8 Pros and Cons of Full Practice Authority for Nurse Practitioners


Written By: Donna Reese MSN, RN, CSN


Becoming a nurse practitioner has been touted as the pinnacle of nursing careers. Our profession has even ranked as the top job in the medical field on numerous occasions. Indeed, there are many great aspects of being a nurse practitioner. And having full practice authority as an NP certainly seems to be the best of the best when it comes to how we can practice.

But there is a downside to full practice authority as well. As with any career details, you may wonder about the good and the bad. So, what are the pros and cons of full practice authority for nurse practitioners? Here’s a rundown of the top 8 pros and cons of full practice authority for nurse practitioners to clearly illustrate the good, the bad, and the ugly for this least restrictive state guideline for NPs.



WHAT EXACTLY DOES NP FULL PRACTICE AUTHORITY MEAN?


The American Association of Nurse Practitioners describes full practice authority as “the authorization of nurse practitioners (NPs) to evaluate patients, diagnose, order and interpret diagnostic tests and initiate and manage treatments — including prescribing medications — under the exclusive licensure authority of the state board of nursing”. NPs in this category can also open independent solo practices without physician oversight.

This freedom to practice as we see fit is a far cry from the original restrictive authority that pioneer NPs were under. We were seen as “physician extenders” only and were heavily supervised by our physician overseers. However, there are still some states and practices where nurse practitioners still function in the dark ages. Fortunately, the landscape for our profession continues to evolve for the better.



WHAT STATES CURRENTLY HAVE FULL PRACTICE AUTHORITY FOR NURSE PRACTITIONERS?


Currently, the scope of practice for nurse practitioners varies from state to state. NPs can celebrate that over half of the states (26) now allow full practice authority for their profession. It has been a long time coming.

Recently one more victory can be added to the list. Starting in 2023, some California nurse practitioners may practice independently only if it is determined that they are in good standing for at least 3 years. At that point, they are eligible to apply for a 104 NP license (license to practice independently). Thus, new grad NPs will not be eligible for full practice authority for their first 3 years in the profession.

Full Practice Authority
Alaska Arizona Colorado Connecticut Delaware
Hawaii Idaho Iowa Kansas Maine
Maryland Massachusetts Minnesota Montana Nebraska
Nevada New Hampshire New Mexico New York North Dakota
Oregon Rhode Island South Dakota Vermont Washington
Wyoming
(Source: American Association of Nurse Practitioners)



WHAT STATES CURRENTLY DO NOT HAVE FULL PRACTICE AUTHORITY FOR NURSE PRACTITIONERS?


There are 13 states that are reduced practice authority for nurse practitioners. Eleven states fall into the restricted practice category for NPs.

Fortunately, this list of nurse practitioners who do not have full practice authority is getting smaller each year. As explained above, California (CA) is the newest state to grant full practice authority (with specific stipulations). But due to the unusual restrictions placed on NPs in this state, CA also shows up as a restricted practice state.

Reduced Practice Authority
Alabama Arkansas Illinois Indiana Kentucky
Louisiana Mississippi New Jersey Ohio Pennsylvania
Utah West Virginia Wisconsin

Restricted Practice Authority
California Florida Georgia Michigan Missouri
North Carolina Oklahoma South Carolina Tennessee Texas
Virginia



(Source: American Association of Nurse Practitioners)



WHAT ARE THE TOP CONS OF FULL PRACTICE AUTHORITY FOR NURSE PRACTITIONERS?

(The following are the top 8 disadvantages of full practice authority for nurse practitioners.)


CON #1: Increased Responsibility.


One of the biggest disadvantages of full practice authority is that you may have more responsibility heaped on you at work. Depending on your particular situation, you may need to oversee staff. Also, you will be expected to take on a full load of patients while working independently instead of more of a team model where the burden is shared.


CON #2: Increased Liability.


When NPs go solo or autonomously at work, accountability increases. As the saying goes, “the buck stops here”; it is true regarding lawsuits. You will be named as the primary provider in a lawsuit if your patient is suing. NPs with full practice authority can no longer hide behind the apron strings of a physician in this instance. This point is one of the scarier cons of full practice authority for nurse practitioners causing many to second guess their career choice.


CON #3: Physician Resistance.


Although the state gives you the green light to work independently, there still is bound to be some pushback and possible resentment from physicians. This is especially true in the states that have come on board recently with full practice authority status for NPs. For example, as California comes on board with increased autonomy for their nurse practitioners, it may take a while before physician doubts are quelled.


CON #4: Patient Resistance.


Some uninformed patients still see NPs as RNs. Many request to see “the doctor” when a nurse practitioner walks into the treatment room. This resistance (and ignorance) can be one of the top cons of full practice authority for nurse practitioners who plan to set up a solo private practice. They simply may not get enough patients because people do not see them as a medical authority that can operate without a physician.


CON #5: Less Consultation.


Sometimes consulting with your supervising physician is a good thing. The intent is that there are checks and balances built in for patient safety. Due to this consultation, you are apt to learn in the process. Since 2 heads are better than one in many instances, a team approach benefits both the patient and NP.

When you have full practice authority, whether in your own practice or within a group, there is less need to discuss patient care. This factor is not always good for you or the patient for the reasons listed above.


CON #6: Higher Liability Insurance.


Liability insurance is still reasonable in many states with restricted or reduced practice authority. However, the insurance may be more costly in full-practice authority states. The reason is that some malpractice insurance is procedure-driven, not specialty driven. That means the more you are allowed to do, the higher the insurance. Premiums are determined by the menu of services and procedures that you provide as a practitioner. Also, NPs owning a private practice need business coverage, not just individual coverage, driving the costs even higher.


CON #7: Increased Educational Requirements.


Many states with full practice authority only grant this privilege with the stipulation of additional educational requirements. Typically, this feature pertains to academic requirements for medication, particularly schedule II drugs. Some states require additional training before permission is granted to open an independent practice.


CON #8: Increased Stress.


Increased responsibility usually translates to more stress. Nurse practitioner burnout caused by stress can be even higher in NPs with full practice authority due to a heavier physical and emotional burden at work. Although it is glorious to have the freedom to operate autonomously, the drawback of all of the responsibility may dim the bright outlook for an NP. Thus, increased stress is one of the bigger cons of full practice authority for nurse practitioners.



WHAT ARE THE TOP PROS OF FULL PRACTICE AUTHORITY FOR NURSE PRACTITIONERS?

(The following are the top 8 advantages of full practice authority for nurse practitioners.)


PRO #1: Patients’ Health Benefit.


According to studies, nurse practitioners with full practice authority have proven to benefit the health outcomes of Medicaid and Medicare patients. Aren’t improved patient outcomes the ultimate goal of healthcare? This critical revelation is possibly one of the biggest advantages of full practice authority for nurse practitioners.


PRO #2: Positive Job Outlook.


With an anticipated 54% job growth expected in the next decade, the nurse practitioner job outlook is undoubtedly good. Although all NPs are in demand, those with full practice authority have more options in their career, making them even more marketable.


PRO #3: Improved Access to Care.


It’s no secret that there are gaps in medical care across the US. Underserved and rural areas are challenged to find providers willing to move to remote or undesirable locales. NPs with full practice authority can fill these gaps without having to employ hard-to-find physicians to give oversight of the practice. It’s a no-brainer, win-win situation. Providing access to care for areas where no healthcare would be available is one of the top pros of full practice authority for nurse practitioners.


PRO #4: Streamlined Care Process.


How annoying is it to go to your supervising physician to sign off on scripts and referrals in the middle of a busy workday? Depending on where you work, there may be other delays due to NP state requirements that further bog down your patient flow. With full practice authority, you can seamlessly see your patients and provide any necessary follow-up and treatment without waiting for a physician to approve or do the job for you. The American Association of Nurse Practitioners points out that a less cumbersome routine will positively impact your patients and practice.


PRO #5: Reduced Cost.


It has been proven that NPs provide excellent care at a lower cost than physicians. When an NP can fill a physician gap without needing oversight, costs go down. An important review of healthcare costs in California demonstrated that “granting full practice authority to nurse practitioners has been found to help control healthcare costs and expenses”.


PRO #6: Increased Treatment for Addiction.


We are all aware of the unfortunate lack of adequate addiction treatment. Having full practice authority to treat and medicate substance abusers frees up more NPs to work in this field. Expanding the opioid treatment workforce by having trained NPs in areas with a high prevalence of opioid abuse makes sense. Increased access to opioid treatment centers is one of the pros of full practice authority that is hard to argue against.


PRO #7: Improved Patient Satisfaction.


Studies show that the more NPs hired, patient satisfaction increases. Having nurse practitioners who can fully provide care without physician input streamlines wait time and patient interaction with the NP. Nurse practitioners have proven to be excellent educators and patient-centric providers, which please patients and result in better health outcomes.


PRO #8: Self-Satisfaction.

One of the more significant pros of full practice authority for nurse practitioners is the thrill you feel when you work autonomously. You can be proud of yourself for your hard work and expertise as you fully utilize your skills as an independent practitioner. An interesting study showed that NPs are much happier than their physician counterparts. This happiness may be due in part to having the ability to realize their potential as an NP.



SHOULD NURSE PRACTITIONERS HAVE FULL PRACTICE AUTHORITY – MY FINAL THOUGHTS


Coming from a state with restricted practice authority, I have hands-on experience working with a supervising physician. Although I needed and appreciated the guidance of a mentor/supervising physician as a new grad NP, I eventually began to feel as if my hands were tied at times when I was confident that I could function independently.

For states that are not on board yet with full practice authority for NPs, it makes sense to ask, "what are the pros and cons of full practice authority for nurse practitioners?” By reading the “top 8 pros and cons of full practice authority for nurse practitioners, " you and others will be more informed on this hot topic. As you can see, the pros far outweigh the cons, especially regarding patient satisfaction, ease of access to care, and health outcomes.



FREQUENTLY ASKED QUESTIONS ANSWERED BY OUR EXPERT


1. What Is The Greatest Advantage Of Full Practice Authority For Nurse Practitioners?

Probably the best argument for full practice authority is to fill gaps in access to care in the US. If all states grant NPs this privilege, it would be one of the most significant advantages of full practice authority for NPs.


2. What Is The Greatest Disadvantage Of Full Practice Authority For Nurse Practitioners?

Possibly the biggest disadvantage of full practice authority for an NP is the increased pressure and stress of holding the sole accountability for patients.


3. Why Do NPs Need Full Practice And Prescriptive Authority?

To function at our fullest capacity, we need to be able to operate independently and have full prescriptive authority. Once this is accomplished, we can better meet the needs of our patients quickly and efficiently.


4. What Can NPs Not Do In Full Practice Authority States?

It depends on the state. Even though an NP has full practice authority, each state still has individual guidelines for NPs. Performing major surgery and delivering babies are examples of things doctors can do that nurse practitioners cannot do in any state.


5. In How Many States Can A Nurse Practitioner Practice Independently?

NPs can practice independently in 26 states. Some NPs can practice independently in California if they meet the state guidelines.


6. Is Texas A Full Practice Authority State?

No, Texas is not a full practice authority state. It is still one of the states operating under restricted practice for NPs.


7. Can Nurse Practitioners Work Independently In New York?

In 2022, nurse practitioners in New York were granted full practice authority.


8. Can Nurse Practitioners Practice Independently In California?

As of January 2023, California NPs who have completed 3 years of practice and are in good standing can apply for a permit to practice independently. So, the answer is yes for NPs who meet the state criteria listed above.


9. Why Does Scope Of Practice Laws Vary By State?

Since each state has its own nursing regulatory board, there are differences in the scope of practice from state to state.


10. In Full Practice Authority States, Do NPs Have To Work Under A Doctor?

No, NPs do not have to work under a doctor when licensed and working in a full practice authority state.


11. In What States Can A Nurse Practitioner Open Their Own Practice?

NPs can open their own practice in any state. However, in states that are not full practice authority states, the NP must have a supervising or collaborating physician agreement. The details of this agreement vary from state to state.


Donna Reese MSN, RN, CSN
Donna Reese is a freelance nurse health content writer with 37 years nursing experience. She has worked as a Family Nurse Practitioner in her local community clinic and as an RN in home health, rehabilitation, hospital, and school nursing.