Health Professions Regulation in the US

The Impact of Scope of Practice

A key goal of health reform in the US is to improve population health through expanded access to health insurance. Demand for high-quality, cost-effective, basic health services is anticipated to grow, particularly for underserved populations. However, there is also growing concern about the impact of health professions scope of practice on access, quality, and cost of health services. Since health professions regulation falls under state jurisdiction, the legal scope of practice for a health profession is typically defined in a state-specific scope of practice act. These acts describe the services that professionals can provide and under what conditions they can be provided. Scope of practice acts also define the requirements for education and training, certification and licensure, and supervision. Restrictive legal scopes of practice often serve as a barrier to effective and efficient delivery of health services.

Key Issues and Challenges Related to Scope of Practice Regulation

Legal Scope of Practice vs Professional Scope of Practice or Competence

While a health professional may be trained and competent to provide a service, a restrictive legal scope of practice in a state may prohibit him/her from providing a service in that state
Legal scope of practice and professional competence overlap, and the amount of overlap varies by state and by profession (eg, state-to-state scope of practice variation for nurse practitioners)

Overly Restrictive Scope of Practice for a Profession Can Limit Patients’ Access to Care

When a service can only be provided by a more highly skilled professional, it can increase the cost of that service (eg, a nurse can immunize a patient while a medical assistant cannot)

Lack of Consistency in Scope of Practice Across States

Limits professional mobility
Challenging for multistate health care provider organizations and providers of telehealth services that cross state lines

Changing Existing Scope of Practice Regulations for a Profession Is Often a Costly, Time-consuming, Adversarial, and Incremental Process Involving Many Stakeholders With Divergent Opinions About the Proposed Change/s

Although the primary purpose of scope of practice regulation is to protect public safety, efforts to change scope of practice requirements often include an element of professional self-interest from professions that already perform a task or provide a service

Policy Reforms to Support Improvements in Scope of Practice Decision Making

Aligning profession-specific legal scopes of practice with professional competence
Increasing participation of consumers in scope of practice decision making
Using the best available evidence about what is best for patients in scope of practice decision making
Allowing short-term demonstration/pilot programs that are carefully evaluated to test new approaches when evidence is not available
Establishing a national clearinghouse on scope of practice information and research with up-to-date and reliable information on scope of practice proposals, modifications, demonstrations, innovations, evaluations, and model practice acts

Relevant Information and Research

General

Norris, C., Timmons, E., Kelley, E., & Carneal, T. (2024). Introducing a new state-level occupational licensing requirement database. Journal of Entrepreneurship and Public Policy, 13(2), 182–199. https://doi.org/10.1108/JEPP-05-2023-0047

Williams, G. A., Ziemann, M., Chen, C., Forman, R., Sagan, A., & Pittman, P. (2024). Global health workforce strategies to address the COVID-19 pandemic: Learning lessons for the future. The International Journal of Health Planning and Management, 39(3), 888–897. https://doi.org/10.1002/hpm.3762

Nguyen A, Schaler-Haynes M, Chou J, Wetzel M, Koller M, Yedidia M, Cantor J. Impact Of The New Jersey COVID-19 Temporary Emergency Reciprocity Licensure Program On Health Care Workforce Supply. Health Affairs 2022 41:8, 1125-1132

Benton, A. D., Ferguson, S. L., Douglas, J. P., & Benton, D. C. (2021). Contrasting Views on Scope of Practice: A Bibliometric Analysis of Allied Health, Nursing, and Medical Literature. Journal of Nursing Regulation, 12(1), 4–18. https://doi.org/10.1016/s2155-8256(21)00016-8

Chappell, K. B., Howard, M. S., Lundmark, V., & Ivory, C. (2021). Credentialing and Certification: Overview, Science, and Impact on Policy, Regulation, and Practice. International Nursing Review. https://doi.org/10.1111/inr.12721

Leslie, K., Moore, J., Robertson, C., Bilton, D., Hirschkorn, K., Langelier, M. H., & Bourgeault, I. L. (2021). Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia and the UK. Human Resources for Health, 19(15). https://doi.org/10.1186/s12960-020-00550-3

Plemmons, A., & Timmons, E. (2021). Occupational Licensing: A Barrier to Opportunity and Prosperity. In The Center for Growth and Opportunity. https://www.thecgo.org/books/regulation-and-economic-opportunity-blueprints-for-reform/occupational-licensing-a-barrier-to-opportunity-and-prosperity/

Szalados, J. E. (2021). Regulation of Provider Practice: State Oversight, Licensing, Credentialing, Peer Review, and the National Practitioner Data Bank. The Medical-Legal Aspects of Acute Care Medicine, 137–169. https://doi.org/10.1007/978-3-030-68570-6_6

Adams, T. L. (2020). Health Professional Regulation in Historical Context: Canada, the USA and the UK (19th Century to Present). Human Resources for Health, 18(1). https://doi.org/10.1186/s12960-020-00501-y

Frogner, B. K., Fraher, E. P., Spetz, J., Pittman, P., Moore, J., Beck, A. J., … Buerhaus, P. I. (2020). Modernizing scope-of-practice regulations – Time to prioritize patients. New England Journal of Medicine. https://doi.org/10.1056/NEJMp1911077

Kleiner, M. M., & Timmons, E. J. (2020). Occupational Licensing: Improving Access to Regulatory Information. Journal of Labor Research, 41(4), 333–337. https://doi.org/10.1007/s12122-020-09314-3

Svorny, S., & Cannon, M. F. (2020). Health care workforce reform: COVID-19 spotlights need for changes to clinician licensing. Cato Institute, Policy Analysis, (899). https://www.jstor.org/stable/pdf/resrep26888.pdf

Benton, D. C., Cleghorn, J., Coghlan, A., Damgaard, G., Doumit, M. A. A., George, J. L., González-Jurado, M. A., Kwek, P.-E., Johansen, C., Msibi, G. S., Nyante, F., Owyer, E., Reed, C. M., Rodriguez, A., & Vogt, T. (2019). Acting in the Public Interest: Learnings and Commentary on the Occupational Licensure Literature. Journal of Nursing Regulation, 10(2). https://doi.org/10.1016/s2155-8256(19)30120-6

Scheffler, G. (2019). Unlocking Access to Health Care: A Federalist Approach to Reforming Occupational Licensing. Health Matrix: Journal of Law-Medicine, 29, 293. https://heinonline.org/HOL/LandingPage?handle=hein.journals/hmax29&div=9&id=&page=

Squires, A., & Dorsen, C. (2018). Qualitative Research in Nursing and Health Professions Regulation. Journal of Nursing Regulation. https://doi.org/10.1016/S2155-8256(18)30150-9

Dower C, Moore J, Langelier M. It is time to restructure health professions scope-of-practice regulations to remove barriers to care. Health Aff. 2013; 32(11)1971-6. https://doi.org/10.1377/hlthaff.2013.0537

Dower C, Christian S, O’Neil E. Center for the Health Professions, University of California, San Francisco. Promising Scope of Practice Models for the Health Professions, 2007.

Hilliard, J. W., & Johnson, M. E. (2004). State Practice Acts of Licensed Health Professions: Scope of Practice. DePaul J. Health Care L., 8, 237. https://heinonline.org/HOL/Page?handle=hein.journals/dephcl8&div=11&g_sent=1&casa_token=&collection=journals

Safriet B. Closing the Gap Between Can and May in Health Care Providers’ Scope of Practice: A Primer for Policymakers. Yale Law School, Faculty Scholarship Series, Paper 4422. 2002;301.

Schlesinger, M. (2002). A Loss of Faith: The Sources of Reduced Political Legitimacy for the American Medical Profession. The Milbank Quarterly, 80(2), 185–235. https://doi.org/10.1111/1468-0009.t01-1-00010

Kleiner, M. M. (2000). Occupational licensing. Journal of Economic Perspectives, 14(4), 189–202.
https://doi.org/10.1257/jep.14.4.189

Gaumer, G. L. (1984). Regulating Health Professionals: A Review of the Empirical Literature. The Milbank Memorial Fund Quarterly. Health and Society, 62(3), 380–416. https://doi.org/10.2307/3349858

Behavioral Health

Choudhury, A. R., & Plemmons, A. (2024). Deaths of Despair: Prescriptive Authority of Psychologists and Suicides. The Center for Growth and Opportunity. https://www.thecgo.org/research/deaths-of-despair/

Zerden, L., Ware, O. D., Lombardi, B. N., & Lombardi, B. M. (2024). Harm reduction workforce, behavioral health, and service delivery in the USA: A cross-sectional study. Harm Reduction Journal, 21(1), 36. https://doi.org/10.1186/s12954-024-00952-9

Schoebel, V., Page, C., Jullie, B., Buche, J., & Beck, A. (2021). Behavioral Health Paraprofessional Accreditation Standards [Research Report]. Behavioral Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/behavioral-health-paraprofessional-accreditation-standards/

Elliot, A., Bohecker, L., Elliott, G. M., Townsend, B. J., Johnson, V., Lopez, A., … & Roach, K. (2019). Interstate Licensure Portability: Logistics and Barriers for Professional Counselors. Professional Counselor, 9(3), 252-266. https://eric.ed.gov/?id=EJ1232236

Atterman, J., Dormond, M., Schreiber, J., Haffajee, R., Andraka-Christou, B., Singer, P., Haworth, S., Foney, D., & Pozuelos, S. (2018). Behavioral Health Workforce Implementation Challenges Related to Medication Assisted Treatment – HWTAC [Research Report]. Behavioral Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/behavioral-health-workforce-implementation-challenges-related-to-medication-assisted-treatment/

Beck, A., Page, C., Buche, J., Rittman, D., & Gaiser, M. (2018). Scopes of Practice and Reimbursement Patterns of Addiction Counselors, Community Health Workers, and Peer Recovery Specialists in the Behavioral Health Workforce [Research Report]. Behavioral Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/scopes-of-practice-and-reimbursement-patterns-of-addiction-counselors-community-health-workers-and-peer-recovery-specialists-in-the-behavioral-health-workforce/

Richman, E., Lombardi, B., Zerden, L. de S., & Randolph, R. (2018). Where is Behavioral Health Integration Occuring? Using NPI Data to Map National Trends [Research Brief]. Carolina Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/where-is-behavioral-health-integration-occuring-using-npi-data-to-map-national-trends/

Dormond, M. (2017). Scope of Practice Alignment for Paraprofessionals and Addiction Counselors [Research Report]. Behavioral Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/scope-of-practice-alignment-for-paraprofessionals-and-addiction-counselors/

Vazquez, C., Singer, P., Perron, B., & Beck, A. (2017). Analysis of Behavioral Health Workforce Competencies Among Professions [Research Report]. Behavioral Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/analysis-of-behavioral-health-workforce-competencies-among-professions/

Page, C., Buche, J., Beck, A., & Singer, P. (2016). A Preliminary Analysis of State Scopes of Practice for Behavioral Health Professions [Research Brief]. Behavioral Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/a-preliminary-analysis-of-state-scopes-of-practice-for-behavioral-health-professions/

Vazquez, C., Buche, J., Beck, A., Ruffolo, M., & Perron, B. (2016). A Preliminary Analysis of State Scopes of Practice for the Profession of Social Work [Research Brief]. Behavioral Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/a-preliminary-analysis-of-state-scopes-of-practice-for-the-profession-of-social-work/

Nursing

Certified Nurse Aides

McMullen T, Resnick B, Hansen J, Miller N, Rubinstein R. Certified nurse aides and scope of practice clinical outcomes and patient safety. Journal of Gerontological Nursing. 2015;41(12):32-39. PMID: 26468657.

Certified Registered Nurse Anesthetists

Ferris, M., Gill, C., Preston, J., & Browne, M. (2021). Validity Evidence for the Continued Professional Certification Assessment: Professional Practice Analysis of the National Board of Certification and Recertification for Nurse Anesthetists. Journal of Nursing Regulation, 11(4), 51-62. https://doi.org/10.1016/S2155-8256(20)30172-1

Giron, S. E., Dishman, D., McMullan, S. P., Riel, J., Newcomer, T., Spence, D., & Choudhry, S. A. (2021). Longitudinal assessment: A strategy to improve continuing professional certification. Journal of Professional Nursing, 37(6), 1140-1148. https://doi.org/10.1016/j.profnurs.2021.09.002

Massie, M. L. (2014). The Tipping Point in Health Care: Using the Full Scope of Practice of Certified Registered Nurse Anesthetists as Advanced Practice Registered Nurses. Clinical Scholars Review, 7(1), 4–6. https://doi.org/10.1891/1939-2095.7.1.4

Midwives

Hoehn-Velasco, L., Jolles, D. R., Plemmons, A., & Silverio-Murillo, A. (2023). Health outcomes and provider choice under full practice authority for certified nurse-midwives. Journal of Health Economics, 92, 102817. https://doi.org/10.1016/j.jhealeco.2023.102817

Noghanibehambari, H., & Fletcher, J. (2023). Long-Term Health Benefits of Occupational Licensing: Evidence from Midwifery Laws. Journal of Health Economics, 92, 102807. https://doi.org/10.1016/j.jhealeco.2023.102807

Jefferson, K., Bouchard, M. E., & Summers, L. (2021). The Regulation of Professional Midwifery in the United States. Journal of Nursing Regulation, 11(4), 26–38. https://doi.org/10.1016/s2155-8256(20)30174-5

Markowitz, S., Adams, E. K., Lewitt, M. J., & Dunlop, A. L. (2017). Competitive effects of scope of practice restrictions: Public health or public harm? Journal of Health Economics, 55, 201–218. https://doi.org/10.1016/j.jhealeco.2017.07.004

Nurse Practitioners

Martsolf, G. R., Kandrack, R., Ferrara, S. A., & Poghosyan, L. (2023). The Impact of the New York Nurse Practitioner Modernization Act on the Employment of Nurse Practitioners in Primary Care. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 60, 00469580231171333. https://doi.org/10.1177/00469580231171333

McMichael, B. J., & Markowitz, S. (2023). Toward a Uniform Classification of Nurse Practitioner Scope of Practice Laws. Medical Care Research and Review, 80(4), 444–454. https://doi.org/10.1177/10775587221126777

Plemmons, A., Shakya, S., Cato, K., Sadarangani, T., Poghosyan, L., & Timmons, E. (2023). Exploring the Relationship between Nurse Practitioner Full Practice Authority, Nurse Practitioner Workforce Diversity, and Disparate Primary Care Access. Policy, Politics, & Nursing Practice, 24(1), 26–35. https://doi.org/10.1177/15271544221138047

Osakwe, Z. T., Kim, R. S., Obioha, C. U., Osborne, J. C., Harun, N., & Saint Fleur-Calixte, R. (2021). Impact of state scope-of-practice laws on nurse practitioner-provided home visits. Geriatric Nursing, 42(3), 674–680. https://doi.org/10.1016/j.gerinurse.2021.03.002

Poghosyan, L., Ghaffari, A., Liu, J., Jin, H., & Martsolf, G. (2021). State policy change and organizational response: Expansion of nurse practitioner scope of practice regulations in New York State. Nursing Outlook, 69(1), 74–83. https://doi.org/10.1016/j.outlook.2020.08.007

Timmons, E. J., Norris, C., Martsolf, G., & Poghosyan, L. (2021). Estimating the Effect of the New York State Nurse Practitioners Modernization Act on Care Received by Medicaid Patients. Policy, Politics, & Nursing Practice, 22(3), 212–220. https://doi.org/10.1177/15271544211018152

Feyereisen S, Puro N. Seventeen states enacted executive orders expanding advanced practice nurses’ scopes of practice during the first 21 days of the COVID-19 pandemic. Rural and Remote Health. 2020;20(4). https://doi.org/10.22605/RRH6068.

Liu, C.-F., Hebert, P. L., Douglas, J. H., Neely, E. L., Sulc, C. A., Reddy, A., … Wong, E. S. (2020). Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health Services Research, 55(2), 178–189. https://doi.org/10.1111/1475-6773.13246

Shakya, S., & Plemmons, A. (2020). Does Scope of Practice Affect Mobility of Nurse Practitioners Serving Medicare Beneficiaries? Journal of Labor Research, 41(4), 421–434. https://doi.org/10.1007/s12122-020-09308-1

Yang, B. K., Johantgen, M. E., Trinkoff, A. M., Idzik, S. R., Wince, J., & Tomlinson, C. (2020). State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review. Medical Care Research and Review. https://doi.org/10.1177/1077558719901216

Ladd, E., Sweeney, C. F., Guarino, A., & Hoyt, A. (2019). Opioid Prescribing by Nurse Practitioners in Medicare Part D: Impact of State Scope of Practice Legislation. Medical Care Research and Review. https://doi.org/10.1177/1077558717725604

Patel, E. Y., Petermann, V., & Mark, B. A. (2019). Does State-Level Nurse Practitioner Scope-of-Practice Policy Affect Access to Care? Western Journal of Nursing Research. https://doi.org/10.1177/0193945918795168

Perloff, J., Clarke, S., DesRoches, C. M., O’Reilly-Jacob, M., & Buerhaus, P. (2019). Association of State-Level Restrictions in Nurse Practitioner Scope of Practice With the Quality of Primary Care Provided to Medicare Beneficiaries. Medical Care Research and Review. https://doi.org/10.1177/1077558717732402

Poghosyan, L., Timmons, E. J., Abraham, C. M., & Martsolf, G. R. (2019). The Economic Impact of the Expansion of Nurse Practitioner Scope of Practice for Medicaid. Journal of Nursing Regulation, 10(1), 15–20. https://doi.org/10.1016/S2155-8256(19)30078-X

McMichael, B. J. (2018). Scope-of-Practice Laws and Patient Safety: Evidence from the Opioid Crisis. https://doi.org/10.2139/ssrn.3300365

Ortiz, J., Hofler, R., Bushy, A., Lin, Y., Khanijahani, A., & Bitney, A. (2018). Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes. Healthcare. https://doi.org/10.3390/healthcare6020065

Park, J., Athey, E., Pericak, A., Pulcini, J., & Greene, J. (2018). To What Extent Are State Scope of Practice Laws Related to Nurse Practitioners’ Day-to-Day Practice Autonomy? Medical Care Research and Review. https://doi.org/10.1177/1077558716677826

Spetz, J., & Muench, U. (2018). California Nurse Practitioners Are Positioned To Fill The Primary Care Gap, But They Face Barriers To Practice. Health Affairs, 37(9), 1466–1474. https://doi.org/10.1377/hlthaff.2018.0435

Xue, Y., Kannan, V., Greener, E., Smith, J. A., Brasch, J., Johnson, B., & Spetz, J. (2018). Full Scope-of-Practice Regulation Is Associated With Higher Supply of Nurse Practitioners in Rural and Primary Care Health Professional Shortage Counties. Journal of Nursing Regulation, 8(4), 5–13. https://doi.org/10.1016/S2155-8256(17)30176-X

Lofgren, M. A., Berends, S. K., Reyes, J., Wycoff, C., Kinnetz, M., Frohling, A., … O’Brien, M. (2017). Scope of Practice Barriers for Advanced Practice Registered Nurses: A State Task Force to Minimize Barriers. Journal of Nursing Administration, 47(9), 465–469. https://doi.org/10.1097/NNA.0000000000000515

McMichael B, Safriet B, Buerhaus P. The extraregulatory effect of nurse practitioner scope-of-practice laws on physician malpractice rates. Medical Care Research and Review. 2017;0(0):1077558716686889.

Spetz, J., Skillman, S. M., & Andrilla, C. H. A. (2017). Nurse Practitioner Autonomy and Satisfaction in Rural Settings. Medical Care Research and Review. https://doi.org/10.1177/1077558716629584

Yang, B. K., Trinkoff, A. M., Zito, J. M., Burcu, M., Safer, D. J., Storr, C. L., … Idzik, S. (2017). Nurse practitioner independent practice authority and mental health service delivery in U.S. Community Health Centers. Psychiatric Services. https://doi.org/10.1176/appi.ps.201600495

Barnes H, Maier C, Sarik D, Germack H, Aiken L, McHugh M. Effects of regulation and payment policies on nurse practitioners’ clinical practices. Medical Care Research and Review. 2016;0(0):1077558716649109. PMID: 27178092.

Graves J, Mishra P, Dittus R, Parikh R, Perloff J, Buerhaus P. Role of geography and nurse practitioner scope-of-practice in efforts to expand primary care system capacity: Health reform and the primary care workforce. Med Care. 2016;54(1):81-89. PMID: 26565526.

Kleiner, M. M., Marier, A., Park, K. W., & Wing, C. (2016). Relaxing occupational licensing requirements: Analyzing wages and prices for a medical service. Journal of Law and Economics. https://doi.org/10.1086/688093

Poghosyan L, Boyd D, Clarke S. Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model. Nursing Outlook. 2016;64(2):146-155. PMID: 26712385.

Xue Y, Ye Z, Brewer C, Spetz J. Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review. Nursing Outlook. 2016;64(1):71-85.

Shilling, D. L., & Hodnicki, D. (2015). APRN prescribing in Georgia: An evolving environment. Journal of the American Association of Nurse Practitioners, 27(6), 300–307. https://doi.org/10.1002/2327-6924.12203

Hain D, Fleck L. Barriers to NP practice that impact healthcare redesign. Online Journal of Issues in Nursing. 2014.

Yang Y, Meiners M. Care coordination and the expansion of nursing scopes of practice. Journal of Law, Medicine and Ethics. 2014;42(1):93-103.PMID: 26767480

Iglehart, J. Expanding the role of advanced nurse practitioners: Risks and rewards. New England Journal of Medicine. 2013;368(20):1935-1941. PMID: 23675663.

Kuo Y, Loresto FL, Rounds LR, Goodwin JS. States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Aff. 2013;32(7):1236–1243. doi:10.1377/hlthaff.2013.0072.

Spetz J, Parente S, Town R, Bazarko D. Scope-of-practice laws for nurse practitioners limit cost savings that can be achieved in retail clinics. Health Aff. 2013;32(11): 1977-1984. doi: 10.1377/hlthaff.2013.0544.

Traczynski J, Udalova V. Nurse Practitioner Independence, Health Care Utilization, and Health Outcomes. [Internet]. Madison, WI: University of Wisconsin; 2013.

Yee T, Boukus E, Cross D, Samueal D. Primary care workforce shortages: Nurse practitioner scope of-practice laws and payment policies. Washington, DC: National Institute for Health Care Reform; February 2013.

Safriet B. Federal Options for Maximizing the Value of Advanced Practice Nurses in Providing Quality, Cost-Effective Health Care. (Excerpted from Appendix H of The Future of Nursing: Leading Change, Advancing Health). Institute of Medicine, 2011.

Mathews, B. P., Boland, M. G., & Stanton, B. K. (2010). Removing barriers to APRN practice in the state of Hawai’i. Policy, Politics, and Nursing Practice, 11(4), 260–265. https://doi.org/10.1177/1527154410383158

Kleinpell, R. M., Hravnak, M., Hinch, B., & Llewellyn, J. (2008). Developing an advanced practice nursing credentialing model for acute care facilities. Nursing Administration Quarterly. https://doi.org/10.1097/01.NAQ.0000336724.95440.fd

Public Health Nurses

Vandenhouten, C. L., DeVance-Wilson, C. L., & Little, B. B. (2015). Credentialing Public Health Nurses: Current Issues and Next Steps Forward. Public Health Nursing, 32(5), 565–576. https://doi.org/10.1111/phn.12206

Bekemeier, B. (2007). Credentialing for Public Health Nurses: Personally Valued … But Not Well Recognized. Public Health Nursing, 24(5), 439–448. https://doi.org/10.1111/j.1525-1446.2007.00654.x

Registered Nurses and Licensed Practical Nurses

Candon, M., Bergman, A., Rose, A., Song, H., David, G., & Spetz, J. (2023). The Relationship Between Scope of Practice Laws for Task Delegation and Nurse Turnover in Home Health. Journal of the American Medical Directors Association, 24(11), 1773-1778.e2. https://doi.org/10.1016/j.jamda.2023.07.023

Brannock, M. K., & Bradford, N. A. (2021). Barriers to licensure for military spouse registered nurses. Journal of Nursing Regulation, 11(4), 4–14. https://doi.org/10.1016/s2155-8256(20)30170-8

Dudley, N., Miller, J., Breslin, M. L., Chapman, S. A., & Spetz, J. (2021). The Impact of Nurse Delegation Regulations on the Provision of Home Care Services: A Four-State Case Study. Medical Care Research and Review, 78(1_suppl), 47S-56S. https://doi.org/10.1177/1077558720960902

Van Wicklin, S. A., Leveling, M. E., & Stobinski, J. X. (2020). What Is the Perceived Value of Certification Among Registered Nurses? A Systematic Review. Journal of Nursing Scholarship, 52(5), 536–543. https://doi.org/10.1111/jnu.12579

Mueller, C., Duan, Y., Vogelsmeier, A., Anderson, R., McConnell, E., & Corazzini, K. (2018). Interchangeability of Licensed Nurses in Nursing Homes: Perspectives of Directors of Nursing. Nursing Outlook, 66(6), 560–569. https://doi.org/10.1016/j.outlook.2018.09.004

Corazzini K, Anderson R, Mueller C, Thorpe J, McConnell E. Licensed practical nurse scope of practice and quality of nursing home care. Nursing Research. 2013;62(5):315-324. PMID: 23995465.

Oral Health

Dental Assistants

Xia, X. (2021). Barrier to Entry or Signal of Quality? The Effects of Occupational Licensing on Minority Dental Assistants. Labour Economics, 71, 102027. https://doi.org/10.1016/j.labeco.2021.102027

Baker B, Langelier M, Moore J, Daman S. The Dental Assistant Workforce in the United States, 2015. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany; October 2015. https://www.oralhealthworkforce.org/wp-content/uploads/2015/11/Dental_Assistant_Workforce_2015.pdf

Post J, Stoltenberg J. Use of restorative procedures by allied dental health professionals in Minnesota. Journal of the American Dental Association. 2014;145(10):1044-1050. PMID: 25270703.

Dental Hygienists

Nasseh, K., Bowblis, J. R., & Wing, C. (2024). How do dental practices respond to changes in scope of practice regulations? Health Economics, n/a(n/a). https://doi.org/10.1002/hec.4878

Chen, J., Meyerhoefer, C. D., & Timmons, E. J. (2024). The effects of dental hygienist autonomy on dental care utilization. Health Economics, 33(8), 1726–1747. https://doi.org/10.1002/hec.4832

Dobrow, M. J., Valela, A., Bruce, E., Simpson, K., & Pettifer, G. (2024). Identification and assessment of factors that impact the demand for and supply of dental hygienists amidst an evolving workforce context: A scoping review. BMC Oral Health, 24(1), 631. https://doi.org/10.1186/s12903-024-04392-6

Zhao, Y., Surdu, S., & Langelier, M. (2024). Safety net patients’ satisfaction with oral health services by provider type and intent to return for more care. Journal of Public Health Dentistry, n/a(n/a). https://doi.org/10.1111/jphd.12629

Akinlotan, M. A., Ferdinand, A. O., Maxey, H. L., Bolin, J. N., & Morrisey, M. A. (2023). Dental hygienists’ scope of practice regulations and preventable non-traumatic dental emergency department visits: A cross-sectional study of 10 U.S. states. Community Dentistry and Oral Epidemiology, 51(2), 274–282. https://doi.org/10.1111/cdoe.12737

Gadbury-Amyot, C. C., Simmer-Beck, M. L., Lynch, A., & Rowley, L. J. (2023). Dental hygiene and direct access to care: Past and present. International Journal of Dental Hygiene, 21(4), 781–788. https://doi.org/10.1111/idh.12772

Bozia, M., Berkhout, E., van der Weijden, F., & Slot, D. E. (2022). Worldwide Review of Dental Hygienists’ Extended Scope of Practice in Radiology. International Dental Journal, 72(3), 373–380. https://doi.org/10.1016/j.identj.2021.05.010

Langelier, M. (2020). Innovations in Scope of Practice. Dimensions of Dental Hygiene. https://dimensionsofdentalhygiene.com/article/innovations-in-scope-of-practice/

Moore, J., & Goodwin, N. (2019). Expanding Access to Care with Scope of Practice. Dimensions of Dental Hygiene. https://dimensionsofdentalhygiene.com/article/innovations-in-scope-of-practice/

Langelier, M., & Surdu, S. (2017). Top-Of-License Dental Hygiene Practice. Dimensions of Dental Hygiene. https://dimensionsofdentalhygiene.com/article/innovations-in-scope-of-practice/

Langelier M, Baker B, Continelli T. Development of a New Dental Hygiene Professional Practice Index by State, 2016. Rensselaer, NY: Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany; November 2016. https://www.oralhealthworkforce.org/wp-content/uploads/2018/02/OHWRC_Dental_Hygiene_Scope_of_Practice_2016.pdf

Langelier M, Baker B, Continelli T, Moore J. A Dental Hygiene Professional Practice Index by State, 2014. Rensselaer, NY: Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany; March 2016. https://www.oralhealthworkforce.org/wp-content/uploads/2016/08/DH_Professional_Practice_Index_By_State_2014.pdf

Langelier M, Continelli T, Moore J, Baker B, Surdu S. Expanded scopes of practice for dental hygienists associated with improved oral health outcomes for adults. Health Aff. 2016;35(12):2207-2215. http://dx.doi.org/10.1377/hlthaff.2016.0807

Dental Therapists

Koppelman J, Vitzthum K, Simon L. Expanding where dental therapists can practice could increase Americans’ access to cost-efficient care. Health Aff. 2016;35(12):2200-6.

Bader J, Lee J, Shugars D, Burrus B, Wetterhall S. Clinical technical performance of dental therapists in Alaska. Journal of the American Dental Association. 2011;142(3):322-326. PMID: 21357866.

Pharmacy

Bacci, J. L., Pollack, S. W., Skillman, S. M., Odegard, P. S., Danielson, J. H., & Frogner, B. K. (2024). Impact of the COVID-19 Pandemic on the Community Pharmacy Workforce. Medical Care Research and Review, 81(1), 39–48. https://doi.org/10.1177/10775587231204101

Shakya, S., Plemmons, A., Bae, K., & Timmons, E. (2023). The pharmacist will see you now: Pharmacist prescriptive authority and access to care. Contemporary Economic Policy, n/a(n/a). https://doi.org/10.1111/coep.12647

Adams, A. J., & Frost, T. P. (2022). Pathways to pharmacist prescriptive authority: Do decentralized models for expanded prescribing work? Research in Social and Administrative Pharmacy, 18(4), 2695–2699. https://doi.org/10.1016/j.sapharm.2021.07.016

Clark, J. S., Knoer, S. J., Waier, K. A., Montgomery, D. R., Cesarz, J., Chapman, N. R. M., & Kotis, D. (2022). Maximizing pharmacists’ scope of practice. American Journal of Health-System Pharmacy, 79(16), 1397–1401. https://doi.org/10.1093/ajhp/zxac053

Hawes, E., Lombardi, B., Galloway, E., Page, C., & McClurg, M. R. (2022). Pharmacists Colocated with Primary Care Physicians: Teaming up for Patient Access [Research Brief]. Carolina Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/pharmacists-colocated-with-primary-care-physicians-teaming-up-for-patient-access/

Maine, L. L. (2020). An Unparalleled Spirit of Collaboration Amid the COVID-19 Pandemic. American Journal of Pharmaceutical Education, 84(6). https://doi.org/10.5688/ajpe8155

Oster, N., Pollack, S., Skillman, S., Stubbs, B., Dahal, A., Guenther, G., & Frogner. (2020). The Pharmacist Workforce in the US: Supply, Distribution, Education Pathways, and State Responses to Emergency Surges in Demand [Research Brief]. University of Washington Center for Health Workforce Studies – Allied Health. https://www.healthworkforceta.org/research-alerts/the-pharmacist-workforce-in-the-us-supply-distribution-education-pathways-and-state-responses-to-emergency-surges-in-demand/

Adams, A. J. (2019). Transitioning pharmacy to “standard of care” regulation: Analyzing how pharmacy regulates relative to medicine and nursing. Research in Social and Administrative Pharmacy. https://doi.org/10.1016/j.sapharm.2018.10.008

Covvey, J. R., Cohron, P. P., & Mullen, A. B. (2015). Examining Pharmacy Workforce Issues in the United States and the United Kingdom. American Journal of Pharmaceutical Education, 79(2), 17. https://doi.org/10.5688/ajpe79217

Hale J, Murawski M, Ives T. Perceived successes and challenges of clinical pharmacist practitioners in North Carolina. Journal of the American Pharmacists Association. 2013;53(6):640. PMID: 24185431.

Telehealth

Andino J, Zhu Z, Surapaneni M, Dunn R, Ellimoottil C. Interstate Telehealth Use Meidcare Beneficiaries Before and After COVID-19 Licensure Waivers, 2017-2020. Health Affairs 2022 41:6, 838-845

Faget, K. Y. (2022). Telehealth Practice Standards With Emphasis on the United States: What Telerehabilitation Providers Need to Know. In Telerehabilitation (pp. 405-415). Elsevier. https://doi.org/10.1016/B978-0-323-82486-6.00028-9

Lee, N. T., Karsten, J., & Roberts, J. (2020). Removing regulatory barriers to telehealth before and after COVID-19. Brookings Institution. https://www.brookings.edu/research/removing-regulatory-barriers-to-telehealth-before-and-after-covid-19/

Page, C., Beck, A., & Buche, J. (2017). An Analysis of Behavioral Telehealth Authorization in Scopes of Practice [Research Report]. Behavioral Health Workforce Research Center. https://www.healthworkforceta.org/research-alerts/an-analysis-of-behavioral-telehealth-authorization-in-scopes-of-practice/

Brannon, J. A., Cohn, E. R., & Cason, J. (2012). Making the case for uniformity in professional state licensure requirements. International Journal of Telerehabilitation, 4(1), 41. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296817/

Cason, J., & Brannon, J. A. (2011). Telehealth regulatory and legal considerations: Frequently asked questions. International Journal of Telerehabilitation, 3(2), 15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296804/

Multiple Occupations

Hughes, P. M., Graaf, G., Gigli, K. H., deJong, N. A., McGrath, R. E., & Thomas, K. C. (2024). Scope-of-Practice Expansions Associated with Reduced Racial Disparities in Pediatric Mental Health Care. Community Mental Health Journal. https://doi.org/10.1007/s10597-024-01310-6

Yeager, V. A., Demosthenidy, M., & Burns, A. (2024). State Laws Governing the Hiring of Public Health Government Employees, 2023. Journal of Public Health Management and Practice, 30(5), E230. https://doi.org/10.1097/PHH.0000000000001943

McMichael, B. J. (2023). Supply-side health policy: The impact of scope-of-practice laws on mortality. Journal of Public Economics, 222, 104901. https://doi.org/10.1016/j.jpubeco.2023.104901

Newlon, J. L., Murphy, E. M., Ahmed, R., & Illingworth, K. S. (2023). Determining and regulating scope of practice for health care professionals: A participatory, multiple stakeholder approach. Research in Social and Administrative Pharmacy, 19(3), 457–467. https://doi.org/10.1016/j.sapharm.2022.11.005

Ziemann, M., Strasser, J., Krips, M., Yang, Y. T., & Pittman, P. (2023). How Governor Directives Changed Health Workforce Flexibility in Response to the COVID-19 Pandemic. Public Health Reports®, 138(1_suppl), 78S-89S. https://doi.org/10.1177/00333549221132534

Chappell, K. B., Howard, M. S., Lundmark, V., & Ivory, C. (2021). Credentialing and certification: Overview, science, and impact on policy, regulation, and practice. International Nursing Review, 68(4), 551–556. https://doi.org/10.1111/inr.12721

Kim, J. (2020). Occupational Credentials and Job Qualities of Direct Care Workers: Implications for Labor Shortages. Journal of Labor Research, 41(4), 403–420. https://doi.org/10.1007/s12122-020-09312-5

McMichael, B. (2020). Healthcare licensing and liability. Indiana Law Journal. https://heinonline.org/HOL/Page?handle=hein.journals/indana95&div=26&g_sent=1&casa_token=&collection=journals

Pittman, P., Leach, B., Everett, C., Han, X., & McElroy, D. (2020). NP and PA Privileging in Acute Care Settings: Do Scope of Practice Laws Matter? Medical Care Research and Review. https://doi.org/10.1177/1077558718760333

Park, J., Han, X., & Pittman, P. (2019). Does expanded state scope of practice for nurse practitioners and physician assistants increase primary care utilization in community health centers? Journal of the American Association of Nurse Practitioners. https://doi.org/10.1097/JXX.0000000000000263

Spetz, J., Toretsky, C., Chapman, S., Phoenix, B., & Tierney, M. (2019). Nurse Practitioner and Physician Assistant Waivers to Prescribe Buprenorphine and State Scope of Practice Restrictions. JAMA. https://doi.org/10.1001/jama.2019.0834

Pittman P, Leach B, Everett C, Han X, McElroy, D. NP and PA privileging in acute care settings: Do scope of practice laws matter? Medical Care Research and Review: MCRR. 2018;1077558718760333. doi:10.1177/1077558718760333

Ritter, A. Z., Bowles, K. H., O’Sullivan, A. L., Carthon, M. B., & Fairman, J. A. (2018). A Policy Analysis of Legally Required Supervision of Nurse Practitioners and Other Health Professionals. Nursing Outlook, 66(6), 551–559. https://doi.org/10.1016/j.outlook.2018.05.004

McMichael, B. J. (2017). Beyond Physicians: The Effect of Licensing and Liability Laws on the Supply of Nurse Practitioners and Physician Assistants. https://doi.org/10.2139/ssrn.3011506

Page C, Beck A, Buche J, Singer P, Vazquez C, Perron B. National Assessment of Scopes of Practice for the Behavioral Health Workforce. Behavioral Health Workforce Research Center, School of Public Health, University of Michigan. April 2017 https://www.behavioralhealthworkforce.org/wp-content/uploads/2017/11/FA3_SOP_Full-Report_1.pdf

Timmons E. The effects of expanded nurse practitioner and physician assistant scope of practice on the cost of Medicaid patient care. Health Policy. 2016. PMID: 28041774.

Gadbois EA, Miller EA, Tyler D, Intrator O. Trends in state regulation of nurse practitioners and physician assistants, 2001 to 2010. Medical Care Research and Review : MCRR. 2015;72(2):200-219. doi:10.1177/1077558714563763.

McMichael, B. J. (2015). The Demand for Healthcare Regulation: The Effect of Political Spending on Occupational Licensing Laws. https://doi.org/10.2139/ssrn.2611532

Van Scoder, L. I. (2001). Recredentialing in the allied health professions. Journal of Allied Health, 30(4), 229–231. https://www.ingentaconnect.com/content/asahp/jah/2001/00000030/00000004/art00005

Other Occupations

Emergency Medical Services

Reed-Schrader, E., & Mohney, S. (2024). EMS Scope of Practice. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK553179/

Yelowitz, A., & Ingram, S. J. (2024). How does occupational licensing affect entry into the medical field? An examination of emergency medical technicians. Southern Economic Journal, 91(1), 38–61. https://doi.org/10.1002/soej.12525

Petterson, D., Stubbs, B., & Nudell, N. (2022). How Actual Practice of Emergency Medical Services Personnel Aligns with the Recommended National Scope of Practice in Rural Versus Urban Areas of the U.S. [Research Report]. University of Washington Center for Health Workforce Studies – Allied Health. https://www.healthworkforceta.org/research-alerts/how-actual-practice-of-emergency-medical-services-personnel-aligns-with-the-recommended-national-scope-of-practice-in-rural-versus-urban-areas-of-the-u-s/

Boehringer B, O’Meara P, Wingrove G, Nudell NG. An Emergency Amendment to the National Scope of Practice for Paramedics in the Setting of a Global Pandemic. J Rural Health. 2021 Jan;37(1):191-193. https://doi.org/10.1111/jrh.12441

Opticians

Timmons, E. J., & Mills, A. (2018). Bringing the Effects of Occupational Licensing into Focus: Optician Licensing in the United States. Eastern Economic Journal. http://dx.doi.org/10.1057/eej.2016.4

Physical Therapists

Boissonnault WG, Badke MB, Powers JM. Pursuit and implementation of hospital-based outpatient direct access to physical therapy services: An administrative case report. Journal of Physical Therapy Science. 2010;90(1):100-109. PMID: 19892855.

Physicians and Physician Assistants

Valentin, V. L., Najmabadi, S., & Everett, C. (2021). Cross-sectional analysis of US scope of practice laws and employed physician assistants. BMJ Open, 11(5), e043972. https://doi.org/10.1136/bmjopen-2020-043972

Valentin, V. L., Najmabadi, S., & Honda, T. J. (2021). Associations between state scope of practice laws and US physician assistant wages from 1997 to 2017: A longitudinal analysis. BMJ Open, 11(8), e052849. https://doi.org/10.1136/bmjopen-2021-052849

Carlson D, Thompson JN. (2005). The Role of State Medical Boards. AMA Journal of Ethics Virtual Mentor, 7(4), 311–314. doi: 10.1001/virtualmentor.2005.7.4.pfor1-0504

Radiologic Technologists

Timmons, E. J., & Thornton, R. J. (2008). The Effects of Licensing on the Wages of Radiologic Technologists. Journal of Labor Research, 29(4), 333–346. https://doi.org/10.1007/s12122-007-9035-9

Respiratory Therapists

Skillman, S., Frogner, B., Dahal, A., Stubbs, B., & Guenther, G. (2020). The Respiratory Therapist Workforce in the US: Supply, Distribution, Education Pathways, and State Responses to Emergency Surges in Demand [Research Brief]. University of Washington Center for Health Workforce Studies – Allied Health. https://www.healthworkforceta.org/research-alerts/the-respiratory-therapist-workforce-in-the-us-supply-distribution-education-pathways-and-state-responses-to-emergency-surges-in-demand/

Scope of Practice Resources

Model Practice Acts

Professional scope of practice or competence is often found in model practice acts developed by a profession and describes the services that its members are trained and competent to perform.