Regulation of the Nurse Practitioner Workforce: Implications for Care Across Settings


      The current shortage of physicians in the United States has potential to dramatically limit access to healthcare. Nurse practitioners (NPs) can provide a cost-effective solution to the shortage, yet few states allow NPs to practice independently.


      The purpose of this study was to provide an up-to-date description of the NP workforce and to identify the professional and organizational factors associated with NP care quality.


      Cross-sectional survey data from a sample of NPs actively employed in four states with reduced or restricted practice (California, Florida, New Jersey, and Pennsylvania) was used. NPs were categorized into acute and primary care. Regression models were fit to estimate the odds of three measures of care quality: overall quality of patient care, NP confidence that patients and their caregivers can manage their care at home, and whether NPs would recommend their practice facility to family and friends.


      Receiving support from administrative staff and physicians was associated with an increase in the three measures of quality. The greatest effects were seen in primary care settings.


      It is imperative that legislators and healthcare administrators implement policies that provide NPs with an environment that supports clinical practice and enhances care delivery.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Nursing Regulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Aiken L.H.
        • Clarke S.P.
        • Sloane D.M.
        • Lake E.T.
        • Cheney T.
        Effects of hospital care environment on patient mortality and nurse outcomes.
        Journal of Nursing Administration. 2008; 38: 223-229
        • Association of American Medical Colleges
        The complexities of physician supply and demand: projections from 2016 to 2030.
        Author, Washington, DC2018
        • Brom H.M.
        • Salsberry P.J.
        • Graham M.C.
        Leveraging healthcare reform to accelerate nurse practitioner full practice authority.
        Journal of the American Association of Nurse Practitioners. 2018; 30: 120-130
        • Bureau of Labor Statistics, U.S. Department of Labor
        Occupational outlook handbook: Nurse anesthetists, nurse midwives, and nurse practitioners.
        (Retrieved from)
        • Dillman D.A.
        • Smyth J.D.
        • Christian L.M.
        Internet, phone, mail, and mixed-mode surveys: The tailored design method.
        John Wiley & Sons, Inc, Hoboken, NJ2014
        • Doblier C.L.
        • Webster J.A.
        • McCalister K.T.
        • Mallon M.W.
        • Steinhardt M.A.
        Reliability and validity of a single-item measure of job satisfaction.
        American Journal of Health Promotion. 2005; 19: 194-198
        • Dye E.
        • Wells N.
        Subjective and objective measurement of neonatal nurse practitioner workload.
        Advances in Neonatal Care. 2017; 17: E3-E12
        • Gaudette E.
        • Tysinger B.
        • Cassil A.
        • Goldman D.P.
        Health and healthcare of Medicare beneficiaries in 2030.
        Forum for Health Economics & Policy. 2015; 18: 75-96
        • Gigli K.H.
        • Dietrich M.S.
        • Buerhaus P.I.
        • Minnick A.F.
        Regulation of pediatric intensive care unit nurse practitioner practice: A national survey.
        Journal of the American Association of Nurse Practitioners. 2018; 30: 17-26
        • Health Resources and Services Administration, National Center for Health Workforce Analysis, U.S. Department of Health and Human Services
        Highlights from the 2012 national sample survey of nurse practitioners.
        Author, Rockville, MD2014
        • Hing E.
        • Hsiao C.J.
        In which states are physician assistants or nurse practitioners more likely to work in primary care?.
        Journal of the American Academy of Physician Assistants. 2015; 28: 46-53
        • Kuo Y.F.
        • Loresto F.L.
        • Rounds L.R.
        • Goodwin J.S.
        States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners.
        Health Affairs. 2013; 32: 1236-1243
        • Kutney-Lee A.
        • Wu E.
        • Sloane D.M.
        • Aiken L.H.
        Changes in hospital nurse work environments and nurse job outcomes: an analysis of panel data.
        International Journal of Nursing Studies. 2013; 50: 195-201
        • Kurtzman E.T.
        • Barrow B.S.
        • Johnson J.E.
        • Simmens S.J.
        • Infeld D.L.
        • Mullan F.
        Does the regulatory environment affect nurse practitioners’ pattern of practice or quality of care in health centers?.
        Health Services Research. 2017; 52: 437-458
        • Medicare Payment Advisory Commission
        Report to the Congress: Medicare and the Healthcare Delivery System.
        (Retrieved from)
        • Ortiz J.
        • Hoffer R.
        • Bushy A.
        • Lin Y.
        • Khanijahani A.
        • Bitney A.
        Impact of nurse practitioner scope of practice regulations on rural population health outcomes.
        Healthcare. 2018; 6: 1-8
        • Phillips S.J.
        30th Annual APRN Legislative Update: Improving access to healthcare one state at a time.
        The Nurse Practitioner. 2018; 43: 27-54
        • Poghosyan L.
        • Liu J.
        • Shang J.
        • D’Aunno T.
        Practice environments and job satisfaction and turnover intentions of nurse practitioners: Implications for primary care workforce capacity.
        Healthcare Management Review. 2016; 42: 162-171
        • Poghosyan L.
        • Nannini A.
        • Finkelstein S.R.
        • Mason E.
        • Shaffer J.A.
        Development and psychometric testing of the Nurse Practitioner Primary Care Organizational Climate Questionnaire.
        Nursing Research. 2013; 62: 325-334
        • Poghosyan L.
        • Norful A.A.
        • Liu J.
        • Friedberg M.W.
        Nurse practitioner practice environments in primary care and quality of care for chronic diseases.
        Medical Care. 2018; 56: 791-797
        • Poghosyan L.
        • Norful A.A.
        • Martsolf G.R.
        Primary care nurse practitioner practice characteristics: Barriers and opportunities for interprofessional teamwork.
        Journal of Ambulatory Care Management. 2017; 40: 77-86
        • Sloane D.M.
        • Smith H.L.
        • McHugh M.D.
        • Aiken L.H.
        Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: A panel study.
        Medical Care. 2018; 56: 1001-1008
        • Smith H.L.
        Double sample to minimize bias due to non-response in a mail survey.
        in: PSC Working Paper Series. Population Studies Center, University of Pennsylvania, Philadelphia, PA2009 (No. 09-05)
        • Spetz J.
        • Fraher E.
        • Li Y.
        • Bates T.
        How many nurse practitioners provide primary care? It depends on how you count them.
        Medical Care Research and Review. 2015; 72: 359-375
        • Wanous J.P.
        • Reichers A.E.
        Overall job satisfaction: How good are single-item measures?.
        Journal of Applied Psychology. 1997; 82: 247-252


      Jeannie P. Cimiotti, PhD, RN, FAAN, is Associate Professor, Nell Hodgson Woodruff School of Nursing, Emory University.


      Yin Li, PhD, is Assistant Professor, Nell Hodgson Woodruff School of Nursing, Emory University.


      Douglas M. Sloane, PhD, is Adjunct Professor, School of Nursing, University of Pennsylvania.


      Hilary Barnes, PhD, NP-C, is Assistant Professor, School of Nursing, University of Delaware.


      Heather M. Brom, PhD, RN, NP-C, is Post-Doctoral Research Fellow, School of Nursing, University of Pennsylvania.


      Linda H. Aiken, PhD, RN, FAAN, is Professor, School of Nursing, University of Pennsylvania.

      Linked Article

      • Conflict of Interest Compliance Article 4
        Journal of Nursing Regulation Vol. 12Issue 2
        • Preview
          As is standard in scholarly publishing, NCSBN’s Journal of Nursing Regulation (JNR) requires its authors to disclose any potential conflicts of interest (COI). Although COI information has always been collected by our staff in order to support editors’ review of the paper, it was not our standard practice to publish COI statements in each article. In this issue, JNR is retrospectively publishing the COI statements, which were collected with the below papers at submission, in order to make potential COI’s transparent to readers, as well as editors.
        • Full-Text
        • PDF