Education, Legal and Work Autonomy of Nurse Practitioners: A Tri (Quad)-State Comparison

Abstract

This study aimed to examine differences in nurse practitioners’ (NPs) education, legal, and work autonomy across three neighboring states/districts—Delaware/DC, Maryland, and Virginia—that have varying NP scope of practice policies. Additionally, the study explored how NPs’ work settings, geographic location, tenure, and demographic factors influenced their work autonomy. With primary care shortages continuing to impact the healthcare workforce, understanding the factors that shape NPs’ autonomous practice across states is critical. Enhanced NP autonomy can help mitigate primary care shortages and improve patient access to essential healthcare services. Data were derived from the National Sample Survey of Registered Nurses (NSSRN), focusing on NPs in the selected states/district. The survey provided information on NPs’ autonomous practice, work settings, geographic location, and demographic characteristics. Independent sample t-tests indicated that NPs reported higher education, legal, and work autonomy in states with full scope of practice. Logistic regression analyses revealed that NPs working in hospitals had greater odds of not practicing autonomously. Additionally, factors such as rural and Health Professional Shortage Area (HPSA) locations, tenure, age, and race/ethnicity significantly influenced autonomous practice, with patterns varying by state. This study demonstrates that NPs are not fully utilized, even in states with full scope of practice. Findings underscore the need for state-specific, tailored approaches to support NP autonomous practice, enabling NPs to contribute more effectively to addressing the healthcare supply-demand gap.