Research Article| Volume 13, ISSUE 4, P44-53, January 2023

Download started.


The State of Advanced Practice Registered Nursing in Alabama

      Scope of practice for advanced practice registered nurses (APRNs) varies according to U.S. jurisdiction licensure requirements. Nineteen U.S. jurisdictions currently allow independent practice in all four APRN roles: certified nurse midwife (CNM), certified nurse practitioner (CNP), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS). Twenty-six U.S. jurisdictions allow full practice authority for CNPs. APRNs practicing in the remaining U.S. jurisdictions have varying practice restrictions, which are dictated by their state licensure laws. Alabama’s scope and standards of practice restrict all APRN roles. During the initial months of the COVID-19 pandemic, Alabama was one of many U.S. jurisdictions that implemented emergency waivers, thereby expanding the scope of APRN practice and granting increased autonomy to APRNs while caring for more complex patients. Once the pandemic threat lessened, many U.S. jurisdictions, including Alabama, returned to pre-pandemic restrictive scope of practice regulations. Through empirical evidence, we conducted a review of APRN practice before, during, and after the pandemic. The literature included anecdotal reports of safe delivery of healthcare provided by APRNs working under the emergency waivers. The literature revealed that APRNs are prepared to practice to the full extent of their scope of practice and provide high-quality healthcare services to improve access to care. Alabama and other U.S. jurisdictions where APRN practice is restricted should advocate for legislative changes supporting APRN full practice authority commensurate with their educational training and certification.


      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


        • Adams E.K.
        • Markowitz S.
        Improving efficiency in the health-care system: Removing anticompetitive barriers for advanced practice registered nurses and physician assistants (Policy proposal 2018-08).
        The Hamilton Project. 2018; (
        • Alabama Board of Medical Examiners Admin
        Code §. 2022; 540
        • Alabama Board of Nursing Admin
        Code. 2021; §: 610-X-5
        • Alabama Board of Nursing Admin
        Code. 2021; §: 610-X-9
      1. Alabama Board of Nursing. (2022). Daily statistics. Retrieved June 1, 2022, from

        • Alabama Rural Health Association
        Alabama primary care physician workforce. 2020; : 2020
        • American Association of Nurse Anesthesiology
        Certified registered nurse anesthetists fact sheet. 2022, October 5; (
        • American Association of Nurse Practitioners
        Nurse practitioner role grows to more than. 2019, January; 270 ( 000
      2. American Association of Nurse Practitioners. (2020a). Position Statement: Nurse Practitioner Education.

      3. American Association of Nurse Practitioners. (2020b). Discussion paper: Quality of nurse practitioner practice.

      4. American Association of Nurse Practitioners. (2022a, October. Issues at a glance: Full practice authority.

        • American Association of Nurse Practitioners
        State practice environment. 2022, October; (
        • Board American Midwifery Certification
        AMCB certification exam candidate handbook nurse-midwifery and midwifery. 2022, April 6;
      5. APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee. (2008, July 7. Consensus model for APRN regulation: Licensure, accreditation, certification & education. APRN Joint Dialogue Group.

      6. Association of American Medical Colleges. (2022). 2021 state physician workforce data report.

        • Benson A.R.
        • Peters J.S.
        • Kennedy C.
        • Patch M.
        In service to others: APRNs as serving leaders during the COVID-19 pandemic.
        Online Journal of Issues in Nursing. 2022; 27 (
        • Best states 2021
        How they were ranked.
        U.S. News & World Report, 2021, March 9
      7. Buerhaus, P. (2018, September. Nurse practitioners: A solution to America’s primary care crisis. American Enterprise Institute.

        • Busca E.
        • Savatteri A.
        • Calafato R.L.
        • Mazzoleni B.
        • Barisone M.
        • Dal Molin A.
        Barriers and facilitators to the implementation of nurse’s role in primary care settings: An integrative review.
        BMC Nursing. 2021; 20, Article 171
      8. Code of Ala. 1975 § 34-21. (2022). Nurses.

        • Combellick J.L.
        • Ibrahim B.B.
        • Julien T.
        • Scharer K.
        • Jackson K.
        • Kennedy H.P.
        Birth during the Covid-19 pandemic: What childbearing people in the United States needed to achieve a positive birth experience.
        Birth. 2022; 49: 341-351
        • Davis-Floyd R.
        • Gutschow K.
        • Schwartz D.A.
        Pregnancy, birth and the COVID-19 pandemic in the United States.
        Medical Anthropology. 2020; 39: 413-427
        • DePriest K.
        • D’Aoust R.
        • Samuel L.
        • Commodore-Mensah Y.
        • Hanson G.
        • Slade E.P.
        Nurse practitioners’ workforce outcomes under implementation of full practice authority.
        Nursing Outlook. 2020; 68: 459-467
      9. Federal Trade Commission. (2014, March. Policy perspectives: Competition and the regulation of advanced practice nurses.

      10. Federal Trade Commission. (2020, January 13). FTC comments to state legislatures in Kansas and Ohio encourage granting advanced practice registered nurses full practice authority [Press release].

        • Hansen M.P.
        • Kollauf C.R.
        • Saunders M.M.
        • Santiago-Rotchford L.
        Clinical nurse specialists: Leaders in managing patients with chronic conditions.
        Nursing Economic$. 2019; 37: 103-109
        • International Council of Nurses
        Guidelines on advanced practice nursing. 2020; : 2020
      11. Johnson & Johnson, American Nurses Association, & American Organization for Nursing Leadership. (n.d.). Accelerating nursing, transforming healthcare.

        • Kacik A.
        FTC supports bills bolstering advanced practice nurse autonomy.
        Modern Healthcare, 2020, January 13
        • Kleinpell R.
        • Myers C.R.
        • Schorn M.N.
        • Likes W.
        Impact of COVID-19 on APRN practice: Results of a national survey.
        Nursing Outlook. 2021; 69: 783-792
        • Kraines K.L.
        Filling critical gaps in primary healthcare: Advanced practice registered nurses meeting the challenge.
        Yale Nursing Matters. 2018; 18 ( 21-23
        • Mamais F.
        • Jasdhaul M.
        • Gawlinski A.
        • Lawanson-Nichols M.
        • Kao Y.
        • Branom R.
        • Ansryan., L. Z.
        The agile clinical nurse specialist navigating the challenges of COVID-19 pandemic.
        Clinical Nurse Specialist. 2022; 36: 190-195
        • Mollard E.
        • Wittmaack A.
        Experiences of women who gave birth in US hospitals during the COVID-19 pandemic.
        Journal of Patient Experience. 2021; 8, Article 2374373520981492
        • Moore C.
        • Kabbe A.
        • Gibson T.S.
        • Letvak S.
        The pursuit of nurse practitioner practice legislation: A case study.
        Policy, Politics, & Nursing Practice. 2020; 21: 222-232
      12. National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education (2nd ed.).

        • National Council of State Boards of Nursing
        NCSBN’s environmental scan COVID-19 and its impact on nursing regulation.
        Journal of Nursing Regulation. 2021, January; 11: S1-S36
        • National Council of State Boards of Nursing
        The NCSBN 2022 environmental scan: Resiliency, achievement, and public protection.
        Journal of Nursing Regulation. 2022; 12: S1-S56
      13. National Council of State Boards of Nursing. (2022b). APRN consensus model by state as of September 2022.

        • O’Reilly-Jacob M.
        • Perloff J.
        • Sherafat-Kazemzadeh R.
        • Flanagan J.
        Nurse practitioners’ perception of temporary full practice authority during a COVID-19 surge: A qualitative study.
        International Journal of Nursing Studies. 2022; 126, Article 104141
        • Patel E.Y.
        • Petermann V.
        • Mark B.A.
        Does state-level nurse practitioner scope-of-practice policy affect access to care?.
        Western Journal of Nursing Research. 2019; 41 (418): 488
        • Phillips S.J.
        34th Annual ARPN legislative update: Trends in APRN practice authority during the COVID-19 global pandemic.
        The Nurse Practitioner. 2022, January; 47: 21-47
        • Phoenix B.J.
        • Chapman S.A.
        Effect of state regulatory environments on advanced psychiatric nursing practice.
        Archives of Psychiatric Nursing. 2020; 34 (376): 370-376
        • Poghosyan L.
        • Pulcini J.
        • Chan G.K.
        • Dunphy L.
        • Martsolf G.R.
        • Greco K.
        • Todd B.A.
        • Brown S.C.
        • Fitzgerald M.
        • McMenamin A.L.
        • Solari-Twadell P.A.
        State responses to COVID-19: Potential benefits of continuing full practice authority for primary care nurse practitioners.
        Nursing Outlook. 2021; 70: 28-35
        • Rosa W.E.
        • Fitzgerald M.
        • Davis S.
        • Farley J.E.
        • Khanyola J.
        • Kwong J.
        • Moreland P.J.
        • Rogers M.
        • Sibanda B.
        • Turale S.
        Leveraging nurse practitioner capacities to achieve global health for all: COVID-19 and beyond.
        International Nursing Review. 2020; 67: 554-559
        • Streeter R.A.
        • Zangaro G.A.
        • Chattopadhyay A.
        Perspectives: Using results from HRSA’s health workforce simulation model to examine the geography of primary care.
        Health Services Research. 2017; 52: 481-507
        • Stucky C.H.
        • Brown W.J.
        • Stucky M.G.
        COVID 19: An unprecedented opportunity for nurse practitioners to reform healthcare and advocate for permanent full practice authority.
        Nursing Forum. 2021; 56: 222-227
        • Wakefield M.K.
        • Williams D.R.
        • Le Menestrel S.
        • Flaubert J.L.
        • (Eds.).
        The future of nursing 2020-2030: Charting a path to achieve health equity.
        The National Academies Press, 2021
        • Waldrop T.
        • Gee E.
        How states can expand health care access in rural communities. 2022, February 9; (
        • Woo B.F.Y.
        • Lee J.X.Y.
        • Tam W.W.S.
        The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review.
        Human Resources for Health. 2017; 15, Article 63