Ask a Professor: The Fight for Full Practice Authority by Pennsylvania’s NPs

“The government first published a report in 1987 proving the safety, effectiveness, and cost savings of NP care. For more than 40 years, research has demonstrated all of these values.”

Ann Lawrence O’Sullivan, PhD, Dr. Hildegarde Reynolds Endowed Term Professor of Primary Care Nursing in the University of Pennsylvania’s School of Nursing

As the Baby Boomers begin to retire, the nation is experiencing a primary care crisis. More patients need more services than ever before, and medical schools cannot graduate enough primary care physicians to meet the growing demand. Those who suffer the worst from the primary care crisis are seniors, veterans, and residents of rural areas. In Pennsylvania, the state’s 15,000-plus nurse practitioners (NPs) could be part of the solution.

An estimated 22 percent of Pennsylvanians live in an area or population group that lacks adequate primary care access, while over half of all NPs are trained in primary care. These NPs can also provide cost savings that are competitive with MD practice. Their services are desperately needed in Pennsylvania’s rural and underserved areas.

Meet the Expert: Ann Lawrence O’Sullivan, PhD, FAAN, CRNP

Ann Lawrence O’Sullivan, PhD, FAAN, CRNP, is the Dr. Hildegarde Reynolds Endowed Term Professor of Primary Care Nursing at the University of Pennsylvania School of Nursing, where she has also served as the director of both the Family Nurse Practitioner Program and the Pediatric Nurse Practitioner Program.

A clinician educator since 1987, Dr. O’Sullivan has worked for over a decade to develop policies that expand full practice authority for advanced practice registered nurses. She is recognized as a leading proponent of the movement, and has written and lectured extensively on the need to remove scope of practice restrictions and increase professional collaborations between physicians and advanced practice registered nurses. In 2016, Dr. O’Sullivan served as chair of the Pennsylvania State Board of Nursing’s advanced practice registered nurses committee, which is monitoring full practice authority legislation introduced in the Pennsylvania House and Senate.

Dr. O’Sullivan graciously shared her thoughts on NP practice within Pennsylvania and how these healthcare professionals can help meet the shortage of primary care providers, particularly in underserved regions and populations.

How NPs in Pennsylvania Can Alleviate Healthcare Service Shortages

“Our rural areas have one primary care provider (PCP) for every 663 clients, while our urban and suburban areas have 382 clients per PCP,” says Dr. O’Sullivan. “NPs are twice as likely as MDs to practice in rural areas. They also provide a great deal of care to veterans, who often go unserved, much less underserved.”

But NPs in Pennsylvania aren’t able to help as much as they’d like. Pennsylvania is classified as a reduced practice state, according to the American Association of Nurse Practitioners (AANP), meaning that certain restrictions prevent NPs from delivering the full scope of services they are trained to provide. Those restrictions require NPs to secure business contracts, called collaborative agreements, with two physicians. That undercuts the reinforcement that NPs could offer and amounts to putting red tape in between NPs and the patients who desperately need their services.

“Years ago, an NP in Oil City lost her collaborating MD and had to close a practice of 3,000 visits a year,” Dr. O’Sullivan says. “After months of work one was finally found, but her MD was retiring, and large health systems forbid such MD collaboration outside of the health system.”

Collaborative agreements add the burden of cost and logistics to NP practice, forcing NPs to seek approval for services that they’ve already been trained to provide themselves. This is putting undue stress on a health system that’s already significantly stretched.

The Promise of Expanded Practice Authority for Pennsylvania’s NPs

One solution is to establish full practice authority (FPA), also known as full scope of practice (FSP), for Pennsylvania’s nurse practitioners. Such a move would follow the lead of 22 other states and the District of Columbia in reducing the barriers to NPs providing care to patients.

Pennsylvania has been pushing to ease the restrictions on its NPs for years. One piece of legislation, Senate Bill 17 (SB17), passed in 2017 but stalled in the House. The bill was reintroduced in 2019 as Senate Bill 25 (SB25) by State Senator Camera Bartolotta and State Representative Jesse Topper and it passed the Senate again, 44 to six. It’s now sitting in the House Professional Licensure Committee, as House Bill 100 (HB100). If passed, it would bring Pennsylvania closer to full practice authority.

“My work on Full Scope of Practice started more than 40 years ago,” Dr. O’Sullivan says. “More recently, State Representative Jesse Topper sat on the PABON with me and truly heard the issues before he left the Board and became a State Representative.”

SB25 and HB100 have received vocal support from the Pennsylvania Coalition of Nurse Practitioners, the Hospital and Healthsystem Association of Pennsylvania, Geisinger Health System, Thomas Jefferson University Hospitals, the University of Pennsylvania Health System, the Lehigh Valley Health Network, and others.

While this legislation would be a step in the right direction, it would not be true full practice authority for all Pennsylvanian NPs. Instead, the bill offers a compromise: qualified NPs would be allowed to practice within their specialty after completing a three-year, 3,600-hour collaborative agreement with a physician. That would represent one of the longest transition periods in the country, but the effects would still be majorly significant.

Other predominantly rural states, such as Nevada, have retired their collaborative agreement requirements, and as a result, seen an increase of 20 percent in the number of NPs seeking licensure. Six years after Arizona retired its legal condition of physician involvement in NP practice, the state’s rural areas saw a 73 percent increase in NP practice. These are exactly the sort of results that Pennsylvania needs and the state’s NPs are advocating heavily for the type of legislation that would help realize them.

“Our NP students and all Pennsylvania NPs are writing and talking to their representatives, especially those in the districts of a person on the House Professional Committee, to help us move the bill out of committee for a full vote this year,” Dr. O’Sullivan says.

NPs are expertly trained to provide team-based, patient-centered care. In practice, this means taking a holistic approach that looks at and listens to the whole patient. Pennsylvania’s legislators would be wise to view their state in the same fashion.

Matt Zbrog

Matt Zbrog


Matt Zbrog is a writer and researcher from Southern California, and he believes a strong society demands a stronger healthcare system. Since early 2018, he’s written extensively about emerging topics in healthcare administration, healthcare research, and healthcare education. Drawing upon interviews with hospital CEOs, nurse practitioners, nursing professors, and advocacy groups, his writing and research are focused on learning from those who know the subject best.