State‐Level Scope of Practice Regulations and Impact on Organizational‐Level Work Environments for Nurse Practitioners

Research Objective The growing nurse practitioner (NP) workforce can play a critical role in meeting the demand for health care services especially in primary care. Yet, many policy and organizational barriers affect this workforce and their ability to deliver high quality care. State‐level scope of practice (SOP) regulations have received substantial attention due to their impact on access and quality of care. Yet, little is known how these state‐level polices also affect organizations employing NPs and potentially NPs' ability to deliver care. This study investigated the relationship between SOP policies governing NP practice and organizational‐level work environment in primary care practices. Study Design We collected survey data from primary care NPs about their work environments from six states (Arizona, Washington, New Jersey, Pennsylvania, California, and Texas) in 2018–2019. All NPs in Arizona and New Jersey, a 75% random sample of NPs in Pennsylvania, and a 50% random sample of NPs for California and Texas were sampled. NPs completed a validated work environment tool, the Nurse Practitioner‐Primary Care Organizational Climate Questionnaire, which measures four domains of work environment: NP Administration Relations (NP‐AR), NP‐Physician Relations (NP‐PR), Independent Practice and Support (IPS), and Professional Visibility (PV). Regression models were used to assess the relationship between state level‐SOP and organizational‐level work environment domains. The models were controlled for demographic and work characteristics. Population Studied Data were collected from 1244 NPs in 1109 practices. Arizona and Washington were characterized as having full SOP for NPs‐NPs independently deliver care. New Jersey and Pennsylvania had reduced SOP‐physician collaboration is required for care delivery; and California and Texas had restricted SOP‐physician supervision required. Principal Findings NP practices from full SOP states were more likely to have higher PV scores compared to practices within reduced (B = 0.16; P‐value = 0.005) and restricted (B = 0.12; P‐value = 0.02) SOP states. Practices from full SOP states were more likely to have higher NP‐AR scores compared to practices from reduced (B:0.22; P‐value = 0.0003) and restricted (B = 0.15; P‐value = 0.009) SOP states. In addition, practices from full SOP states were more likely to have higher IPS score compared to practices from reduced (B:0.14; P‐value = 0.0003) and restricted (B = 0.09; P‐value = 0.01) SOP states. There was no relationship between SOP type and practice‐level NP‐PR score. Conclusions Findings show that state‐level policies indeed affect organizational‐level work environment. NP work environment is more favorable in states with more favorable policy environment which does not require physician supervision or collaboration for NP care delivery. NPs practicing in full SOP states have better relationships with administration, report more visibility in NP role, and more support within their organizations for independent NP practice. Implications for Policy or Practice NPs play a critical role in the U.S. health care system and creating optimal state‐ and organizational‐ level policies will help to optimally utilize NPs and maximize their contributions to patient care and the overall health care system. Full SOP regulations should be the gold‐standard, and policy makers in reduced and restricted SOP states should invest efforts to remove unnecessary restrictions. Practice administrators should create favorable work environments for NPs. Primary Funding Source National Institutes of Health.