NURS 721 Week 7 Group Electronic Presentation Project Example

Full Practice Authority for Nurse Practitioners: Access, Safety, Ethics and What the Change Would Mean for Nursing Practice

Slide 1: Full Practice Authority for Nurse Practitioners

• Evidence, ethics and nursing practice
• A restricted-practice state weighs a change
• Group 3, NURS 721

Speaker notes: Our presentation examines one of the most debated policies in American nursing: whether nurse practitioners should be allowed to use all they are educated and licensed to do, with no physician agreement required. We take as our case a state that still requires those agreements and whose legislature is considering a bill to remove them. Our question is what the evidence says and what the change would mean for nursing practice.

Slide 2: Why This Policy, Why Now

• Primary care shortages persist
• Bills appear in legislatures every year
• Two of us practice under supervision agreements

Speaker notes: We chose this policy because it is current and because it touches our own practice. Primary care shortages persist, especially in rural areas, and legislatures in restricted states consider scope-of-practice bills nearly every session. Two members of our group are nurse practitioners who currently pay for and maintain physician agreements, and one directs hospital nursing where nurse practitioners serve as hospitalists. Goudreau and Smolenski (2014) describe policy engagement as part of the advanced practice role, and this is a policy we will be asked to engage.

Slide 3: What Full Practice Authority Means

• Evaluate, diagnose, order and interpret tests
• Initiate and manage treatment, including prescribing
• Under the state board of nursing alone

Speaker notes: Full practice authority means that state law allows nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, and initiate and manage treatment, including prescribing, with the state board of nursing as their only licensing authority and no required supervision or collaboration agreement with a physician. It does not change the nurse practitioner's education, certification or scope of training; it changes who must sign off on practice.

Slide 4: Three Kinds of State Rules

• Full practice
• Reduced practice: an agreement for some tasks
• Restricted practice: supervision for some tasks

Speaker notes: States are commonly grouped into three categories. Full practice states require no physician agreement. Reduced practice states require a written collaborative arrangement covering some part of practice, most often prescribing. Restricted practice states go further, requiring physician supervision or delegation for some part of practice. Researchers have noted that these labels hide real differences between states, which complicates research comparing them (McMichael, 2026), a point we return to when we weigh the evidence.

Slide 5: A Brief History

• First nurse practitioner program, 1965
• Steady growth in the role and its scope
• 2011: a national call to remove scope barriers

Speaker notes: The nurse practitioner role began in 1965 with a pediatric program in Colorado and has grown into a profession of several hundred thousand clinicians. In 2011, the Institute of Medicine's report on the future of nursing urged that nurses be allowed to use everything their education and training prepared them to do, and that the laws limiting their scope be lifted (Institute of Medicine, 2011). Many states have changed their laws since, but many have not.

Slide 6: Our Case State

• Restricted practice today
• Bill would end required physician agreements
• Supporters and opponents both organized

Speaker notes: Our case state currently requires a supervising physician agreement for nurse practitioner practice, including prescribing. A bill before the legislature would remove that requirement after a transition period of supervised practice for new graduates. Nursing organizations support the bill; the state medical society opposes it. The debate centers on access in rural counties and on patient safety, which is why our presentation is organized around those two questions.

Slide 7: Our Question

• What does the evidence show?
• What would change for nursing practice?
• What do ethics and faith ask of us?

Speaker notes: Our question has three parts. First, what does the research show about how full practice authority affects access, quality and safety? Second, what would the change mean for nursing practice, not only for nurse practitioners but for registered nurses, educators and nurse leaders? Third, how should nurses think about the policy ethically and from a Christian worldview, and how should we engage the debate?

Slide 8: Access: Where Nurse Practitioners Practice

• More nurse practitioners in shortage areas
• Better retention and provider-to-patient ratios
• Benefits depend on integration

Speaker notes: A 2026 systematic review of 27 studies found that regulatory liberalization, especially full practice authority, was associated with improved access indicators, more nurse practitioners in shortage areas and fewer hospitalizations (Koyuncu et al., 2026). An integrative review of 13 studies found that full practice authority positively influences nurse practitioner migration, retention and provider-to-patient ratios (Pitts & Lindley, 2026). Workforce distribution is the first link between the law and patients.

Slide 9: Access: Use of Primary Care

• More primary care visits with nurse practitioners
• No drop in physician visits
• Fewer non-urgent emergency visits

Speaker notes: Using national survey data from 1997 to 2018 and a staggered difference-in-differences design across all states, Fitzpatrick et al. (2026) found that states adopting full practice authority saw a modest but significant increase in primary care visits with nurse practitioners without a corresponding decline in physician visits. Non-urgent emergency department use fell, and patient-reported activities of daily living improved modestly. Added capacity, not substitution, is the pattern.

Slide 10: Access: Rural Practice

• Clinics without an on-site physician
• Rural nurse practitioners most supportive
• Rural communities stand to gain most

Speaker notes: A survey of 20,830 nurse practitioners found those in full practice states more than twice as likely to practice in clinics with no on-site physician and twice as likely to have no physician collaborator (Slade et al., 2025), the kind of practice that can open in a small town. In Tennessee, 76.5% of rural advanced practice registered nurses preferred full practice authority, compared with about 63% in suburban and urban areas (Miller & Barut, 2026).

Slide 11: Quality: Preventable Hospitalizations

• Fewer avoidable admissions for diabetes
• Fewer for other chronic conditions
• Consistent among privately insured patients

Speaker notes: Preventable hospitalizations measure whether outpatient care is working. Examining discharges across 22 states from 2010 to 2019, McMichael (2025) found that full practice authority reduced avoidable hospitalizations for diabetes and other chronic conditions, with particularly consistent effects among privately insured patients. Hospital stays for these conditions became longer on average, suggesting that the patients still admitted were sicker, while healthier patients were managed in the community.

Slide 12: Quality: Children

• About 10% fewer chronic condition admissions
• About 16% more admissions for some acute conditions
• Mixed evidence calls for monitoring

Speaker notes: The pediatric evidence is mixed. Using the same 22-state design, McMichael (2026) found that full practice authority reduced hospitalizations for chronic conditions such as asthma and diabetes complications by about 10%, but increased hospitalizations for some acute conditions, including gastroenteritis and urinary tract infections, by roughly 16%. The author concluded that expanded authority may improve chronic disease management while posing challenges for acute care, a finding we take seriously.

Slide 13: Safety: Opioid Prescribing

• 1.5 billion prescriptions analyzed
• Relaxed laws generally reduced opioid prescriptions
• Counters a common safety argument

Speaker notes: Opponents have argued that relaxing scope-of-practice laws would increase opioid prescribing during an overdose crisis. McMichael (2021) examined about 1.5 billion opioid prescriptions from 2011 to 2018 and found that relaxing nurse practitioner scope-of-practice laws generally reduced opioid prescriptions. This does not settle every safety question, but it addresses one of the most frequently raised concerns directly.

Slide 14: Safety: Older Adults' Medications

• Maryland's 2015 law studied
• No change in potentially harmful prescribing
• Neither worse nor better

Speaker notes: Lipori and Thorpe (2025) used synthetic control models to examine whether Maryland's 2015 full scope of practice law changed statewide rates of potentially harmful medication prescribing to adults aged 65 and older. They found no significant difference compared with a weighted comparison of similar states. The finding suggests that the law did not worsen prescribing safety for older adults, though it also did not improve it.

Slide 15: Patient Perceptions

• Favorable views of nurse practitioner care
• Limited public knowledge of scope
• A small sample

Speaker notes: In a small California survey of 24 patients, perceptions of care by nurse practitioners were significantly more favorable than perceptions of care by physicians, but respondents showed substantial gaps in knowledge of nurse practitioner scope and of the legislation (Hemp et al., 2026). The sample is too small to generalize, but the knowledge gap is a finding our advocacy should address.

Slide 16: The Opposing Case

• Training differs in length and content
• Substitution trials studied supervised care
• Physicians argue for team-based oversight

Speaker notes: The strongest opposing argument is not that nurse practitioners provide poor care but that the evidence for independent practice is weaker than advocates claim. Bernard and Shaffer (2026) reanalyzed the 82 trials in a widely cited Cochrane review of nurse-physician substitution and found that only 10 evaluated inpatient care, all with stable or selected patients in physician-led systems, and that none evaluated independent nurse-led management of hospitalized or intensive care patients. They concluded that the evidence supports protocolized care within physician-led teams.

Slide 17: Weighing the Evidence

• Mostly observational, natural experiment designs
• State categories hide variation
• Outcomes rarely worse, often better

Speaker notes: Most studies of full practice authority are observational, using difference-in-differences or synthetic control designs that compare states before and after a change. These are reasonable designs, but they cannot rule out every alternative explanation, and state categories hide real differences in rules. Taken together, the studies rarely find worse outcomes and often find better access. Bernard and Shaffer's (2026) critique is fair about hospital substitution, but most full practice authority studies concern community and primary care.

Slide 18: Law Alone Is Not Enough

• Credentialing and privileging
• Billing and reimbursement
• Workforce deployment and governance

Speaker notes: The most important finding for policymakers may be that legal authority does not produce benefits by itself. Koyuncu et al. (2026) concluded that the benefits of full practice authority depended on integration mechanisms, including credentialing and privileging, billing and reimbursement, workforce deployment and organizational governance, and recommended that reforms be designed as packages rather than stand-alone changes. Our recommendations reflect that conclusion.

Slide 19: What Changes for Nurse Practitioners

• More autonomous practice settings
• Higher earnings, practice ownership
• Visits billed under their own numbers

Speaker notes: For nurse practitioners, full practice authority changes the conditions of work. Slade et al. (2025) found greater practice autonomy in full practice states, with larger changes where the laws had been in place more than ten years. Tracy et al. (2023) found that nurse practitioners in full practice states had higher mean earnings, were more likely to own practices and billed a greater share of visits under their own provider numbers, making their work visible in data.

Slide 20: What Changes for Registered Nurses and Teams

• New roles in nurse practitioner-led clinics
• Different consultation patterns
• Clearer accountability

Speaker notes: Registered nurses will feel the change as well. Nurse practitioner-led clinics, especially in rural areas, employ registered nurses in care coordination, chronic disease management and triage, and those roles grow when clinics can open without a physician agreement. In hospitals and teams, consultation becomes a clinical choice rather than a legal requirement, and accountability for decisions becomes clearer.

Slide 21: What Changes for Education

• Preparation for independent accountability
• Transition-to-practice periods
• Fellowships and residencies

Speaker notes: Graduate programs must prepare nurse practitioners for independent accountability, including business, legal and quality responsibilities that supervision agreements once shared. Our state's bill includes a supervised transition period for new graduates, a common feature of recent laws. Postgraduate fellowships and residencies offer another bridge, and educators should consider how to build them into the path from graduation to independent practice.

Slide 22: What Changes for Nurse Leaders

• Credentialing and privileging processes
• Peer review by nurse practitioners
• Governance that includes advanced practice

Speaker notes: Nurse leaders carry much of the integration work Koyuncu et al. (2026) describe. Hospitals and health systems must credential and privilege nurse practitioners on their own merits, establish peer review by nurse practitioners and include advanced practice nurses in medical staff or professional governance. Leaders who prepare these structures before a law passes will help their organizations realize its benefits.

Slide 23: Misconceptions Within the Profession

• 67.4% preferred full practice authority
• 81.5% claimed strong understanding
• About 25% of those held misconceptions

Speaker notes: Advocacy depends on accurate knowledge, and the profession has work to do. In a survey of 1,281 Tennessee advanced practice registered nurses, 67.4% preferred full practice authority and 81.5% reported a strong understanding of it, yet analysis of open-ended responses found that about a quarter of those reporting high understanding held misconceptions about its scope and implications (Miller & Barut, 2026). Education must precede advocacy.

Slide 24: Public Understanding

• Patients value nurse practitioner care
• Few understand the law
• Advocacy must inform, not only persuade

Speaker notes: The public knowledge gap found by Hemp et al. (2026) matters for advocacy. Legislators respond to constituents, and constituents who do not understand what nurse practitioners can do, or what the law currently requires, cannot weigh the debate. Our advocacy recommendations therefore include public education that explains the policy plainly rather than campaigns that only ask for support.

Slide 25: Ethics: Justice and Access

• Fair distribution of care
• Rural and underserved communities
• Restrictions carry costs too

Speaker notes: The principle of justice asks whether care is distributed fairly. The evidence on shortage areas and rural practice suggests that restrictive rules fall hardest on rural and underserved communities, where physicians willing to sign agreements may be scarce. Restrictions are often presented as cost-free protections, but limiting access is itself a potential harm that an ethical analysis must weigh. A rule that protects patients in theory but leaves a county without a prescriber has not avoided harm; it has only made the harm harder to see.

Slide 26: Ethics: Safety and Nonmaleficence

• Do no harm applies to both sides
• Monitor acute care outcomes
• Build quality oversight into the law

Speaker notes: Nonmaleficence, the duty to avoid harm, applies to both sides of the debate. Opponents rightly ask whether independent practice could harm patients; supporters rightly ask whether lack of access does. The mixed pediatric findings (McMichael, 2026) suggest that a responsible law should include monitoring of outcomes and quality oversight, so that any harms are detected and addressed.

Slide 27: A Christian Worldview

• Care for the least of these
• Stewardship of gifts
• Truthfulness in advocacy

Speaker notes: Jesus taught that care given to the hungry, the sick and the stranger is care given to him (English Standard Version Bible, 2001/2016, Matthew 25:35-40), which calls Christian nurses to ask who goes without care under current rules. The parable of the talents commends using gifts fully rather than burying them (English Standard Version Bible, 2001/2016, Matthew 25:14-30). Faith also requires truthfulness, so Christian advocates must present the evidence honestly, including findings that complicate their case.

Slide 28: How Nurses Engage the Debate

• Know the evidence and the bill
• Build coalitions and relationships
• Testify, write and educate

Speaker notes: Muswede and Matahela (2026) analyzed political astuteness in nurse leadership and found it made up of reading the strategic situation, understanding policy, advocating, working with stakeholders and reasoning ethically, with experience in governance and emotional intelligence among the conditions that develop it. For our state, that means knowing the bill's text, meeting legislators and their staff, working with nursing organizations, testifying at hearings and offering constituents accurate information.

Slide 29: Our Recommendations

• Support the bill with a transition period
• Pair it with integration measures
• Require outcome monitoring and reporting

Speaker notes: Based on the evidence, we recommend that nurses support the bill, including its supervised transition period for new graduates. We also recommend amendments that reflect the integration evidence: requirements that payers credential nurse practitioners directly, guidance on hospital privileging, and a requirement that the state report access and quality outcomes, including pediatric acute care admissions, for five years after the change.

Slide 30: Conclusion

• Access improves, outcomes rarely worsen
• Integration determines benefit
• Nurses must lead with evidence and integrity

Speaker notes: The evidence suggests that full practice authority improves access, especially where shortages are worst, and rarely worsens outcomes, though some findings call for monitoring. The benefits depend on integration, which nurse leaders can shape. Our profession's credibility in this debate rests on presenting the evidence fairly and on caring for the patients who need us most. Thank you; we welcome your questions.

References

Bernard, R., & Shaffer, P. (2026). Misleading at best: A critical appraisal of "Nurse-physician substitution in hospital settings." Missouri Medicine, 123(4), 284-287.

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Fitzpatrick, J. J., Duffy, E. G., Mehlman, M., Votruba, M., Gerlick, J. A., Dower, C. M., Davis, S., Plemmons, A., & Norful, A. A. (2026). Variations in nurse practitioner full practice authority in the United States: Difference in difference analysis of access and health performance at a national level. Health Policy OPEN, 10, Article 100167. https://doi.org/10.1016/j.hpopen.2026.100167

Goudreau, K. A., & Smolenski, M. C. (Eds.). (2014). Health policy and advanced practice nursing: Impact and implications. Springer Publishing Company.

Hemp, N., Walker-Vischer, L., & Rose, J. (2026). Patient perception of nurse practitioner care, nurse practitioner scope of practice, and how that influences provider choice. Journal of the American Association of Nurse Practitioners, 38(2), 77-84. https://doi.org/10.1097/JXX.0000000000001204

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://doi.org/10.17226/12956

Koyuncu, F., Sengul, T., Sarıköse, S., Shoqirat, N., Marsh, Z., Minnick, J., İyigün, E., Kirkland-Kyhn, H., & Singh, C. (2026). Global regulatory and policy pathways for nurse practitioners and their health system contributions: A systematic review. Nursing Outlook, 74(5), Article 102848. https://doi.org/10.1016/j.outlook.2026.102848

Lipori, J., & Thorpe, J. (2025). Impact of Maryland's 2015 nurse practitioner full scope of practice law on statewide rates of outpatient potentially harmful medication prescribing to older adults. Medical Care, 63(8), 588-593. https://doi.org/10.1097/MLR.0000000000002163

McMichael, B. J. (2021). Nurse practitioner scope-of-practice laws and opioid prescribing. The Milbank Quarterly, 99(3), 721-745. https://doi.org/10.1111/1468-0009.12524

McMichael, B. J. (2025). The impact of nurse practitioner scope-of-practice laws on preventable hospitalizations. Journal of Health Economics, 103, Article 103044. https://doi.org/10.1016/j.jhealeco.2025.103044

McMichael, B. J. (2026). Nurse practitioner scope-of-practice laws and preventable pediatric hospitalizations. Medical Care Research and Review, 83(4), 239-250. https://doi.org/10.1177/10775587261420485

Miller, M. D., & Barut, J. C. (2026). Attitudes, perceptions, and beliefs related to full practice authority for advanced practice registered nurses. Journal of the American Association of Nurse Practitioners, 38(10), 837-846. https://doi.org/10.1097/JXX.0000000000001315

Muswede, N. J., & Matahela, V. E. (2026). Political astuteness in nurse leadership: A concept analysis. Journal of Nursing Management, 2026(1), Article e7258276. https://doi.org/10.1155/jonm/7258276

Pitts, C. J., & Lindley, L. C. (2026). The impact of nurse practitioner state practice regulation on health and health outcomes: An integrative review. Journal of the American Association of Nurse Practitioners, 38(7), 487-495. https://doi.org/10.1097/JXX.0000000000001264

Slade, E. P., DePriest, K., Commodore-Mensah, Y., Samuel, L., Hanson, G. C., & D'Aoust, R. (2025). State full practice authority regulations and nurse practitioner practice autonomy: Evidence from the 2018 National Sample Survey of Registered Nurses. Medical Care Research and Review, 82(1), 68-78. https://doi.org/10.1177/10775587241282163

Tracy, C., Russell, N. G., DePriest, K., Knestrick, J., D'Aoust, R., & Slade, E. (2023). The impact of full practice authority on nurse practitioner compensation, collaboration, and billing. Journal of the American Association of Nurse Practitioners, 35(11), 691-698. https://doi.org/10.1097/JXX.0000000000000918