Ask a Professor: The Practice Environment in Wisconsin

“NPs are in demand, by patients and by healthcare systems. We can and do make a difference, every day.”

Kim Litwack, PhD, Dean of the University of Wisconsin-Milwaukee’s School of Nursing

America is facing down a primary care crunch. As the population ages, the nation needs more medical professionals, but medical schools aren’t graduating enough physicians at a fast enough rate. 

According to the Association of American Medical Colleges (AAMC), the US could face a shortage of up to 55,200 primary care physicians by 2033. And for many states, including Wisconsin, the gap between healthcare needs and healthcare access is already acutely felt. 

According to the Kaiser Family Foundation (KFF), Wisconsin has 105 Health Professional Shortage Areas (HPSAs), which are home to over 1.1 million people. The Wisconsin Collaborative for Healthcare Quality (WCHQ) has found persistent and significant health disparities in the state’s rural and underserved populations, where access to quality healthcare services may be limited. Without intervention, the situation will worsen. 

Wisconsinites need greater access to high-quality, affordable healthcare. The state’s nurse practitioners (NPs) and other advanced practice registered nurses (APRNs) could be a powerful resource in providing it. 

Meet the Expert: Kim Litwack, PhD, RN, APNP, FAAN

Dr. Kim Litwack is the Dean of the University of Wisconsin-Milwaukee’s School of Nursing, where she has been a tenured Professor since 2004. Prior to this, she was an Associate Professor at Grand Valley State University in Grand Rapids, Michigan (2000-2004), the University of New Mexico in Albuquerque (1992-2000), and Rush University (1984-1992). 

Dr. Litwack received her MSN in medical-surgical nursing from Case Western Reserve University and her PhD in educational administration from Kent State University. Her nursing background has been in the areas of critical care, perianesthesia care, and, more recently, ambulatory care and pain management. 

Dr. Litwack has won several awards for her contributions to nursing and nursing education, including the DAISY Foundation’s Award for Extraordinary Faculty in 2015. 

The Value of Wisconsin’s NPs

Over 50 years of research has shown that NPs can and do improve patient outcomes, and provide care on par with that of their physician colleagues. While the majority of NPs focus on primary care, their expertise can extend into specialties such as family care, acute care, pediatric care, and women’s health. And in addition to diagnosis and treatment, NPs are adept at counseling and educating patients, which is particularly important in cases of chronic disease. 

“The top health concerns in Wisconsin are the same as in every other state: heart disease, stroke, cancer, diabetes, and arthritis,” Dr. Litwack says. “All are expected to increase as the population increases and obesity increases. And all of these conditions are chronic, requiring patient education in self-management. NPs are in an ideal position to manage these chronic health conditions with medical monitoring, medication management, and health education related to symptom management.”

NPs can help increase access to quality care throughout the state, but they’re especially valuable in rural and underserved areas where the needs are more severe. Nationwide, NPs are more likely than physicians to practice in rural areas and make up approximately 25 percent of the rural healthcare workforce. 

“NPs often self-select practice sites and practice populations where their impact can be maximized,” Dr. Litwack says. “NPs recognize the impact of social determinants of health on populations and use their expertise to help manage individual patients while helping to address community needs as well. As we do have a shortage of MDs in our population-dense and rural communities, NPs are in a ready position to support healthcare delivery, to reduce wait times, and to increase access to care.”

The Burdens of Reduced Practice

Wisconsin’s rules around NP practice are out of date. According to the American Association of Nurse Practitioners (AANP), Wisconsin is still a reduced practice state, meaning that its state laws reduce the ability of NPs to engage in at least one element of NP practice. In Wisconsin, that primarily manifests itself in the requirement that NPs have a documented collaborative agreement with a physician in order to provide pharmacologic-related care. 

Across the nation, NPs collaborate with physicians and other health professionals whether there’s a requirement to do so or not, but the red tape around regulating such collaboration can be a burden to NP practice. The laws around NP practice aren’t as restrictive in Wisconsin as they are in some other states—an NP’s collaborating physician doesn’t have to be on-site, for example—but the laws aren’t as progressive as they could be, either. According to the Wisconsin Nurses Association (WNA), the collaborative requirement has created a barrier for NPs, and the current rules around NP practice need modernization.

Several other groups agree. The Federal Trade Commission (FTC) has stated that requirements around physician collaboration for APRN licensure create scope of practice restrictions that can have negative effects. Studies have shown that scope of practice restrictions limit the growth of the number of NPs available to provide care, and deter some NPs from locating in areas of greatest need where there are few physicians. And the Wisconsin Hospital Association’s 2018 report on the healthcare workforce called for a switch from formal collaborative agreements to informal collaborative relationships, as well as a modernization of legislation to match the evolution of the APRN workforce. 

The Future of NP Practice in Wisconsin

Wisconsin’s NPs, and the Wisconsin Nurses Association (WNA), have been advocating for a change.

In 2020, they helped introduce two bills to the legislative session that would’ve modernized laws around APRN practice; unfortunately, no public hearings were held for either. The key sticking point was over the collaborative agreement requirement, which the WNA opposed as having impacts on patient access to quality care. 

The fight is far from over. In 2021, committees from the Wisconsin Senate and Assembly met with APRNs to discuss the APRN Modernization Act (AB 396 and SB 394). If passed, the proposed legislation would facilitate the state’s NPs to practice to the highest extent of their license. But more advocacy work is necessary to push the bills over the finish line. 

“To get involved in advocacy efforts that support NP practice, NPs, NP students, and RNs can all join the WNA, a powerful driver of nursing practice in the state,” Dr. Litwack says. “This includes testifying, providing information to legislators, and representing nursing practice in the press and organizing responses. Research repeatedly demonstrates that APRNs can and do provide safe, high-quality healthcare with equivalent outcomes to their physician counterparts. We need the public to know this and help us in this campaign.”

In every state with progressive laws around NP practice, those states’ NPs have played a key role in attaining it. And while engaging with the legislative system can seem complicated, organizations like the WNA offer resources that make it easy. 

There’s good reason to be hopeful that this year’s legislative session will be more fruitful than the last: the collaborative requirements for NP practice are currently suspended because of the Covid-19 public health emergency. NPs, and their patients, are getting firsthand experience with what full practice authority could look like. As Wisconsin struggles to meet the growing needs of an aging population, it may once again look to NPs and APRNs to help provide safe, quality, and accessible care. 

“The future is promising,” Dr. Litwack says. “NPs are in demand, by patients and by healthcare systems. We can and do make a difference, every day.”

Matt Zbrog

Matt Zbrog


Matt Zbrog is a writer and researcher from Southern California, and he believes nurse practitioners (NP) are an indispensable component of America’s current and future healthcare workforce. Since 2018, he’s written extensively about the work and advocacy of NPs, with a particular focus on the rapid growth of specialization programs, residencies, fellowships, and professional organizations. As part of an ongoing series on state practice authority, he’s worked with NP leaders, educators, and advocates from across the country to elevate policy discussions that empower NPs. His articles have featured interviews with the leadership of the American Association of Nurse Practitioners (AANP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and many other professional nursing associations.