A Policy Analysis of Legally Required Supervision of Nurse Practitioners and Other Health Professionals.

The use of legally required supervision occurs across health professionals who provide similar services. Legally required supervision has the potential to disrupt the production of high-quality, cost-efficient, accessible health services across disciplines. This paper examines the effects of nurse practitioner collaborative practice agreements and similar models of health professional regulation, defined as legally required supervision, on the cost and delivery of health services. A policy analysis examines empirical, policy, and law literature between two health professionals providing a similar service. Analysis includes literature on dental hygienists, dentists, certified registered nurse anesthetists, midwives, nurse practitioners, physicians, and pharmacists. A framework for legally required supervision across health professionals is presented. Antecedents of legally required supervision include occupational licensure, reimbursement policy, and institutional policy. Legally required supervision inhibits provider entry to practice and the production of health services by supervised providers. The cost of care increases under legally required supervision. Costs are measured by wages for providers and the price of services for patients. This paper and proposed framework summarize the antecedents and consequences of legally required supervision. Discipline-specific antecedents and provider characteristics must be considered when calculating the full effect of legally required supervision on the delivery and cost of health services.

Supportive Practice Environments Are Associated With Higher Quality Ratings Among Nurse Practitioners Working in Underserved Areas.

Background: Deployment of nurse practitioners (NPs) to health professional shortage areas (HPSA) may help to address challenges in patient access to care. However, restrictive scope of practice imposed by regulatory and state legislative bodies or unsupportive organizational climates in clinical practice settings may constrain NP care delivery and perpetuate lower assessments of quality of care provided in these underserved communities. Purpose: The purpose of this study was to investigate the associations between state NP scope of practice regulations, NP practice environment, and self-reported ratings of quality of care in primary care practices located in HPSAs. Methods: This was a cross-sectional analysis of data from 1,972 participant NPs practicing across 1,711 primary care practices in six states representing full (Arizona and Washington), reduced (Pennsylvania and New Jersey), and restricted (California and Florida) NP scope of practice regulation. Survey data were merged with the Area Health Resource Files to determine practices located in primary care HPSAs. Logistic regression models estimated the relationship between quality ratings, scope of practice regulations, and practice environment scores while accounting for NP and practice characteristics. Results: Among all included NPs, 95.7% rated their practice as having "excellent," "very good," or "good" quality of care. Practice environments with higher scores had higher ratings of quality of care after accounting for NP and practice characteristics (OR = 3.73, 95% CI: 2.84, 4.89). Conclusion: Unsupportive clinical practice environments were associated with lower ratings of quality of care in HPSAs, suggesting that improvements in working conditions may be necessary adjuncts to greater deployment of NPs to improve primary care in shortage areas.