to answer the question, What are the patterns of physician supervision of NPs in Florida and the relationships between physician supervision, practice setting, and NP characteristics? Physician supervision was measured by three factors: the percentage of time the physician is on site, the percentage of medical records reviewed, and the percentage of patients requiring consultations. The relationships between these variables and NP characteristics (sex, race, education, years of NP experience) and practice setting were examined. The institutional review boards (IRBs) at both of the authors universities approved the study. The survey was an anonymous, online survey that did not collect identifying information. The IRBs approved the research as expedited and exempt from IRB review. FIGURE 1 Can Certified NPs Prescribe Independently? WA OR CA NV CNMI ID UT AZ AK MT GU WY CO NM Independent Not independent AS ND MN ME SD WI MI NH IA NY NE VT IL IN OH PA MA CT RI KS NJ MO WV KY VA DE OK TN NC AR MD SC DC LA MS AL GA TX HI Source: National Council of State Boards of Nursing (2016a, 2016b). FIGURE 2 Can Certified NPs Practice Independently? WA OR CA NV CNMI ID UT AZ AK MT GU WY CO NM Independent Not independent AS ND MN ME SD WI MI NH IA NY NE VT IL IN OH PA MA CT RI KS NJ MO WV KY VA DE OK TN NC AR MD SC DC LA MS AL GA TX HI No data Source: National Council of State Boards of Nursing (2016a, 2016b). Methodology Building on a survey deployed by the Florida Coalition of Advanced Practice Nurses (FCAPN) in 2012 that explored Florida advanced practice nurses perceptions of practice barriers and political activism, the authors developed survey questions to examine NP supervision as well as NP views of barriers and advocacy. The 24 questions in the 2015 survey included six questions regarding clinical practice and supervision for those currently providing NP care; three questions each regarding nursing organizations, practice barriers, and advocacy; and eight demographic questions. In the qualitative component of the survey, respondents could supplement their quantitative responses with text comments. The survey was pilot tested by members of the FCAPN for content validity and reliability. In September 2015, an invitation to participate in the survey and a link were ed to the 8,524 NPs who had both a Florida mailing address and an address on file with the Florida BON. After the initial invitation, a series of three FL FL VI VI Volume 7/Issue 4 January

3 reminder s were sent to nonresponders. Additionally, some member organizations of FCAPN ed an invitation to participate and the survey link to their members. Some FCAPN member organizations also posted the invitation to participate on their website. Of the 8,524 NPs, 935 (11%) completed the survey. The achieved sample size had a 3.02% margin of error at a 95% confidence level. The study analyzed the responses of the 857 Florida NPs who reported currently providing direct patient care as an NP. The dependent variables were three NP-reported measures of physician oversight: Percentage of time the physician is on site when the NP is seeing patients TABLE 1 Sample Demographics of Sample Compared to Demographics of Florida NPs Variable Survey Florida NPs Responses Sex Women 91% 91% Men 9% 9% Race/Ethnicity White, not Hispanic 84% 70% Other than White, non-hispanic 16% 30% Age > 50 57% 44% Education Doctorate 19% 5%* Master s 79% 79%* Note. NP = nurse practitioner. *Data for education are based on all APRNs in the state, not just NPs. NPspecific data were not available. Percentage of patient medical records reviewed by the physician Percentage of patients for whom the physician requires a consultation. Additionally, a composite dependent variable, no physician oversight, was defined as having none of the three components of physician oversight. The independent variables in the study were respondentreported sex, race, education, years of NP experience, and practice setting. Stata 2012 was used to calculate descriptive statistics and to tabulate correlations. Relationships among categorical data were examined and tested using chi-square tests of association. Differences among population means for continuous variables (e.g., the percentage of time a physician is on site by sex, education level, etc.) were tested using ANOVA and t tests. Regression analyses examined the combined relationships of sex, race, setting, NP experience, and education on the dependent variables measuring physician oversight. Sample Table 1 shows the sample characteristics. The study subjects were similar to the state profile for the NP population (Florida Center for Nursing, 2016). The respondent sample had more white (84% versus 70%) and older (57% over age 50 versus 44%) NPs than the state but had the same proportion of women (91%). The majority (79%) of respondents highest degree was a master s degree, similar to the state data for education of advanced practice registered nurses (APRNs), which encompasses NPs, nurse midwives, and nurse anesthetists. Almost one in five (19%) respondents had a doctorate in nursing or another field, much higher than the state rate of 5% for APRNs. The remaining 2% were older NPs with less than a master s degree but with an average of 29 years of experience. Survey respondents had a range of NP experience from 0 to 43 years; the average was 12 years. The range of nursing experience was 0 to 56 years; the average was 24 years. The majority (55%) practiced in ambulatory care 33% in private and 22% in public settings. Newer NPs were more likely than more experienced NPs to work in private ambulatory care settings, and those with more than 20 years of experience were more likely to work in public ambulatory settings and home health, hospice, and longterm care. Findings The data revealed wide variability and inconsistency in the supervision of NPs in Florida, as detailed below. Each measure of supervision percentage of time the physician on site, percentage of records reviewed, and percentage of required consults ranged from 0 to 100%, across the spectrum of NP experience. Males worked without a physician on site more often and had fewer record reviews than females. NPs with doctorates worked without a physician on site more often, had fewer record reviews, and fewer required consults than NPs without a doctorate. Twelve percent of respondents worked with no physician on site, no record reviews, and no required consults. For these NPs, the only associate factors in bivariate analysis was setting; years of experience were not. Supervision The relationships between the independent and dependent variables are shown in Tables 3 and 4. On average, NPs practiced with a physician on site almost half the time (49%). One in five NPs (19%) worked with a physician on site all of the time, and 26% always worked with no physician on site, although the frequency of physician presence on site ranged from 0 to 100% for all levels of experience. The average percentage of patient medical records reviewed by the physician was 42%, ranging from 0 to 100%, although respondents pointed out that a review could be a perfunctory signature or a check off. Twenty-four percent report no record reviews; 28% had 100% record reviews or signatures. On average, supervising physicians required that the NP consult 24 Journal of Nursing Regulation

4 on 17% of patients, with a range from 0 to 100%. Sixty percent of NPs surveyed had no required consultations. Almost one out of eight (12%) NPs worked with no routine physician oversight; they had no physician on site, no medical record review, and no required consultations. The 146 comments from respondents provide more texture to the nature of the physician-np supervisory relationship. Of the 146 who opted to write comments on the survey, 12 stated a cosignature was required on every record by the electronic medical record, insurance, or the facility. Five reported that the physician sees the patient for the last few minutes of the visit. Ten NPs identified specific tasks for which the physician requires a consultation, such as electrocardiograms or radiograph interpretations, certain procedures, emergency and hospital admissions, and referrals. Thirteen reported the only consults with the supervising physician are those required by state or federal regulations, such as for controlled substances or home health. Fourteen of the writein comments state they consult with the physician as needed, or based on patient acuity. Twenty-eight percent of respondents reported that physicians reviewed 100% of the records, but ten NPs reported that, in reality, the physicians simply sign 100% of the records with minimal or no review. As one NP reported, [Medical records] are co-signed for billing purposes only. Therefore, the physician signs, but hardly ever reviews. In some hospitals, the electronic medical record requires a physician to sign off on the record, but it may occur without any review. Twenty-six NPs described weekly or monthly meetings with the supervising physician or the ability to consult as needed. Fifteen NPs wrote of a collaborative consultative relationship with the physician or the availability to consult as needed. One NP wrote, My physician and I collaborate. We discuss cases and try to find the best practice. One NP wrote that she frequently consults with a physician who is in the office with her, but never sees the supervising physician. A psychiatric nurse practitioner, supervised by a primary care physician, wrote that her collaborating physician more often consults with her and refers patients with mental health needs to her because he was not as familiar with psychiatric care, rather than her consulting with him. Among those who wrote additional comments, 17 stated they had no relationship with the supervising physician or a relationship only as required by law (for a collaborative agreement, sign for controlled substances, or home health care.). One NP wrote, I am not even sure if my supervising physician even knows who I am. We have never met and certainly never practiced together. Another wrote, There is no supervision or collaboration. I have never met my collaborating physician and he does not come to the clinic in which I work. He signs DME [durable medical equipment] orders for reimbursement but only after I sign them! He never sees my patients. Another found the supervising physician s involvement to be minimal: He only comes in once a week to sign prescriptions [and is] here less than 15 minutes. Another NP wrote of her supervising physician, I only consult with him when needed, maybe two or three times a year. Sex, Education, Years of NP Experience, Practice Settings, and Physician Oversight Sex was significantly associated with the level of physician supervision, but race was not. Male NPs, on average, worked less time with a physician on site compared with female NPs (36% versus 51%). Male NPs also had fewer records reviewed on average (26% versus 43%). The percent of required consults did not differ by sex. Also, males and females were equally likely to practice with no routine oversight. NPs with doctorates worked with a physician on site less frequently than NPs without doctorates (38% versus 53%). They also had fewer records reviewed (33% versus 44%) and fewer required consultations (11% versus 18%). They were also more likely to work with no physician oversight (17% versus 10%). Years of NP experience were inversely associated with the extent of physician supervision with regard to physician on site, record review, and required consult. NPs with fewer years of experience were more likely to have a physician on site when they saw patients, have more patient cases reviewed, and have more required consultations. However, at all levels of experience, the supervision ranged from 0 to 100%. Among new NPs, 12% worked with no physician on site while 29% always worked with the physician on site. Among NPs with 21 years or more of experience, 35% worked without a physician on site, and 11% always had a physician present (Table 4). Almost 18% of NPs with 0 to 2 years of NP experience had no medical record review, while 20% of NPs with 21 or more years of NP experience had 100% of their medical records reviewed. Almost half (47%) of NPs with 0 to 2 years of experience were not required to consult with the physician, compared with 73% of those with 21 or more years of experience. However, 11% of the newer NPs (0 to 2 years of experience) were required to consult with their supervising physician on 100% of their patients compared with 6% of the seasoned (21 years or more of experience) NPs. Furthermore, years of NP experience was not associated with having no physician oversight, that is, no physician on site, no record review, and no required consultations. NPs with no experience were just as likely as NPs with more than 20 years of experience to work without routine physician oversight. Practice settings were associated with the percentage of time the physician was on site (Table 2) and with the composite variable of having no routine physician oversight. As expected, physicians were on site most often in hospital and hospital-affiliated settings and least often in home health, hospice, and longterm care settings. NPs in private ambulatory settings worked with the physician on site more often, on average, than NPs in public ambulatory settings (62% versus 41%). The practice setting was not correlated with the percentage of records reviewed or consultations required. NPs working in home health, hospice, Volume 7/Issue 4 January

5 TABLE 2 Practice Characteristics of Respondents Variable Survey Responses NP Experience Average 12 years Range 0 43 years 0 2 years 17% 3 5 years 16% 6 10 years 17% years 32% 21 years 18% Practice Setting Ambulatory, private 34% Ambulatory, public 22% Hospital-affiliated 23% Home health, hospice, and long-term care 20% or long-term care were most likely (30%) to have no physician oversight. NPs in public ambulatory care worked with no physician oversight twice as often as NPs in private ambulatory care (15% versus 7%). In multivariate regressions (Table 5), the practice setting, male sex, more years of NP experience, and a doctorate degree were inversely associated with the percentage of time a physician was on site. Regression analysis also showed that male sex, years of NP experience, and a doctorate were significantly and inversely associated with the percentage of records reviewed, but the setting was not a significant factor. Years of NP experience, a doctorate degree, and the setting were significant variables in the percentage of required consultations, but sex was not. Working with no physician oversight (no physician on site, no record reviews, and no required consults) was influenced by the setting and a doctorate, but not by years of NP experience. Although males were more likely to have doctorates than females (46% versus 23%), both sex and education were statistically significant variables in the regression analyses for percentage of time physician is on site and the percentage of records reviewed. Having a doctorate was associated with practice setting; 30% of NPs with doctorates worked in public ambulatory care, and 32% worked in home health, hospice, or long-term care. Both having a doctorate and setting were statistically significant factors in the regression for physician on site and percentage of required consultations. The setting was not a statistically significant factor for required record reviews in the regression, but having a doctorate and years of NP experience were significant. Some NPs encountered barriers to care for their patients stemming from requirements for physician signatures or from different perspectives on patient needs. One NP has a supervising physician 4 hours away, so signing for home health, as required by Medicare, delays care. Another observed that her supervising physician would not sign for diabetic shoes for her patients, a need she would respond to if she had professional autonomy. Discussion This descriptive study sought to identify the patterns of physician supervision of NPs in Florida and the relationships between physician supervision, practice setting, and NP characteristics. This study found that state regulations requiring supervision by physicians over NPs are unevenly applied. This variability and inconsistency in the supervision of NPs that was revealed by the data may reflect the preferences of individual physicians or NPs, institutional policies, billing requirements, the logistics of the settings, or sex biases. Physician groups have argued that supervision is needed to ensure quality. No study has demonstrated that physician supervision of NPs improves quality (Federal Trade Commission, 2014; Institute of Medicine, 2011). However, professional standards, certifications, credentialing systems, institutional policies, accreditation standards such as those of the Joint Commission, and legal liability are direct strategies for ensuring quality of care (Summers, 2016). Inconsistent supervision can also raise the cost of care because it introduces a hidden physician tax to care, incurring costs either directly (payment to the supervising physician) or by consuming physician time unnecessarily. The perfunctory signing of medical records described by respondents in this study does not serve a clinical quality purpose, misuses the talents and time of physicians, and increases the cost of care. The Florida Legislature s Office of Program Policy Analysis and Government Accountability (2010) estimated that removing required physician oversight of NPs and physician assistants could yield a savings of $339 million across the state s health care system, including $7 to $44 million in Medicaid and $700,000 to $2.2 million in state employee health insurance costs. With inflation, it is likely that these costs, which were estimated in 2010, have increased. Furthermore, required physician involvement in NP practice may create access barriers (Federal Trade Commission, 2014; Kuo et al., 2013). NPs provide more care to Medicare beneficiaries in states with full-practice authority (Kuo et al., 2013). In states requiring physician supervision, NPs are limited to practicing where they can find a physician willing to be the supervising physician. In 2014, the Federal Trade Commission wrote that physician supervision requirements imposed on NPs are anticompetitive and can restrict consumers access to health care services (2014). The Federal Trade Commission also noted that lack of competition can block the development of new models of health care delivery. Regulatory choices that affect [NP] scope of practice may have a direct impact on health care prices, quality, and innovation, often without countervailing benefits. (Federal Trade 26 Journal of Nursing Regulation

6 TABLE 3 How Physician Oversight Varies with NP Characteristics and Practice Settings NP Characteristics % of time physician was on site (average) % of medical records reviewed (average) % of required consults (average) % of NPs with no physician oversight* All Range Sex, p value <.01 < Male Female Race, p value White Not white Education, p value <.01 <.01 < Doctorate No doctorate Years of NP experience, p value <.01 <.01 < years years years years years Setting, p value < <.01 Ambulatory, private Ambulatory, public Hospital-affiliated Home health, hospice, long-term care Note. NP = nurse practitioner. *No physician oversight: no physician on site, no medical record review, and no required consultations. Commission, 2014). Requiring that medicine or dentistry supervise limits the ability of nursing to develop innovative models of care, such as hospital-to-home transitions or in-home primary care for patients unable to travel, unless they can find a physician willing to be the collaborating physician for the record. The Federal Trade Commission s (2014) examination of NP regulation found supervisory or collaborative practice agreement requirements can be inconsistent with a truly collaborative and team-based approach to health care. Professional consultations and collaborations are essential and necessary elements in providing high-quality, patient-centered care, as no one health care provider possesses adequate knowledge to care for an entire spectrum of health care conditions. Health care providers rely on intra- and interprofessional consultations and collaborations that can benefit patients with a wider pool of expertise and to provide the best care for their patients. A common theme found in the present study is that NPs reported that they routinely consult with physicians as needs arise. This practice enables all professionals time and expertise to be used appropriately and ensures that precious physician resources are not wasted on activities that do not impact health outcomes positively. Mandatory, inconsistent supervision creates a hierarchy that works against effective interprofessional teamwork. Professional collaboration, not a supervisory relationship, is the element that builds on the strengths and perspectives of each profession and that improves the quality and safety of patient care (Interprofessional Education Collaborative, 2011). Limitations Physician presence on site, review of medical records, and required consultations are just three aspects of supervision that this study examined. Other possible components of the supervising relationship not in this study are the supervising provider s role in establishing standing orders or protocols, the extent to which the supervising provider is available for consultation, and the frequency of established routine meetings for case reviews and consultations. Volume 7/Issue 4 January

7 TABLE 4 Physician Oversight of NPs with 0 to 2 Years of Experience and Those with 21 or More Years of Experience Years of NP experience TABLE 5 Regression Analyses of the Impact of Sex, Setting, Experience, and Education on Extent of Physician Oversight of NPs Variable % of time physician was on site Percentage of time physician was on site % of records reviewed Percentage of records reviewed % of patients that required consultations Percentage of patients that required consultations % with no physician oversight 0% 100% 0% 100% 0% 100% 0 2 years years All Note. NP = nurse practitioner. No physician oversight Coef. p > t Coef. p > t Coef. p > t Coef. p > t Female Setting Years of NP Experience Doctorate Constant Note. NP = nurse practitioner, coef = correlation coefficient The information is reported by NPs and reflects their perceptions of their work environment. Some response options may have not been a close fit with the NP s situation. For example, medical record review could be a thorough review of the patient s need and care plan or a perfunctory signature with no review. Also, respondents may have participated in the survey more than once. The BON mailing list in Qualtrics did not allow duplicates, but an NP could have accessed the survey through the Qualtrics as well as through a link sent from one of the participating organizations. The response rate was 11%. At the 95% confidence level, the margin of error was 3.02%. Possibly, the findings are not representative of NPs in Florida, although the profile of respondents aligned with the statewide profile of NPs demographically. The respondent sample had more doctorate degrees than NPs statewide, which may have influenced the findings, as education was inversely associated with supervision. Because this study examined physician oversight of NPs in one state, the findings may or may not relate to supervision in other states due to variations in NP and population demographics, as well as NP regulations from state to state. Another limitation may be the survey instrument; given the wide variation of supervision scenarios, the quantitative multiple-choice responses may not have fit some of the situations. Conclusion This study reveals that supervision is often a legal formality and financial arrangement that is not consistently applied. Physician supervision of NPs is not supported by evidence in the literature. Supervision can add to the cost of care, either through a payment to the supervising physician and/or physician time. As the nation shifts toward an era of interdisciplinary care teams providing patient-centered care, the unique contributions of nurse practitioners can create new delivery models that meet community and patient needs. The dramatic transformation of care that is occurring calls for legislators and regulatory bodies to examine and use the evidence and to address health care delivery by qualified, licensed, and competent professionals across disciplines. References American Academy of Family Physicians. (2014). Nurse practitioners. Retrieved from American Academy of Family Physicians. (2013). Guidelines on the supervision of certified nurse midwives, nurse practitioners, and physician assistants. Retrieved from American Academy of Pediatrics (2016). AAP publications reaffirmed or retired. Pediatrics, 137(2). Retrieved from aappublications.org/content/137/2/e Buerhaus, P. I., DesRoches, C. M., Dittus, R., & Donelan, K. (2015). Practice characteristics of primary care nurse practitioners and physicians. Nursing Outlook, 63: Federal Trade Commission. (2014). Policy perspectives: Competition and the regulation of advanced practice nurses. Retrieved from policy/reports/policy-reports/commission-and-staff-reports Florida Administrative Code. (2016). Rule 64B : Standards for Protocols. Retrieved from asp?id=64b Florida Center for Nursing. (2016). Florida s advanced registered nurse practitioner supply: workforce characteristics and trends. Retrieved from 2mind/DMX/Download.aspx?Command=Core_Download&EntryI d=1196&portalid=0&tabid=151 Florida Legislature s Office of Program Policy Analysis and Government Accountability. (2010). Expanding scope of practice for advanced registered nurse practitioners, physician assistants, optometrists, and dental hygienists [Research memo]. Retrieved from org/arnpcorner/arnpdocs/oppagascopeofpracticememo.pdf Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from Interprofessional Education Collaborative. (2011). Core competencies for interprofessional collaborative practice (p. 22). Retrieved from ipecollaborative.org/uploads/ipec-core-competencies.pdf 28 Journal of Nursing Regulation

8 Kuo, Y., Loresto, F., Round, L., Goodwin, J. (2013). States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Affairs, 32(7): doi: /hlthaff National Council of State Boards of Nursing. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from APRN_Regulation_July_2008.pdf National Council of State Boards of Nursing. (2016a). Independent practice map-cnp. Retrieved from (These maps have been listed as two separate references.) National Council of State Boards of Nursing. (2016b). Independent prescribing map CNP. Retrieved from National Governors Association. (2012). The role of nurse practitioners in meeting increasing demand for primary care. Washington, D.C: Author.. Retrieved from main-content-list/the-role-of-nurse-practitioners.html Oliver, G., Pennington, L., Revelle, S. & Rantz, M. (2014). Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nursing Outlook, 62(6): Perloff, J., DesRoches, C., Buerhaus, P. (2016). Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians. Health Services Research. 51(4): doi: / Reagan, P. & Salsberry, P. (2013). The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners. Nursing Outlook, 61(6): doi: /j.outlook Stange, K. (2014). How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants. Journal of Health Economics, 33:1 27. Stanik-Hutt, J., Newhouse, R., White, K., Johantgen, M., Bass, E., Zangaro, G., Weiner, J. P.. (2013). The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners, 9(8): Retrieved from Summers, L. (2016, May). Positioning the NP for a changing healthcare environment. Presented at the 17th Annual Advanced Practice Nurse Conference, Philadelphia, PA. Swan, M., Ferguson, S., Chang, A., Larson, E., & Smaldone, A. (2015). Quality of primary care by advanced practice nurses: A systematic review. International Journal for Quality in Health Care, 27(5): doi: /intqhc/mzv054 Westat. (2015). Impact of state scope of practice laws and other factors on the practice and supply of primary care nurse practitioners final report contract number: HHSP WC. Retrieved from gov/sites/default/files/pdf/167396/np_sop.pdf Yee, T., Boukus, E., Cross, D., & Divya, R. (2013). Primary care workforce shortages: Nurse practitioner scope-of-practice laws and payment policies (National Institute for Health Care Reform Research Brief 13). Retrieved from Nancy Rudner, DrPH, NP, is part-time faculty, School of Nursing, George Washington University, Washington, DC. Ying Mai Kung, DNP, NP, is Senior Teaching Faculty, College of Nursing, Florida State University, Tallahassee. Volume 7/Issue 4 January