psychiatric/mental health. Most NPs train in primary care; however, increasing numbers are being trained in acute care medicine and other specialty disciplines (Cooper, 1998).

The growing use of APRNs and physician assistants has helped ease access bottlenecks, reduce waiting times, increase patient satisfaction, and free physicians to handle more complex cases (Canadian Pediatric Society, 2000; Cunningham, 2010). This is true of APRNs in both primary and specialty care. In orthopedics, the use of APRNs and physician assistants is a long-standing practice. NPs and physician assistants in gastroenterology help meet the growing demand for colon cancer screenings in either outpatient suites or hospital endoscopy centers. Because APRNs and physician assistants in specialty practice typically collaborate closely with physicians, legal scope-of-practice issues pose limited obstacles in these settings.

Variation in Nurse Practitioner Scope-of-Practice Regulations

Regulations that define scope-of-practice limitations vary widely by state. In some states, they are very detailed, while in others, they contain vague provisions that are open to interpretation (Cunningham, 2010). Some states have kept pace with the evolution of the health care system by changing their scope-of-practice regulations to allow NPs 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 NPs are able to do once they graduate varies widely across the country for reasons that are related not to their ability, their education or training, or safety concerns (Lugo et al., 2007) but to the political decisions of the state in which they work. For example, one group of researchers found that 16 states plus the District of Columbia have regulations that allow NPs to see primary care patients without supervision by or required collaboration with a physician (see Figure 3-3). As with any other primary care providers, these NPs refer patients to a specialty provider if the care required extends beyond the scope of their education, training, and skills.

Other legal practice barriers include on-site physician oversight requirements, chart review requirements, and maximum collaboration ratios for physicians who collaborate with more than a single NP. See Safriet (2010, Appendix H on the CD-ROM in the back of this book) for further discussion of inconsistencies in the regulation of NP practice at the state level.

There are fundamental contradictions in this situation. Educational standards—which the states recognize—support broader practice by all types of APRNs. National certification standards—which most states also recognize—likewise support broader practice by APRNs. Moreover, the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by the decades of research that has examined this question (Brown and Grimes, 1995; Fairman, 2008; Groth et al., 2010; Hatem et al.,



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