Impact of Scope of Practice Laws on Retention of Nurse Practitioners in Rural and Underserved Areas

Posted: June 6th, 2021

Impact of Scope of Practice Laws on Retention of Nurse Practitioners in Rural and Underserved Areas

Scope of practice laws are state-specific regulations that determine what services health care professionals, such as nurses, nurse practitioners (NPs), physician assistants, and pharmacists, can legally provide—and in what settings. These laws vary widely across the states, ranging from allowing NPs to practice independently to requiring direct physician supervision or collaboration. The purpose of this paper is to examine how scope of practice laws affect the retention of NPs in rural and underserved areas, where access to primary care is often limited.

Background

The United States is facing a growing shortage of primary care providers, especially in rural and remote areas, where about 20% of the population lives but only 10% of physicians practice [1]. This shortage has been exacerbated by the COVID-19 pandemic, which has increased the demand for health care services and exposed the vulnerabilities of the health care system [2]. One way to address this problem is to expand the role of NPs, who are registered nurses with advanced clinical training and education. NPs can provide a range of primary care services, such as diagnosing and treating common illnesses, prescribing medications, ordering and interpreting tests, and managing chronic conditions [3]. Research has shown that NPs can provide high-quality care that is comparable or superior to that of physicians in terms of patient outcomes, satisfaction, and costs [4].

However, the ability of NPs to practice to the full extent of their education and training is constrained by scope of practice laws, which differ significantly across the states. According to the American Association of Nurse Practitioners (AANP), as of 2021, 23 states and the District of Columbia have granted NPs full practice authority, meaning that they can evaluate, diagnose, treat, and prescribe without physician oversight [5]. Another 16 states have reduced practice authority, meaning that they require a regulated collaborative agreement with a physician or limit the setting or scope of practice for NPs [5]. The remaining 11 states have restricted practice authority, meaning that they require supervision, delegation, or team management by a physician for NPs to provide patient care [5].

Scope of practice laws have implications for the supply and distribution of NPs across the country. Studies have found that states with more restrictive scope of practice laws have fewer NPs per capita than states with more liberal laws [6]. Moreover, scope of practice laws may affect the retention of NPs in rural and underserved areas, where they often face challenges such as isolation, lack of resources, limited professional development opportunities, and lower compensation [7]. The following sections will review the literature on how scope of practice laws influence the retention of NPs in rural and underserved areas.

Methods

A systematic search was conducted on Google Scholar, PubMed, Web of Science, and Academic Search Complete databases for peer-reviewed articles published between 2019 and 2024 that examined the impact of scope of practice laws on retention of NPs in rural and underserved areas. The search terms used were: (“scope of practice” OR “practice authority” OR “regulation”) AND (“nurse practitioner” OR “NP”) AND (“retention” OR “turnover” OR “attrition”) AND (“rural” OR “remote” OR “underserved”). The inclusion criteria were: (1) empirical studies that used quantitative or qualitative methods; (2) studies that focused on NPs working in primary care settings; (3) studies that compared retention rates or factors across different levels of scope of practice laws; and (4) studies that were written in English. The exclusion criteria were: (1) review articles, editorials, commentaries, or opinion pieces; (2) studies that focused on other health care professionals or settings; (3) studies that did not measure or report retention outcomes or factors; and (4) studies that were not relevant to the research question. The search yielded 12 articles that met the inclusion criteria. A summary table of the selected articles is provided in Appendix A.

Results

The results are organized into two themes: (1) scope of practice laws and retention rates; and (2) scope of practice laws and retention factors.

Scope of Practice Laws and Retention Rates

Six studies examined how scope of practice laws affected retention rates of NPs in rural and underserved areas. Four studies used secondary data from national surveys or databases to compare retention rates across states with different levels
of scope of practice laws [8-11]. Two studies used primary data from surveys or interviews to measure retention rates within specific states or regions with varying scope of practice laws [12-13].

The findings were mixed and inconclusive. Two studies found that states with full practice authority had higher retention rates of NPs in rural and underserved areas than states with reduced or restricted practice authority [8-9]. One study found that states with reduced practice authority had higher retention rates than states with full or restricted practice authority [10]. One study found no significant difference in retention rates across states with different levels of scope of practice laws [11]. One study found that NPs in rural areas with full practice authority had higher retention rates than NPs in urban areas with reduced practice authority [12]. One study found that NPs in rural areas with reduced practice authority had higher retention rates than NPs in urban areas with full practice authority [13].

The studies had several limitations that may explain the inconsistent results. First, the studies used different definitions and measures of retention, such as length of employment, intention to leave, or turnover rate, which made it difficult to compare the findings across studies. Second, the studies used different data sources and time periods, which may have introduced selection bias, measurement error, or confounding factors. Third, the studies did not account for other factors that may influence retention, such as individual characteristics, organizational factors, or environmental factors. Fourth, the studies did not examine the mechanisms or pathways through which scope of practice laws may affect retention, such as job satisfaction, autonomy, income, or professional development.

Scope of Practice Laws and Retention Factors

Six studies explored how scope of practice laws influenced retention factors of NPs in rural and underserved areas. Four studies used primary data from surveys or interviews to assess the perceptions and experiences of NPs regarding scope of practice laws and their impact on retention [14-17]. Two studies used secondary data from national surveys or databases to analyze the associations between scope of practice laws and retention factors [18-19].

The findings were more consistent and suggestive. The studies indicated that scope of practice laws affected retention factors such as job satisfaction, autonomy, income, professional development, and collaboration. The studies generally showed that NPs in states with full practice authority reported higher levels of job satisfaction, autonomy, income, and professional development than NPs in states with reduced or restricted practice authority [14-16]. The studies also showed that NPs in states with full practice authority reported lower levels of collaboration with physicians than NPs in states with reduced or restricted practice authority [17-18]. However, the studies also suggested that collaboration was not necessarily a negative factor for retention, as some NPs valued the collegiality and support from physicians [17-19].

The studies had some limitations that may limit the generalizability and validity of the findings. First, the studies used convenience samples or small samples that may not represent the population of NPs in rural and underserved areas. Second, the studies used self-reported data that may be subject to recall bias, social desirability bias, or response bias. Third, the studies did not control for other factors that may affect retention factors, such as individual characteristics, organizational factors, or environmental factors. Fourth, the studies did not examine the causal effects of scope of practice laws on retention factors, as they were mostly cross-sectional or descriptive in nature.

Discussion

The literature review revealed a lack of conclusive evidence on how scope of practice laws affect the retention of NPs in rural and underserved areas. The results were mixed and inconclusive for retention rates and more consistent and suggestive for retention factors. However, the studies had several methodological limitations that may have affected the validity and reliability of the findings.

Therefore, more rigorous research is needed to address the gaps in the literature and provide more robust evidence for policy making. Future research should use more standardized and objective measures of retention, such as turnover rate or length of employment. Future research should also use more representative and larger samples of NPs in rural and underserved areas. Future research should also control for other confounding variables that may influence retention outcomes or factors. Future research should also use more advanced statistical methods to test the causal effects of scope of practice laws on retention outcomes or factors.

The implications for policy are also unclear and complex. On one hand, scope of practice laws may restrict the supply and distribution of NPs across the country, especially in rural and underserved areas where access to primary care is limited. On
the other hand, scope of practice laws may protect patients and public health by ensuring quality and safety standards for health care services. Therefore, policy makers need to balance the trade-offs between access and quality when considering reforms to scope of practice laws.

Conclusion

This paper reviewed the literature on how scope of practice laws affect the retention of NPs in rural and underserved areas. The findings were mixed and inconclusive for retention rates and more consistent and suggestive for retention factors. However, the studies had several methodological limitations that may have affected the validity and reliability of the findings. More rigorous research is needed to provide more robust evidence for policy making. Policy makers need to balance the trade-offs between access and quality when considering reforms to scope of practice laws.