riers have limited nurses’ ability to generate widespread transformation. Other barriers include fragmentation of the health care system, high rates of turnover among nurses, difficulties for nurses transitioning from school to practice, and an aging workforce and other demographic challenges. Many of these barriers have developed as a result of structural flaws in the U.S. health care system; others reflect limitations in the present work environment or the capacity and demographic makeup of the nursing workforce itself. Regulatory barriers are particularly problematic.

Regulations defining scope-of-practice limitations vary widely by state. Some are highly detailed, while others contain vague provisions that are open to interpretation. Some states have kept pace with the evolution of the health care system by changing their scope-of-practice regulations to allow nurse practitioners to see patients and prescribe medications without a physician’s supervision or collaboration. However, the majority of state laws lag behind in this regard. As a result, what nurse practitioners are able to do once they graduate varies widely for reasons that are related not to their ability, education or training, or safety concerns, but to the political decisions of the state in which they work. Depending on the state, restrictions on the scope of practice of an advanced practice registered nurse may limit or deny altogether the authority to prescribe medications, admit patients to the hospital, assess patient conditions, and order and evaluate tests.

Because many of the problems related to varied scopes of practice are the result of a patchwork of state regulatory regimes, the federal government is especially well situated to promote effective reforms by collecting and disseminating best practices from across the country and incentivizing their adoption. Specifically, the Federal Trade Commission has a long history of targeting anticompetitive conduct in the health care market, including restrictions on the business practices of health care providers, as well as policies that could act as a barrier to the entry of new competitors in the market. As a payer and administrator of health insurance coverage for federal employees, the Office of Personnel Management and the Federal Employees Health Benefits Program have a responsibility to promote and ensure the access of employees/subscribers to the widest choice of competent, cost-effective health care providers. Principles of equity would suggest that this subscriber choice should be promoted by policies ensuring that full, evidence-based practice is permitted to all providers regardless of geographic location. Finally, the Centers for Medicare and Medicaid Services has the responsibility to promulgate rules and policies that promote Medicare and Medicaid beneficiaries’ access to appropriate care, and therefore can ensure that its rules and polices reflect the evolving practice abilities of licensed providers.

In addition to barriers related to scope of practice, high turnover rates among newly graduated nurses highlight the need for a greater focus on managing the transition from school to practice. In 2002, the Joint Commission recommended the development of nurse residency programs—planned, comprehensive periods of time during which nursing graduates can acquire the knowledge and skills to



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