discussion: Professional Nursing and State-Level Regulations

American Academy of Nursing on Policy

* Corr
E-m

0029-6
https:/

Position statement: Full practice authority for
advanced practice registered nurses is necessary to

transform primary care

Jordon Bosse, MS, RN(Academy Jonas Policy Scholar),

Katherine Simmonds, MS, MPH, RN, WHNP-BC(Academy Jonas Policy Scholar),
Charlene Hanson, EdD, RN, CS, FNP-BC, FAAN,
Joyce Pulcini, PhD, RN, FNP-BC, FAAN, FAANP,
Lynne Dunphy, PhD, FNP-BC, FAAN, FAANP*,

Patricia Vanhook, PhD, RN, FNP-BC, FAAN, Lusine Poghosyan, PhD, MPH, RN, FAAN
American Academy of Nursing Primary Care Expert Panel

Executive Summary

Lack of full practice authority (FPA) for advanced
practice registered nurses (APRNs) is a barrier to the
provision of efficient, cost-effective, high-quality, and
comprehensive health care services for some of our
most vulnerable citizens (Agency for Healthcare
Research and Quality, 2014; Buerhaus, DesRoches,
Dittus, & Donelan, 2015; Pohl et al., 2010a; Seibert,
Alexander, & Lupien, 2004). APRNs have the educa-
tion, knowledge, skills, and experience necessary to
provide basic and comprehensive primary care ser-
vices; they are a ready workforce, ideally positioned
to improve access to care, contribute to health dis-
parities reduction efforts, and lower the cost of
providing such care (National Center for Workforce
Analysis Health Resources and Services
Administration, 2013; Perloff, DesRoches, &
Buerhaus, 2016). However, barriers at the state and
national levels continue to prevent these highly
qualified health care providers from practicing to the
full extent to which their education and training have
prepared them. It is the position of the American
Academy of Nursing (academy) that FPA of APRNs is
essential to achieving health equity.

Background

Despite the increase in the number of individuals who
obtained health insurance under the Patient Protection
and Affordable Care Act (ACA), 17% of U.S. women and
28% of U.S. men did not have access to primary care

esponding author: Lynne Dunphy, Primary Care and Care Coord
ail address:

[email protected]

(L. Dunphy).

554/$ – see front matter � 2017 Elsevier Inc. All rights reserved
/doi.org/10.1016/j.outlook.2017.10.002

services in 2013 to 2015 (The Henry J. Kaiser Family
Foundation, 2016a, 2016b). Rates of primary care
access varied by race and ethnicity, with people from
racial and ethnic minority backgrounds having least
access; twice as many Hispanic men (47%) than white
men (23%) reported not having a doctor (The Henry J.
Kaiser Family Foundation, 2016a, 2016b). Other
marginalized populations, including older adults,
people who are poor or who live in rural areas, and
people who are gay, lesbian, bisexual, transgender
(including nonbinary or genderqueer), among others
also have reduced access to comprehensive health
services including primary care (Gates, 2014; Mather,
Jacobsen, & Pollard, 2015; Ritchie, 2014; Ward,
Schiller, Freeman, & Clarke, 2015; Weaver et al., 2014).
People who do not have primary care providers have
less access to the health care system as a whole, are
less likely to obtain preventative health care services,
and have worse health (Starfield, Shi, & Mackinko,
2005), contributing to increased health care costs and
increased mortality (Hossain, Ehtesham, Salzman,
Jenson, & Calkins, 2013; Office of Disease Prevention
and Health Promotion, 2010; Weaver et al., 2014). The
proposed repeal and potential replacement of the ACA
(along with state Medicaid expansions, tax credits, and
some coverage provisions) is concerning as it will
dramatically increase the number of individuals who
do not have access to basic health services, including
primary care (Congressional Budget Office, 2017).
Essential health benefits, such as emergency services,
maternity and newborn care, preventive and wellness
services, and chronic disease management, also face
an uncertain future; if this coverage is eliminated,
existing health disparities are likely to worsen

ination Expert Panel.

.

2 CPAs require that APRNs deliver care with physician over-
sight. APRNs often must pay for this mandated oversight and
receive little actual oversight. Sometimes, these agreements are
temporary, as in the case of transition-to-practice periods, which

Nur s Out l o o k 6 5 ( 2 0 1 7 ) 7 6 1e 7 6 5762

(Congressional Budget Office, 2017). Access to high-
quality, affordable, and comprehensive primary care
health care services is critical to the health of our
nation, and APRNs can help meet this need (Josiah
Macy, 2010; Lenz, Mundinger, Kane, Hopkins, & Lin,
2004).

APRN Workforce, Roles, and Scope of Practice

There are four distinct APRN roles: nurse practitioner
(NP), certified nurse midwife (CNM), clinical nurse
specialist (CNS), and certified registered nurse anes-
thetist (CRNA). Each role has a specific scope of practice
that is based on their unique educational preparation
and training and allows them to contribute to primary
care in distinct and important ways (Federation of
State Medical Boards, 2017; Safriet, 2002). APRNs bring
a holistic as well as patient-centered and family-
centered approaches to the prevention and manage-
ment of complex health and behavioral issues
addressed in various care settings across the life span.
They work collaboratively with physicians and other
members of the health workforce to optimize patient
care and health. For example, NPs provide a range of
comprehensive care services to address individuals’
physical and mental health needs across the life span,
and CNMs provide primary sexual and reproductive
health services across the life span as well as post-
partum care, childbirth, and care of newborns (Phillippi
& Barger, 2015; Pohl et al., 2010b). CNSs and CRNAs
increase access to affordable care services for pop-
ulations in rural areas (Seibert et al., 2004). APRNs
provide needed services to some of the most vulner-
able populations in our society, including individuals
from racial and ethnic minorities, Medicaid and Medi-
care recipients, residents of rural and frontier areas,
and the uninsured and underinsured (Agency for
Healthcare Research and Quality, 2014; Buerhaus
et al., 2015; Seibert et al., 2004).

The ability of APRNs to practice to the full extent of
their education and training is inextricably linked to
state-level scope of practice1 laws and regulations
(National Coalition of State Boards of Nursing [NCSBN],
2008). At the state level, scope of practice for nurses is
established either by legislative statute or by regula-
tion, the Board of Nursing (BON), or other executive
agencies (Buppert, 2014). Scope of practice in many
states is limited by Board of Medicine (BOM) and/or
Board of Pharmacy (BOP) oversight, removing the au-
thority of nursing to govern APRN practice and licen-
sure, and the ability for APRNs to practice to the full
extent of their training as part of organized interpro-
fessional health care teams (Hanson, 2014; Pohl et al.,
2010a). Requirements such as mandated collaborative

1 Scope of practice refers to “the activities that an individual
health care practitioner is permitted to perform within a specific
profession. Those activities should be based on appropriate ed-
ucation, training, and experience” (Federation of State Medical
Boards, 2017; p. 8).

practice agreements (CPAs) and physician-supervised
transition-to-practice periods2 increase the cost of
providing care, lead to gaps in care, and deter APRNs
from working in these restrictive states, without any
demonstrated improvement in safety or quality
(Fauteux, Brand, Fink, Frelick, & Werrlien, 2017;
Kleiner, Marier, Park, & Wing, 2014; Safriet, 2011).

State-level challenges to APRN FPA have been
exacerbated by ambiguities at the federal level. For
example, failure to define APRNs as primary care pro-
viders under the ACA left this matter up to individual
states, which contributed to barriers to FPA such as
inconsistent policies regarding reimbursement for
services delivered by APRNs, including lower payment3

rates (Brooks Carthon, Barnes, & Altares Sarik, 2015;
Kurtzman et al., 2017; Safriet, 2002, 2011). Centers for
Medicaid and Medicare prohibit APRNs from common
tasks such as conducting admission evaluations and
monthly assessments of patients admitted to skilled
nursing facilities (American Association of Nurse
Practitioners, 2012). In some cases, APRNs who have
been authorized to perform within the full scope of
their practice are later denied reimbursement for their
services (Government Accountability Office, 2014),
which limits patients’ access to care. FPA for all
APRNs in every state is further impeded by lack of
consumer awareness of the type and amount of
training APRNs receive and the services that they
can provide, opposition from professional medical
associations, and legislators who are tired from
previous legislative attempts to widen APRN scope of
practice (Safriet, 2011).

The Benefits of FPA

In states where NPs have FPA, benefits to patients, the
health care system, and payers have been identified,
including:

� Significantly fewer emergency room visits for
nonemergency health care (Traczyndski & Udalova,
2013), lower hospitalization rates (Oliver,
Pennington, Revelle, & Rantz, 2014), and expanded
health care utilization, particularly among the most
vulnerable (Traczyndski & Udalova, 2013; Xue, Ye,
Brewer, & Spetz, 2016).

� Care provided at lower cost than physicians,
including preventative care (Perloff et al., 2016;
Traczyndski & Udalova, 2013).

exist in 10 states. In these states, transition to practice requires
that APRNs have physician oversight for a varying number of
hours or years after which they can apply to work independently
(Phillips, 2015).

3 Nurse practitioners are reimbursed at rates of 65% to 85%
lower than physicians for providing the same services of the
same quality (Kurtzman et al., 2017; Safriet, 2011).

Nur s Ou t l o o k 6 5 ( 2 0 1 7 ) 7 6 1e 7 6 5 763

� Fewer prescriptions for drugs commonly linked to
overdose deaths (Schirle & McCabe, 2016).

� Reports of increased teamwork between NPs
and physicians in primary care organizations
(Poghosyan, Boyd, & Knutson, 2014).

Policies and Positions

2008: NCSBN releases the Campaign for Consensus
(NCSBN, 2008), an initiative to encourage states to
implement a consensus model for the standardization
of regulatory requirements, such as licensure, accred-
itation, certification, and education of all four roles of
APRNs.

2010: The Future of Nursing report is released inwhich
The National Academy of Sciences, Engineering, and
Medicine (formerly the Institute of Medicine) in
collaboration with the Robert Wood Johnson Founda-
tion (RWJF) called for “nurses to practice to the full
extent of their education and training. [and].should
be full partners, with physicians and other healthcare
professionals, in redesigning healthcare in the United
States” (Institute of Medicine, 2011; p. 4).

The ACA is passed, and in anticipation of the need to
bolster primary care services, key provisions sought to
increase access to clinical placements among graduate
nursing students, the number of NPs who provide care
in medically underserved areas, and access to primary
care by the nation’s poor and underserved individuals
(Brooks Carthon et al., 2015).

2010: The Center to Champion Nursing in America
(CCNA)4 provided its support for The Future of Nursing
and supported the development of state-level action
coalitions to work on building infrastructure to imple-
ment the report’s recommendations (Brown, 2012). By
2012, 48 states had active state-level coalitions (Brown,
2012).

2016: The Veteran’s Administration (VA) finalizes a
rule allowing three types of APRNs (NPs, CNMs, and
CNSs) who work within the VA to have unrestricted
practice authority for their work in the VA regardless of
the state in which the individual VA hospital or facility
is located (U.S. Department of Veterans Affairs, 2016).

2017: The ACA is in jeopardy, and an additional 14
million U.S. citizens would be without health insur-
ance in 2018 (Congressional Budget Office, 2017). Pro-
posed cuts to reproductive health and family planning
reimbursement and essential health benefits threaten
the health of our most vulnerable citizens
(Congressional Budget Office, 2017).

American Academy of Nursing’s Position

Health care is a human right; as such, the increasing
health care needs of the public, existence of disparities,
and decreasing availability of primary care providers

4 A collaboration between RWJF, the AARP, and AARP
foundation.

are of concern to the academy. Allowing APRNs to have
FPA has the potential to improve health equity while
providing care that costs patients, health care systems,
and payers less money. Furthermore, APRNs who are
able to work to the full extent of their education and
training have greater potential to identify creative ap-
proaches for solving problems within these systems,
which will benefit nursing as a discipline, the larger
health care community, and most importantly the
public whom we serve (Safriet, 2011).

Therefore, the academy stands with the NCSBN,
National Academies of Sciences, Engineering, and
Medicine, RWJF, American Association of Retired Per-
son (AARPs), CCNA, VA, National Governor’s Associa-
tion (National Governors Association, 2012), American
Hospital Association (American Hospital Association,
2013), Federal Trade Commission (Federal Trade
Commission, 2014), and others in favor of removing
all practice restrictions on APRNs, allowing them to
practice independently and to the full extent of their
education, training, and experience. We are also in
favor of eliminating barriers to FPA such as BOM and
BOP oversight and mandated CPA requirements.
Furthermore, APRNsmust be recognized for the quality
of care that they provide and should be able to be
reimbursed directly and at the same rate as physicians.

To this end, we provide the following
recommendations:

� Congress should (a) reform the public and private
payment systems to allow equitable independent
reimbursement for APRN delivery of primary care in
all settings, allowing direct remuneration from
Medicare, Medicaid, and private payers for the care
that is provided by APRNs; (b) enact global signature
authority to allow APRNs to sign or complete forms
related to patient care within their state, including
ordering home health care; (c) allow nurse-led pro-
grams such as nurse-managed health centers to be
acknowledged as essential community providers
and reimbursed by Medicaid at 100%; (d) allow
APRNs to join and independently operate account-
able care organizations; and (e) standardize reim-
bursement reporting policies to help facilitate more
throughput in health care systems (Josiah Macy,
2010).

� State Boards of Nursing should (a) remove all barriers
and restrictions for APRNs in all four roles, in all
states and federal agencies and clarify credentialing
requirements for each role; and (b) ensure that scope
of practice regulations conform with the NCSBN
Practice Act and Model Nursing Administrative Rules
(NCSBN, 2012) as suggested in The Future of Nursing
report.

� State and federal legislators, policymakers, and
public and private payers should use provider neutral
language (e.g., replace physician with clinician or
provider) in all state and federal health care legisla-
tion and reimbursement-related policies.

Nur s Out l o o k 6 5 ( 2 0 1 7 ) 7 6 1e 7 6 5764

� The VA should continue to support FPA for NPs,
CNMs, and CNSs by making FPA mandatory in all VA
facilities and amend the rule to grant CRNAs FPA as
well.

� The Workforce Commission and Health Research
Services Administration should be fully funded to
provide leadership and develop infrastructure for
collecting and analyzing interdisciplinary health care
workforce data in collaboration with state licensing
boards to assist in planning of future workforce
needs (Schirle & McCabe, 2016).

� Nursing organizations and consumer-based organi-
zations should work together to develop messages
targeting consumers that aim to improve the public’s
understanding about the role and duties of APRNs
(Safriet, 2011) and that “projects the image of APRNs
as . professionals who are strong and competent”
(Lugo, 2016) to provide health care services in all
practice settings and all individuals, andwho do so in
collaboration with other members of the interdisci-
plinary care team.

Acknowledgments

The academy acknowledges the work of the members
of the Primary Care Expert Panel.

r e f e r e n c e s

Agency for Healthcare Research and Quality. (2014). Primary care
workforce facts and stats no. 3. Agency for Healthcare Research
and Quality, Rockville, MD. Retrieved from http://www.ahrq.
gov/research/findings/factsheets/primary/pcwork3/index.
html

American Association of Nurse Practitioners. (2012). Fact sheet:
Long term care. Retrieved from https://www.aanp.org/
legislation-regulation/federal-legislation/68-articles/351-fact-
sheet-long-term-care

American Hospital Association. (2013). Workforce roles for
redesigned primary care. Retrieved from http://www.aha.org/
content/13/13-0110-wf-primary-care.pdf

Brooks Carthon, J. M., Barnes, H., & Altares Sarik, D. (2015). Federal
polices influence access to primary care and nurse practitioner
workforce. The Journal for Nurse Practitioners, 11(5), 526e530.

Brown MH. (2012). The center to champion nursing in America: A
progress report. Retrieved from http://www.rwjf.org/content/
dam/farm/reports/program_results_reports/2012/rwjf72607

Buerhaus, P. I., DesRoches, C. M., Dittus, R., & Donelan, K. (2015).
Practice characteristics of primary care nurse practitioners
and physicians. Nursing Outlook, 63(2), 144e153.

Buppert, C. (2014). Nurse practitioners business and legal guide (5th
ed.) Burlington, MA: Jones & Bartlett Publishers.

Congressional Budget Office. (2017). H.R. 1628, American
Health Care Act of 2017. Washington, D.C. Congressional
Budget Office. Retrieved from https://www.cbo.gov/
publication/52752

Fauteux N, Brand R, Fink J, Frelick M, Werrlien D. (2017). The case
for removing barriers to APRN practicedRobert Wood Johnson
Foundation. Princeton, NJ: The Robert Wood Johnson
Foundation. Retrieved from http://www.rwjf.org/en/library/

research/2017/03/the-case-for-removing-barriers-to-aprn-
practice.html

Federal Trade Commission. (2014). Policy perspectives: Competition
and the regulation of advanced practice nursing. Washington, D.C.:
Federal Trade Commission. Retrieved from https://www.ftc.
gov/system/files/documents/reports/policy-perspectives-
competition-regulation-advanced-practice-nurses/
140307aprnpolicypaper.pdf

Federation of State Medical Boards. Assessing scope of practice in
health care delivery: Critical questions in assuring public
access and safety. Retrieved from https://www.fsmb.org/
Media/Default/PDF/FSMB/Advocacy/2005_grpol_scope_of_
practice.pdf

Gates, G. J. (2014). In U.S., LGBT more likely than non-LGBT to be
uninsured; LGBT adults more likely to lack a personal doctor and
enough money for healthcare. Los Angeles, CA: Gallup Poll News
Service. 2014. Retrieved from http://bit.ly/2zFkunV

Government Accountability Office. (2014). Nurse anesthetists billed
for few chronic pain procedures: Implementation of CMS payment
policy inconsistent. Washington, DC: Government
Accountability Office.

Hanson, C. (2014). Understanding regulatory, legal, and
credentialing requirementsjnurse key. In Hamric, A.,
Hanson, C., Tracy, M., & O’Grady, E. (Eds.), Advanced practice
nursing: An integrative approach (5th ed.). (pp. 557e558) St.
Louis, MO: Elsevier.

Hossain, W. A., Ehtesham, M. W., Salzman, G. A., Jenson, R., &
Calkins, C. F. (2013). Healthcare access and disparities in
chronic medical conditions in urban populations. Southern
Medical Journal, 106(4), 246e254.

Institute of Medicine. (2011). The future of nursing: Leading
change, advancing health. Washington, DC: National
Academies Press.

Josiah Macy Jr. Foundation. (2010). Who will provide primary care
and how will they be trained. Durham, NC: Josiah Macy Jr.
Foundation. Retrieved: http://ww.macyfoundation.org/docs/
macy_pubs/JMF_PrimaryCare_Monograph.pdf

Kleiner, M., Marier, A., Park, K. W., & Wing, C. (2014). Relaxing
occupational licensing requirements: Analyzing wages and
prices for a medical service. The Journal of Law and Economics,
59(2), 261e291.

Kurtzman, E. T., Barnow, B. S., Johnson, J. E., Simmens, S. J.,
Infeld, D. L., & Mullan, F. (2017). Does the regulatory
environment affect nurse practitioners’ patterns of practice or
quality of care in health centers? Health Services Research,
52(S1), 437e458.

Lenz, E. R., Mundinger, M. O., Kane, R. L., Hopkins, S. C., & Lin, L. S.
(2004). Primary care outcomes in patients treated by nurse
practitioners or physicians: Two-year follow-up. Medical Care
Research and Review, 61(3), 332e351.

Lugo, R. M. (2016). Full practice authority for advanced practice
registered nurses is a gender issue. Online Journal of Issues in
Nursing, 21(2), 6.

Mather M, Jacobsen LA, Pollard KM. (2015). Population bulletin. 70.
Retrieved from http://www.prb.org/pdf16/aging-us-
population-bulletin.pdf

National Center for Workforce Analysis. (2013). Projecting the
supply and demand for primary care practitioners through
2020. Rockville, MD: Health Resources and Services
Administration Bureau of Health Professions. Retrieved from
http://bhpr.hrsa.gov/healthworkforce/index.html

National Coalition of State Boards of Nursing. (2008). Consensus
model for APRN regulation: Licensure, accreditation,
certification & education. Chicago, IL: APRN Consensus Work
Group & the National Council of State Boards of Nursing APRN
Advisory Committee. Chicago, IL: Retrieved from https://www.
ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.
pdf

Nur s Ou t l o o k 6 5 ( 2 0 1 7 ) 7 6 1e 7 6 5 765

National Council of State Boards of Nursing. (2012). NCSBN model
act. Chicago, IL. Retrieved from. https://www.ncsbn.org/14_
Model_Act_0914.pdf

National Governors Association. (2012). Nurse practitioners have
potential to improve access to primary care. Retrieved from
http://www.nga.org/files/live/sites/NGA/files/pdf/
1212NursePractitionersPaper.pdf

Office of Disease Prevention and Health Promotion. (2010). Access
to health services. Washington, DC: United States Department
of Health and Human Services. Retrieved from. https://www.
healthypeople.gov/2020/topics-objectives/topic/Access-to-
Health-Services#7

Oliver, G. M., Pennington, L., Revelle, S., & Rantz, M. (2014). Impact
of nurse practitioners on health outcomes of Medicare and
Medicaid patients. Nursing Outlook, 62(6), 440e447.

Perloff, J., DesRoches, C. M., & Buerhaus, P. (2016). Comparing the
cost of care provided to Medicare beneficiaries assigned to
primary care nurse practitioners and physicians. Health
Services Research, 51(4), 1407e1423.

Phillippi, J. C., & Barger, M. K. (2015). Midwives as primary care
providers for women. Journal of Midwifery & Women’s Health,
60(3), 250e257.

Phillips, S. J. (2015). 27th Annual APRN legislative update. The
Nurse Practitioner, 40(1), 16e42.

Poghosyan, L., Boyd, D., & Knutson, A. R. (2014). Nurse
practitioner role, independent practice, and teamwork in
primary care. The Journal for Nurse Practitioners, 10(7),
472e479.

Pohl, J. M., Hanson, C., Newland, J. A., & Cronenwett, L.
(2010a). Unleashing nurse practitioners’ potential to deliver
primary care and lead teams. Health Affairs (Millwood),
29(5), 900e905.

Pohl, J. M., Hanson, C. M., & Newland, J. A. (2010b). Nurse
practitioners as primary care providers: History, context, and
opportunities. In Who will provide primary care and how will they
be trained? (pp. 167e213). Durham, NC: Josiah Macy Jr.
Foundation.

Ritchie A. (2014). Access to primary care remains a challenge for
62 million Americans. Medical Economics, Practice
Management. Retrieved from http://medicaleconomics.
modernmedicine.com/medical-economics/content/tags/
affordable-care-act/access-primary-care-remains-challenge-
62-million-

Safriet, B. J. (2011). Federal options for maximizing the value of
Advanced Practice Nurses in providing. In The future of

nursing: Leading changes, advancing health (pp. 443e475).
Washington, D. C.: The National Academies Press.

Safriet, B. (2002). Closing the gap between can and may in health
care providers’ scopes of practice: A primer for policymakers.
Yale Journal of Regulation, 19, 301e334.

Schirle, L., & McCabe, B. E. (2016). State variation in opioid and
benzodiazepine prescriptions between independent and
nonindependent advanced practice registered nurse
prescribing states. Nursing Outlook, 64, 86e93.

Seibert, E. M., Alexander, J., & Lupien, A. E. (2004). Rural nurse
anesthesia practice: A pilot study.AANA Journal, 72(3), 181e190.

Starfield, B., Shi, L., & Mackinko, J. (2005). Contribution of primary
care to health systems and health. The Milbank Quarterly, 83(3),
457e502.

The Henry J. Kaiser Family Foundation. (2016a). Percent of women
who report having no personal doctor/health care provider, by race/
ethnicity. Menlo Park, CA: The Henry J. Kaiser Family
Foundation. Retrieved from http://www.kff.org/disparities-
policy/state-indicator/no-personal-doctor/?
currentTimeframe¼0&sortModel¼%7B%22colId%22:%
22Location%22,%22sort%22:%22asc%22%7D

The Henry J. Kaiser Family Foundation. (2016b). Percent of men who
report having no personal doctor/health care provider, by race/
ethnicity. Menlo Park, CA: The Henry J. Kaiser Family
Foundation. Retrieved from http://kaiserf.am/2yNLQsT

Traczyndski, J., & Udalova, V. (2013). Nurse practitioner
independence, health care utilization, and health outcomes.
Paper presented at the Fourth Annual Midwest Health
Economics Conference, Madison, WI.

U.S. Department of Veterans Affairs. (2016). VA grants full
practice authority to advance practice registered nurses.
Retrieved from https://www.va.gov/opa/pressrel/pressrelease.
cfm?id¼2847

Ward, B. W., Schiller, J. S., Freeman, G., & Clarke, T. C. (2015). Early
release of selected estimates based on data from the January-June
2015. Hyattsville, MD: National Health Interview Survey.

Weaver, R. G., Manns, B. J., Tonelli, M., Sanmartin, C.,
Campbell, D. J. T., Ronksley, P. E., & Hemmelgarn, B. R. (2014).
Access to primary care and other health care use among
western Canadians with chronic conditions: a population-
based survey. CMAJ Open, 2(1), E27eE34.

Xue, Y., Ye, Z., Brewer, C., & Spetz, J. (2016). Impact of state
nurse practitioner scope-of-practice regulation on health
care delivery: Systematic review. Nursing Outlook, 64(1),
71e85.