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The number of primary care physicians in the United States isn’t keeping pace with the demand for primary care that’s being fueled by a growing population, an aging population, and more people with medical insurance. Experts estimate a shortage of 20,000 primary care providers in the next few years. Advanced practice nurses could fill this void, but state regulations often stand in their way.

Advance practice nurses include nurse practitioners (NPs), certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists. Of these, NPs are most likely to deliver primary care. Advanced practice nurses must complete nationally accredited graduate programs and must pass a rigorous content exam to attain national certification. More than 50 years of research have demonstrated that NPs deliver safe and effective primary care.


In about half of all states, NPs have what’s called full practice authority. They are able to practice to the full extent of their professional education and training, in collaboration with other health professionals, but without needing to be supervised by a physician. By improving access to primary care, this helps improve the overall health of patients and decrease the cost of medical care. In the other states, laws limit what NPs are allowed to do. They must work under a physician’s supervision, with a written agreement outlining what services the NP can and cannot provide for patients, including limits on prescribing medications. Such requirements hinder the cost-effective deployment of NPs. They add to the cost of care without improving care.

I wondered why some states allow NPs to do what they were trained to do, and others don’t. I compared nursing regulations in states that supported the Equal Rights Amendment (ERA) in the 1980s to regulations in states that opposed the ERA. What I found is disappointing but not surprising: gender — 91 percent of nurses are women — plays a role.

Writing this month in the Online Journal of Issues in Nursing, I showed that 53 percent of states that supported the ERA give NPs full practice authority, compared to only 20 percent of states that opposed the ERA. In other words, states that did not support equality for women are less likely to support professional autonomy for a female-dominated profession such as nursing.


While the ERA votes occurred more than 40 years ago, the social and cultural perspectives on women’s roles that led either to a state’s approval or disapproval of the amendment likely persist today and influence current regulations for advanced practice nurses.

We need to modernize our views of women and how nurse practitioners are able to practice. It is high time to move away from the patchwork of varied regulations and requirements for nurse practitioners and update them across the country to align with the model recommended by the National Council of State Boards of Nursing. Recognizing nurse practitioners’ professional autonomy will be good for patients, the health care system, and NPs themselves.

Nancy Rudner Lugo is an adjunct professor at the George Washington University School of Nursing, where she teaches health policy, quality, and population health; an advanced practice registered nurse in a free clinic in Orlando, Fla; and a workplace health coach.

  • NPs are very limited. They get in over their heads and don’t know it, their decision making is not refined, and their lack of knowledge can be shocking. There’s less accountability and responsibility for a reason.

    My practice employes NPs, so I’m familiar with their abilities. I would not feel comfortable having an NP in my practice act without oversight. Even after years of practice, they have narrow limits. And there is an idea that NPs make good economical sense overlooks their tendency to overutilize. And to suggest that any of this is sexist is simply specious.

    Fortunatly there is a role for NPs, with physician oversight.

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