Graduation Date

Summer 8-14-2020

Document Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

Kathryn Fiandt

Second Advisor

David Palm

Third Advisor

Jungyoon Kim

Fourth Advisor

Keidi Keeler


Background: Over 80 million Americans reside in or are part of a population designated as Health Professional Shortage Areas (HPSAs). Of the primary medical HPSA areas designated in the U.S., 66.74% are located in rural or partially rural areas (HRSA, 2020). To combat this shortage, 23* states and Washington, D.C. have enacted full practice authority laws for nurse practitioners (NP). Over 60% of NPs work in communities of less than 250,000.

Problem: The variability and extent of utilization of NPs in states with full practice authority (FPA) is unknown. To ensure access to quality healthcare, nurse practitioners need to be utilized to their full capabilities. There are well documented variances in utilization across the U.S., yet no studies have specifically examined utilization of NPs within full practice authority states.

Conceptual Framework: The framework for this study was derived from three theories involving innovation, translation, and bureaucracy. In this framework, the “system translation of innovation”, it is hypothesized that state regulations for full practice authority might undergo translation at the healthcare system-level or are impacted by local bureaucracy and result in a negative impact on utilization of NPs at the top of their scope.

Objective: The objectives of this study were to 1) describe the utilization of NPs in states with full practice authority using four components of utilization: billing, privileges, supervision, and prescriptive authority. 2) determine if a significant difference in utilization is present between rural and urban areas, and 3) determine if there is a relationship between the four components of utilization and the geographical location (urban vs. rural) of the practicing NP when controlling for multiple demographic and practice variables.

Methods: A cross-sectional, descriptive, correlational design was used. Data were collected using a survey instrument designed by the investigator and validated in a pilot study. A population of NPs (N=1522) from Maine, North Dakota, and New Mexico were surveyed. T-test of proportions were used to evaluate differences between rural and urban NP practice utilization. Binary logistic regressions assessed the associations between each component of utilization and rural/urban status.

Results: A sample of n=292 was obtained for a 19% response rate. Urban NPs made up 68% of the sample. The majority of respondents practice without supervision requirements, are allowed to perform procedures and privileges without limitation, bill under their own NPI, and can prescribe independently. However, there were still healthcare system-level restrictions evident in these states with full practice authority and significant differences between rural and urban practices. Urban NPs are more likely to work in specialty settings, have restrictions on their privileges, and are less likely to bill under their own NPI. Rural NPs tend to be certified as Family NPs, work in a primary care area, and in a federally funded facility. Rural NPs are also less likely to have restrictions on their practice.

Discussion: Despite the efforts to abolish practice restrictions for NPs, there remain significant barriers to full practice authority at the healthcare system level, even in states with FPA. There are significant differences in NP utilization between rural and urban areas. More research is needed at the healthcare system level to determine drivers behind differences in NP utilization.

Potential Implications: Continued practice restrictions within healthcare systems limit the ability of NPs to be fully utilized. For NPs to provide high quality, cost effective, patient centered care, healthcare system support, especially elimination of restrictions, is necessary.


Committee Members outside of UNMC: Mary Jo Goolsby, Rashid Ahmed