Scope Creep or Full Practice Authority?

Authored by: Grace Bian

Art by: Kain Wang

The subreddit “r/Noctor” is full of individuals lamenting on their experiences with physician assistants (PAs), nurse practitioners (NPs), and other mid-level practitioners. Users of this sentiment generally share the sentiment that mid-level practice expansion (MLPE) has gone too far. 

MLPE refers to a changing shift in health care labor dynamics. Within the United States, NPs and PAs have been given the right to diagnose, treat, and manage patients without the supervision of a physician. Currently, NPs are granted full practice authority in 27 states [1]. This is five more states then there were in 2016 [2].

Much of the legislation advancing MLPE was passed to address provider shortages and increase patient capacity in healthcare settings. For example, the Department of Veteran’s Affairs implemented Directive 1350 in 2016, which enables advanced practice registered nurses (APRN) to “diagnose, treat, and manage patients”, “order laboratory and imaging studies and integrate the results into clinical decision making”, and “prescribe medication” without the clinical supervision of physicians [3]. This directive applies specifically to VA hospitals rather than to all hospitals or healthcare settings nationwide. The regulation was passed in an effort to reduce wait time for appointments and increase healthcare accessibility. In general, those in favor of full practice authority (FPA), such as the American Association of Nurse Practitioners, emphasize issues of access and efficiency [4]. They believe that expanding MLPE will improve healthcare access and outcomes. Conversely, those who are opposed to full practice authority (FPA), such as the American Medical Association are concerned with patient safety and differences in training standards between physicians and mid-level practitioners [5].   

From an operational and administrative perspective, hiring mid-levels is less expensive. For example, in 2025 the average primary care physician made about $162,948 annually and the average nurse practitioner made $112,501 annually [6]. The American Hospital Association (AHA), one of the most powerful lobbying organizations that represents nearly 5,000 hospitals, has backed the VA’s efforts to grant FPA to certain types of mid-level practitioners [7].

Politically speaking, this issue seems to be fairly apolitical. Especially within recent years, given the genuine burden that healthcare systems are facing in the United States many states are passing FPA laws across partisan lines. 

The aforementioned VA Full Practice Authority Directive explicitly retains FPA for VA nurses regardless of state restrictions. For example, in VA hospitals in states that have FPA for nurses, nurses working in VA hospitals may still keep practice authority. However in the case of the State restrictions that limit the authority to prescribe and administer controlled substances, APRNs must practice within the scope of state laws. According to Rebekah Bernard, “While most VA sites implemented what the VA terms ‘full practice authority’ for nurse practitioners, about 10% elected to maintain physician supervision” [8]. The VA countered this with further mandates and memorandums. Consequently, the remaining 10% of VA hospitals have acquiesced to this directive. When individual hospitals come into conflict with this federal policy, they usually must follow mandates from the broader Veteran’s Admnistration. 

The primary regulatory legislation for nursing is each state’s Nursing Practice Act (NPA). Each state has its own NPA, which outlines nursing practice standards and defines the scope of practice. Each state also has a unique Board of Nursing (BON) that manages licensure, sets standards in nursing education, and carries out disciplinary processes [9]. Each state’s BON is a National Council of State Boards of Nursing (NCSBN). However, the NCSBN is an independent, non-profit organization that serves as a forum for state BONs to collaborate and communicate. The NCSBN is not a government body and holds no true regulatory or enforcement board. In fact, there is no centralized, federal body that explicitly oversees the BONs. However, the federal government still holds significant power in regulating the American healthcare industry. Through programs such as Medicaid, Medicare, and the Affordable Care Act, the federal government maintains control over the incentives and structures in healthcare and public insurance systems. Additionally, the US Department of Education oversees the accreditation processes of nursing schools which sets the tone for training/education standards [10]. Whilst, the federal government does have a large role in healthcare as a whole and in the accreditation process of nursing schools, most of the regulatory responsibilities and capabilities do fall on each state’s BON. 

Some professionals in the field have called for the federal standardization of scope of practice laws. For example, Candon et al. (2023), asserts that inconsistency in scope of practice complicates matters not only for nurses, but for researchers, patients, and other healthcare stakeholders [11]. 

The most influential political actors in this issue are interest groups and labor unions. In general, nursing unions are much stronger than physician unions. By magnitude, there are simply far more nurses in the healthcare workforce than there are physicians. Additionally, nurses are more likely to be directly employed by healthcare institutions, while physicians are more likely to run a private practice. For example, according to Smith (2024), about half of physicians were self-employed in 2022. National Nurses United (NNU), the largest nursing union, has about 225,000 registered nurses with membership [12]. On the other hand, the largest union for physicians, the Union of American Physicians and Dentists (UAPD), only represents 7,000 physicians and clinicians [13]. This is only two specific examples, but broadly speaking, nursing-interest advocacy groups are more organized and robust than physician-interest advocacy groups. 

These patterns of scope expansion are likely to continue despite their unforeseen impacts on patient care. Physicians often lack the political will and power to advocate for their scope and patient safety. Concurrently, administrators and health executives are heavily in favor of more affordable labor. 

References:

1. Walsh University. (2021). Full Practice Authority for Nurse Practitioners: The Facts. Walsh.edu. https://online.walsh.edu/blog/nurse-practitioner-full-practice-authority

2. Center for Disease Control and Prevention. (2016). State Law Fact Sheet: A Summary of Nurse Practitioner Scope of Practice Laws, in Effect April 2016. https://www.cdc.gov/cardiovascular-resources/media/pdfs/SLFS_NSOP_508.pdf?utm_source=chatgpt.com

3. Veterans Affairs Department. (2016, December 14). Advanced Practice Registered Nurses. Directive 1350 38 CFR Part 17 RIN 2900-AP44.

4. American Association of Nurse Practitioners. (2024). Issues at a glance: Full practice authority. American Association of Nurse Practitioners. https://www.aanp.org/advocacy/advocacy-resource/policy-briefs/issues-full-practice-brief

5. American Medical Association. (2023, August 14). Advocacy in action: Fighting scope creep. American Medical Association. https://www.ama-assn.org/practice-management/scope-practice/advocacy-action-fighting-scope-creep

6. Indeed. (2024). Family Doctor Salary: State-by-State Guide and Similar Jobs. Indeed Career Guide. https://www.indeed.com/career-advice/pay-salary/family-doctor-salary

7. American Hospital Association. (2016). VA grants full practice authority to certain advanced practice nurses | AHA News. American Hospital Association | AHA News. https://www.aha.org/news/headline/2016-12-13-va-grants-full-practice-authority-certain-advanced-practice-nurses

8. Bernard, R. (2020, January 16). Opinion | VA Goes Too Far on NP Independence. Www.medpagetoday.com. https://www.medpagetoday.com/opinion/rockstar/84396

9. Boehning, A. P., & Haddad, L. M. (2023). Nursing Practice Act. In StatPearls. StatPearls Publishing.

10. United States Department of Education. (n.d.). DAPIP. Ope.ed.gov. https://ope.ed.gov/dapip/#/home

11. Candon, M., Spetz, J., & Rose, A. (2023, October 2). Confusing Patchwork of Laws Govern Nurses’. Penn LDI. https://ldi.upenn.edu/our-work/research-updates/a-confusing-patchwork-of-laws-govern-nurses-ability-to-practice/

12. National Nurses United. (2022, April 18). Organizing with NNU. National Nurses United. https://www.nationalnursesunited.org/organizing-with-nnu

13. Union of American Physicians and Dentists. (n.d.). Home. Www.uapd.com. https://www.uapd.com/'