Strides Toward NP Full Practice Authority in 2023: What States Are Left?

“Nurse practitioners have been around for over 50 years. The evidence is clear that the quality of care delivered by nurse practitioners is outstanding. They open up access to quality care that is safe, effective, and affordable. Allowing nurse practitioners to have full practice authority is a way that Texas can improve the health outcomes, especially for our rural and medically underserved populations.”

Dr. Cynthia Weston, President of the Texas Nurse Practitioners Association, Associate Dean and Associate Professor at Texas A&M University College of Nursing

Nurse practitioners provide a wide range of preventive and therapeutic health services, including conducting physical exams, diagnosing and treating illnesses, ordering medical tests, prescribing medications, and providing patient education and counseling. They offer a high level of care that is both cost-effective and accessible. 

To become a nurse practitioner, registered nurses must have a master’s degree in nursing and complete extensive clinical training. Despite board-certified nurse practitioners’ high level of expertise, many states restrict their practice authority by requiring collaborative agreements with supervising physicians or limiting prescriptive authority. 

“Nurse practitioners have been around for over 50 years. The evidence is clear that the quality of care delivered by nurse practitioners is outstanding. They open up access to quality care that is safe, effective, affordable,” says Dr. Cynthia Weston, president of the Texas Nurse Practitioners Association, associate dean for clinical and outreach affairs, and associate professor at Texas A&M University College of Nursing. “Allowing nurse practitioners to have full practice authority is a way that Texas can improve the health outcomes, especially for our rural and medically underserved populations.”

Many states are making strides to reduce restrictions on nurse practitioners, but much work still needs to be done. Currently, 17 states require physician supervision for the duration of a nurse practitioner’s career, while in the rest of the states, nurse practitioners either have full practice authority upon licensure, or they can earn it after completing a required number of supervised work hours or years under a physician or nurse practitioner. 

Many states are changing laws to decrease the requirements towards full practice authority. “Virginia recently revised their five-year requirement to only two years,” shares Dr. Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California San Francisco.

Keep reading to learn more about the movement towards full practice authority from two experts in this field.

Meet the Experts: Joanne Spetz, PhD and Cynthia Weston, DNP, FNP-BC

Dr. Joanne Spetz directs the Philip R. Lee Institute for Health Policy Studies (IHPS) at the University of California San Francisco, a 50-year-old research unit dedicated to supporting, guiding, and informing policymakers, communities, and clinicians in their decision-making. She is also the Brenda and Jeffrey L. Kang Presidential Chair in Health Care Financing at IHPS. 

Her expertise centers on the economics of the healthcare workforce, the organization of healthcare services, and healthcare quality. She is currently directing a federally funded UCSF Health Workforce Research Center on Long-Term Care, which provides evidence to address individuals’ needs across the lifespan with patient-centered care. She is an internationally renowned scholar in nursing workforce studies researching nurse supply and demand. She holds a master’s and a doctorate in economics from Stanford University.

Dr. Cynthia Weston is the president of the Texas Nurse Practitioners Association, the associate dean for clinical and outreach affairs, and an associate professor at Texas A&M University College of Nursing. She is also a registered nurse, family nurse practitioner, and critical care clinical nurse specialist. 

She obtained her DNP degree from the University of Texas Health Science Center at San Antonio and her post-master’s family nurse practitioner degree from the Texas Tech Health Science Center University. Her research interests include increasing access to health care, health promotion, disease prevention and wellness,  cancer prevention and screenings, and improving health outcomes for vulnerable populations.

How Practice Authority Differs By State

The laws on where and how nurse practitioners can practice vary from state to state. Some states are very restrictive, such as Missouri, where nurse practitioners are not only required to maintain a collaborative agreement with a supervising physician but are also not allowed to practice more than 75 miles away from that physician. Other states, such as Alaska and Oregon, award nurse practitioners full practice authority when they obtain a state license. 

The requirements for licensure will vary from state to state, but typically holding certification from a national organization approved by the state, completing a master’s of science nursing for advanced practice registered nurses or higher, passing a background check, and providing a clear drug screening. 

In the rest of the states, nurse practitioners must complete a set number of hours or years of supervised work experience before earning full independent practice authority. For example, in Virginia, nurse practitioners can apply for an Autonomous Practice License (APL) after two years and at least 3,600 hours of documented practice.

Benefits of Full Practice Authority

Ensuring nurse practitioners have full practice authority has several benefits. “The evidence shows that in states where there is more independence in practice, there is a growth of the workforce because it’s just a better work environment,” says Dr. Spetz. “Nobody likes to feel like they’re an expert, but somebody’s second-guessing them all the time. Higher overall job satisfaction is linked to growth in the workforce. There’s evidence that employment growth is even greater in community health centers, in rural communities, and other areas that typically are underserved when nurse practitioners can practice independently.”

Full independent practice for nurse practitioners also comes with significant cost savings: “Having a physician with a formal collaborative agreement takes time, and there are liability implications for the physician. All those things add cost,” shares Dr. Spetz. “Physicians’ time is not free to complete this oversight, and there’s no evidence that it improves the quality of care. You’re just throwing money away and putting physicians into this oversight role that is taking them away from patients.”

In addition to being expensive and diminishing morale, requiring nurse practitioners to have physician oversight significantly impacts rural areas. “We have numerous examples of rural towns with only one primary care or family doctor who was providing home care for everybody in the town, and they wanted to retire,” says Dr. Spetz. “They would go through various strategies to recruit somebody to sell their practice to and had incredible barriers trying to find anyone.  Often these physicians could identify a nurse in the area who would be a great nurse practitioner, and they just needed to complete the required education.” 

This option is viable in states where nurse practitioners have full practice authority. However, in states requiring a collaborative agreement, this option becomes much more complicated, leaving an entire rural community at risk of having no healthcare provider.

California Full Practice Now In Effect

In September 2020, Governor Gavin Newsom signed Assembly Bill (AB) 890 into law, which created a pathway for nurse practitioners to obtain full practice authority. This law was finally implemented in January 2023. 

Before this law, nurse practitioners in California had to always work in a collaborative practice with a physician or surgeon. “With three years of work experience, nurse practitioners can practice without the formal written agreements and standardized procedures,” shares Dr. Spetz. It should be noted that there is no change in the scope of practice for nurse practitioners, but this new law will allow them to set up an independent practice eventually.  

In total, nurse practitioners must complete three years of supervised work experience, also called a transition to practice. After the initial three years, nurse practitioners may work independently, but they must be in a clinic, health facility, or group practice with other physicians or nurse practitioners. After these last two years are completed, they can work independently and are not required to be in a facility with other physicians or nurse practitioners. 

“There has been rhetoric around this law that it will make the healthcare system more expensive because NPs will do all these terrible things and cause all these malpractice cases. However, the evidence is directly opposite of that. Malpractice costs go down when you remove these oversight requirements,” says Dr. Spetz. “There are financial and efficiency benefits in getting rid of unnecessary oversight. It gets rid of the time you have to compensate a physician for spending time doing all the extra work that has no benefit to patients.”

Texas Lobbying Continues

On the other hand, Texas is still working towards full independent practice. “Nurse practitioners in Texas are required to contract with a physician in order to deliver the care that we have been educated, trained, licensed in our state, and board certified to do,” says Dr. Weston. “In addition to the contract with the physician, nurse practitioners must have a registration through the Texas Medical Board site and a signed delegation agreement that’s reviewed annually between the providers.”

These contracts, unfortunately, do not come free. “Some nurse practitioners in Texas have to pay to enter into an agreement with a physician. We surveyed the Texas Nurse Practitioners Association members and have found that rates range from $1,000 a month up to $87,000 a year. Psychiatric-mental health nurse practitioners seem like they’re required to pay the most. And there’s a dwindling number of physicians available to delegate to nurse practitioners in our state because many are contemplating retirement within the next several years,” remarks Dr. Weston.

Nurse practitioners who provide vital services are struggling to care for their patients and follow regulatory requirements. “We have colleagues in our state who own and operate clinics and are having trouble finding a delegating physician. There are now proprietary companies that have arisen whose business model is to match nurse practitioners with delegating physicians,” says Dr. Weston. “Of course, this comes with an ongoing monthly fee that hinders the expansion of access to care and is a hidden tax on health care.”

According to research and Dr. Weston’s personal experience, these agreements aren’t necessary or helpful: “Nurse practitioners are always going to collaborate with colleagues in the healthcare team to do what’s in the best interest of the patient. We don’t have to have a piece of paper that requires collaboration to do that,” she says. “In Texas, the physician is never required to step foot in the nurse practitioner’s clinic, and they never have to see a single patient that the nurse practitioner sees. They’re just required to do a retrospective review of a handful of charts which the law doesn’t specify a particular number of charts,” she says. 

Nurse practitioners across the state and associations like Texas Nurse Practitioners are lobbying to change the laws: “We are working hard to spread the message that this is a way to increase access to care in Texas. We know that nurse practitioners accept more patients covered by Medicare and Medicaid and provide vital primary care to our rural areas. Texas currently ranks 51st in access to care and affordability by the Commonwealth Fund rankings. We’re in the bottom quartile for healthcare metrics and healthcare scorecards of all the states in the US, so we have the opportunity for improvement. Our state leads the nation in so many industries. Let’s change policy to increase access to care,” says Dr. Weston.

Kimmy Gustafson

Kimmy Gustafson


Among her many diverse writing endeavors, Kimmy Gustafson has also lent her expertise to since 2020, providing insightful and engaging content about the significant role of education in shaping our future generations of nurse practitioners. Many of her pieces include interviewing experts on timely topics such as healthcare workplace violence and moral distress.

Kimmy has been a freelance writer for more than a decade, writing hundreds of articles on a wide variety of topics such as startups, nonprofits, healthcare, kiteboarding, the outdoors, and higher education. She is passionate about seeing the world and has traveled to over 27 countries. She holds a bachelor’s degree in journalism from the University of Oregon. When not working, she can be found outdoors, parenting, kiteboarding, or cooking.