Each year, Independence Day invites us to reflect on freedom, responsibility, and the courage it takes to create change.
For our profession, it’s an opportunity to think about another kind of independence: professional practice authority.
To this day, nurse practitioners across the US do not all practice under the same rules.
In a little more than half of states, NPs have full practice authority.
They are free to independently evaluate patients, diagnose conditions, order and interpret tests, and initiate treatment, including prescribing medications.
However, in the other states, NPs still face reduced or restricted practice requirements, often requiring physician collaboration, supervision, or formal agreements, even though they provide the same services as NPs in full practice authority states.
Which begs the question …
How is it that an NP may be trusted to practice independently in one state, while just across the border, that same NP may be required to maintain a contractual relationship with another professional to provide similar care?
It doesn’t make much sense, no matter how you look at it.
Why?
So now the question is, why are we still dealing with this?
The reasons are complex and multifactorial.
Historical Reasons
State practice laws developed over time, often long before today’s healthcare shortages, access challenges, and modern NP education standards.
However, once laws and regulatory structures are in place, they are slow to change … but not impossible.
Professional Reasons
Those who oppose NP full practice authority argue that physician oversight is necessary to protect patients because NPs have limited training and scope of practice.
However, supporters of full practice authority point to decades of NP practice, research, and patient outcomes showing that NPs provide safe, high-quality care within their scope of education and certification.
Research and patient outcomes are well documented and available to anyone who cares to look at the data.
Other Reasons …
Some economic and structural factors cannot be discounted.
Collaborative agreements may have a price tag, providing a side income for the collaborating physician.
In some instances, collaboration fees are reasonable; in others, they are exorbitant, creating a significant financial burden for NPs, especially those opening small practices in rural or underserved areas.
Additionally, some agreements limit where NPs can practice and how they can respond to community needs, ultimately determining whether the practice may remain viable at all.
For patients, this means limited access to care or delayed care, fewer local options, or no care close to home at all.
Cooperation not Isolation
Independent practice is not the same as practicing alone, and that’s an important distinction.
Full practice authority doesn’t mean NPs work in isolation.
No one works alone. It’s common practice for providers to exchange ideas and information and share their clinical expertise when asked.
Like other providers, NPs routinely work and collaborate with NPs, physicians, pharmacists, therapists, specialists, hospitals, community agencies, and other healthcare professionals to achieve better outcomes for their patients.
Collaboration is a normal and necessary part of good patient care.
Collaboration should not be mandated by law through a formal agreement that may not reflect the actual care being provided, but must be based on patient needs and professional judgment.
Responsibility
For all healthcare providers, including NPs, professional independence comes with responsibility.
It requires strong clinical judgment, ethical decision-making, clear documentation, appropriate referrals, ongoing education, and a commitment to quality care.
And for those who operate their own practices, it also requires a certain level of business professionalism.
Change …
What can NPs do to facilitate change in their professional status?
First, it’s essential that all NPs fully understand their state practice environment.
Not all are clear on whether their state is considered full, reduced, or restricted practice. Knowing the law is the first step toward changing it.
Second, NPs must support their state and national professional organizations.
Scope-of-practice change rarely happens because of one person. It happens through organized, consistent advocacy.
Most State NP associations monitor legislation, educate lawmakers, coordinate testimony, and build coalitions.
If you are not a member, support your profession by joining your state and national organizations!
Third, collect and tell patient-centered stories.
Lawmakers don’t respond to abstract professional arguments. What they understand and respond to are real-life examples:
- patients who cannot find a primary care provider
- rural communities without enough clinicians
- mental health patients waiting months for care
- an NP-owned clinic, delayed because of outdated regulatory barriers
Fourth, build relationships in your community.
Business leaders, patient advocacy groups, senior organizations, rural health coalitions, employers, and community leaders all have a stake in healthcare access.
When the conversation moves from “NPs want independence” to “communities need access,” the message carries more weight.
Finally, avoid NPs versus physicians.
In fact, that stance is rarely helpful…
A more powerful message is:
“Access to healthcare increases and patients benefit when every qualified healthcare professional can practice to the full extent of their education, training, and licensure.”
In Conclusion …
Independence Day reminds us that freedom and responsibility go hand in hand. This is true for the citizens of a country as it is for healthcare providers.
For Nurse Practitioners, professional independence is not about rejecting collaboration or practicing outside one’s scope.
It is about removing outdated barriers so all NPs can practice to the full extent of their qualifications, and serve their patients and communities more effectively.
Independence, in this context, is the freedom to bring our full education, judgment, and commitment to the patients who need us.
P.S.: If you’re ready to start your own practice but don’t know how, we can help. The Essentials of Starting a Practice includes everything you need to get started and grow your practice; click the link and see for yourself!
Your thoughts about the state of NP Independent Practice across the US? Let us know, share your thoughts in the section below…
By Johanna Hofmann, MBA, MAc., regular contributor to the NPBusiness blog and author of “Smart Business Planning for Clinicians.”