The demand for primary care services in the United States (U.S.) is increasing due to aging population, growing chronic disease burden, and the health insurance expansion stemming from the passage of the Affordable Care Act in 2010, which provided millions of previously uninsured Americans with health insurance coverage. The growing workforce of nurse practitioners (NPs) in the U.S. can help meet the demand for primary care services (Institute of Medicine, 2010). The NP workforce is expected to grow by 93% between 2013 and 2025 (U.S. Department of Health and Human Services Health Resources and Services, 2016). However, a number of policy and organizational barriers constrain NPs’ ability to deliver high quality care and meet the demand for primary care services. Despite the uniformity in NPs’ educational preparation across the country guided by a common accreditation agency, variation persists in state level scope of practice (SOP) regulations. These SOP regulations determine the type and breadth of the services NPs can provide across the U.S. Currently, 22 states and the District of Columbia allow NPs to practice independently from physicians. However, 28 states impose a restriction on NPs by requiring them to have supervisory or collaborative relationships with physicians to deliver care. The variations in the SOP regulations impact the access and quality of care in the country (Graves et al., 2016; Xue, Ye, Brewer, & Spetz, 2016). Similarly, organizations employing NPs also create barriers for NP practice including not providing NPs with adequate support and resources, not fostering NP autonomy and not providing NPs with their own patient panel to deliver ongoing continuous care (Poghosyan & Aiken, 2015). The purpose of this study was to investigate NP practice, work environment, and NP outcomes in two states with different scope of practice regulations. Specifically, we investigated how different health care organizations utilized NPs in care delivery as well as how state and organizations impact NP work environment, ownership of patient panels, job satisfaction, and turnover in these states.
Methods:
A cross-sectional survey design was used to collect data in 2012 from 314 NPs in Massachusetts (MA) and 278 NPs New York (NY) state. The SOP regulations for NPs were stricter in NY where they needed an agreement with physicians for both prescribing medications and delivering care whereas in MA an agreement with physicians was only needed for delivering care. NPs completed measures of patient panel status (i.e., whether NPs have their own patient panel or share patient panel with physicians), work environment, job satisfaction, intentions of turnover, and demographics. NP work environments were measured with the 4 subscales of the Nurse Practitioner Primary Care Organizational Climate Questionnaire: NP-Physician Relations (NP-PR), NP-Administration Relations (NP-AR), Independent NP Practice and Support (IPS), and Professional Visibility (PV). Multivariate Analysis of Variance investigated the effect of state and organization type on work environments. The chi-square tests examined the effect of organization type on job satisfaction, turnover, and NP patient panel status.
Results:
State and organization type predicted NP work environment (p<0.05) with no significant interaction between state and organization type in affecting NP work environment (p>0.05). NP work environment was better in community-based clinics. The mean scores on all four subscales measuring work environment were higher in MA than in NY (NP-PR-3.36 in MA and 3.18 in NY; NP-AR-2.87 in MA and 2.74 in NY, IPS-3.48 in MA and 3.29 in NY, PV-3.15 in MA and 2.85 in NY). Overall, 26% of NPs were dissatisfied with their job (22% in MA and 30% in NY) while 15% of NPs planned to leave their job (19% in MA and 11% of NPs in NY). In addition, 45% of NPs in MA and 40% of NPs in NY had their own patient panel. NPs in these states were employed in three types of organizations: physician offices, hospital-based clinics, and community health centers. Organization type had no significant effect on job satisfaction (χ2=1.21, p>0.05) or turnover (χ2=2.30, p>0.05). A statistically significant relationship existed between organization type and whether NPs had their own patient panel (χ2=29.38, p<0.05) with community health centers exhibiting a significantly higher proportion than any other clinic type.
Conclusion:
NPs in both states faced significant organizational challenges with NPs in NY reporting more challenges in their work environments. Better work environments in MA might be explained by the state’s less restrictive scope of practice regulations. Poor work environments in hospital-based clinics may be attributable to the setting’s hierarchical organizational structure. As the NP workforce is growing not only in the U.S. but also internationally and the health care organizations globally will see an increase in the number of NPs in their staffing mix, it is important to address work environment issues and create effective environments in order to fully exploit the capacity of the NP workforce. State and organizational reforms should be considered to maximize the NPs’ contribution to patient care and outcomes.