State responses to COVID-19: Potential benefits of continuing full practice authority for primary care nurse practitioners

The COVID-19 pandemic has proven to be a shock to our healthcare system, producing a sudden growth in the need for health care services. It has exposed the vulnerabilities of our health care system, particularly a shortage of adequately trained health care providers (Lopez et al., 2021). The pandemic disproportionately affected historically marginalized groups and accentuated the health disparities and unequal access to care facing millions of Americans (Lopez et al., 2021). The pandemic has brought attention to the fragile primary care system and its inability to meet the demand for health care services. Due largely to population growth, aging, and, to a smaller extent, expanded health insurance years, the demand for primary care clinicians is projected to rise by nearly 20% the next five to 10 years (Duchovny et al., 2017), yet the country is struggling to train adequate number of clinicians. The timeline for the country's recovery from the COVID-19 pandemic is unclear and likely to further deepen inequities, and further stress the primary care system.

Nursing has a lengthy history of social and practice change emanating from crises like epidemics, wars, and disasters. Florence Nightingale's enormous contributions during the Crimean War ranged from sanitation to statistics (Haynes, 2020). Mary Seacole established a nursing facility for wounded soldiers during the Crimean War (Mary Seacole Trust, n.d.). Sojourner Truth, a former slave, worked as a Civil War nurse and became an advocate for formal nursing education (DeWitty, 2017). Clara Barton and Susie King Taylor were also nurses in the Civil War who founded the American Red Cross (Lindquister, 2019). Lillian Wald was an advocate for immigrant health (Wald, 1908). Many others such as Mary Breckinridge, founder of the Frontier Nursing Service, began their careers by answering the overwhelming need for nurses during the 1918 influenza epidemic (American Association for the History of Nursing n.d; Barry, 2004; Keeling, 2010; Wood, 2017). These nurses all stepped out as advocates for health care delivery models to improve access and quality of care during times of social change or crisis, before statutory regulations were able to keep pace. Because of their pioneering contributions and visionary stance, laws were changed.

Nurse practitioners (NPs) are a group of nurses pivotal in meeting the growing demand for primary care services. They represent the fastest growing sector of the primary care workforce, and 90% are prepared to deliver primary care services (American Association of Nurse Practitioners, 2021). Projections show that the NP workforce will increase by 93% between 2013 and 2025 (Auerbach et al., 2020). NPs also disproportionately care for vulnerable populations, especially racial minorities and those living in rural communities (Poghosyan & Carthon Brooks, 2017; Xue et al., 2019). Yet, many barriers impact the ability of primary care NPs to maximally contribute to improving access and quality of health care services before, during, and after the COVID crisis.

One of the particular challenges affecting this workforce are the restrictive scope of practice (SOP) regulations in many U.S. states. Currently, the SOP laws are not consistent across the states. Before the COVID, only 23 states and the District of Columbia supported full practice authority for NPs, allowing NPs to care for their patients to the fullest extent of their educat