In the United States, Advanced Practice Registered Nurse (APRN) regulations are determined at the state level, through legislation and rule making. The lack of an evidence base to APRN regulation has resulted in a patchwork of varied regulations and requirements for nurse practitioners. The author begins this article by reviewing the history of the Equal Rights Amendment (ERA) in the United States and describing her study that assessed APRN fullpractice authority in states that ratified the ERA versus states that opposed it. She presents the study findings, limitations of the comparison, and discussion of the findings and implications. In conclusion, the findings demonstrated that progress toward full APRN practice will require building strategies for political support and framing the need to update APRN regulations in a manner that aligns with each state’s social and political values.
Keywords: advanced practice registered nurse, nurse practitioner, nurse midwives, nurse anesthetists, clinical nurse specialists, political environment, women’s equality, state regulations, Equal Rights Amendment/ERA, professional autonomy, nursing regulations, full practice authority, APRN, APN
... APRNs in many states do not have full practice authority that allows them to practice to the full extent of their education. The United States Institute of Medicine (IOM) 2010 report, the Future of Nursing, has recommended that regulations and policies be designed so as to facilitate nurses practicing to the full extent of their education and training in every state. The report has recommended that states reform scope-of-practice regulations for advanced practice registered nurses (APRNs) so that each state’s APRN regulations conform to the National Council of State Boards of Nursing (NCSBN) Model Nursing Practice Act (IOM, 2010). The four roles of APRNs include nurse practitioner (NP), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS).
The United States (US) NCSBN Model Nursing Practice Act, a template for harmonizing regulations among the states, has called for each state to recognize APRNs as licensed practitioners with a full practice authority for advanced nursing practice, including independent prescribing (NCSBN, 2012). Yet APRNs in many states do not have full practice authority that allows them to practice to the full extent of their education.
The US has not employed an evidence base to APRN regulation and now has a patchwork of varied regulations and requirements for nurse practitioners. In the US, APRN regulations are determined at the state level, through legislation and rule making. The US has not employed an evidence base to APRN regulation and now has a patchwork of varied regulations and requirements for nurse practitioners (Rudner Lugo, O’Grady, Hodnicki & Hanson, 2007; Safriet, 1994). Although the APRN role has been in existence for 50 years, and almost as many years of research have demonstrated the safety and efficacy of advanced practice nurses, APRN practice authority in some states remains limited by state regulations (Newhouse et al., 2011; Rudner Lugo, O’Grady, Hodnicki & Hanson, 2010; Stanik-Hutt, 2013). These state limitations on APRN practice involve other professionals, typically physicians, in APRN licensure, practice, and/or prescribing. This diversity of regulation among the 50 states provides an opportunity to examine factors associated with regulations of advanced practice nursing.
Nursing remains a predominantly female profession. Although now nine percent of the profession in the US is male, the profession has long been perceived as a profession of females (Bunting & Campbell, 1990). The nursing profession was initially developed by women, such as Florence Nightingale, Lavinia Dock, Lillian Wald, Mary Breckinridge, Margaret Sanger, and others, who saw healthcare in the context of the social and political environment (Lewenson, 2012). These nurses early on joined forces with other female-oriented groups to address policy issues, including improvement of living conditions, access to family planning, and women’s right to vote (Bunting & Campbell, 1990; Lewenson, 2012).
...state limitations on APRN practice involve other professionals, such as physicians, in APRN licensure, practice, and/or prescribing. This article will examine the political dynamics around both the perceptions of women’s role in society and the state regulations governing the four APRN roles. In this article, I review the history of the Equal Rights Amendment in the US and describe my study that compared advanced practice registered nurse (APRN) practice authority including prescribing authority in those states accepting women’s equality compared with those states not accepting women’s equality, as reflected by the state’s vote on the Equal Rights Amendment. After reviewing my findings, I note the limitations of this comparison, and then describe my conclusion that attitudes toward women’s equality are associated with the updated status of APRN regulations. I suggest that progress toward full APRN practice authority will require the building of political support and developing of strategies that align with each state’s social and political values.
History of the Equal Rights Amendment in the United States
The Equal Rights Amendment (ERA) to the U.S. Constitution sought to obtain equal rights among both men and women. The Equal Rights Amendment (ERA) to the U.S. Constitution sought to obtain legal equality from both men and women. The ERA stated “equality of rights under the law shall not be denied or abridged by the United States or by any State on account of sex.” The ERA was passed by Congress in 1972 with a large majority but failed to be ratified by the required quota of three-fourths (38) of the states. State ratification required that the electorate approve the amendment. However, the momentum required to approve the amendment did not prevail; social mobilization and public sentiment successfully opposed it in 15 states: Alabama, Arizona, Arkansas, Florida, Georgia, Illinois, Louisiana, Mississippi, Missouri, Nevada, North Carolina, Oklahoma, South Carolina, Utah and Virginia. Another five states, Idaho, Kentucky, Nebraska, South Dakota, and Tennessee, which had originally ratified the ERA, later rescinded the vote.
The ERA vote reflected cultural, religious, and other social values related to the expected roles of women. The ERA vote reflected cultural, religious, and other social values related to the expected roles of women. While dramatic demographic and cultural shifts have occurred since that time period, this indicator of the historical attitude toward women may be an ongoing gender dynamic affecting regulations of nursing practice.
The Congressional passage of the ERA stipulated that the states had to ratify the amendment within 10 years. By 1982, when the window of time for ERA passage ended, the nation was three states short of the number needed to make the ERA a Constitutional amendment. Religion, economic structures, social norms, and community values can influence the perceptions of women. The ERA was opposed most strongly in the South as well as in the predominantly Mormon states of Utah and Nevada. These were the least affluent states, with a conservative, populist tradition (Nice, 1986). The states that opposed the ERA were: more likely to have policies that relegated women to a disadvantaged position, more likely to have unemployed women, less likely to have policies to control domestic violence, and less likely to have welfare benefits for families with dependent children (Nice, 1986). They were also more likely to have policies that retained school segregation and lower state and local taxes (Nice, 1986). Ratifying and non-ratifying states have had many social and political differences which may continue to play a role in the dynamics influencing the progress toward the updating of APRN regulations.
Ratifying and non-ratifying states have had many social and political differences which may continue to play a role in the dynamics influencing the progress toward the updating of APRN regulations. Crowley (2006) found states that ratified the ERA had a higher percentage (5.2%) of state legislators who were female compared to non-ratifying states (3.7%) in 1972. Crowley noted that almost 30 years later, a five percentage point gap remained. In 2000, 24.7% of the state legislators in the ERA-ratifying states were women, compared to 19.4% in the states that never ratified the ERA.
The ratifying states were also more innovative and more likely to be the early adopters of amendments supporting policy innovations. For example, in the 20th century, 11 amendments were sent to the states for ratification. These spanned the 16th amendment, authorizing federal income tax, to the 26th amendment, lowering the voting age to 18. More of the ERA-ratifying states (91.5%) ratified at least one of the 10 other amendments, compared to 74.1% of the states opposed to the ERA (Daniels & Darcy, 1985).
The anti-ERA coalition, STOP ERA, was well-financed and organized. Its strong and vocal leader, Phyllis Schlafly, used an emotional appeal to opposition, proposing that the ERA would destroy social mores, change women’s roles and behaviors, and destroy families. ERA opponents deployed a range of strategies. They positioned the ERA as a maneuver by political elites and feminists which was out of sync with the average woman (Critchlow & Stachecki, 2008). Critchlow and Stachecki (2008) describe how the national women’s organizations, centralized in Washington, D.C., did not build a strong grass-roots constituency to support the ERA, leaving an opportunity for opponents to discredit the value of the ERA to voters who were more distant from the Northeastern corridor.
Sociologists Soule and Olzak (2004) found the anti-ERA efforts were most successful in those states that had competitive elections. As the debate intensified and populist opposition to the ERA grew, the ERA became an important issue for mobilization in elections; the ERA roused strong emotions that got out the votes. In the states that rejected the ERA, a relatively small portion of the population was well informed on the ERA, and supporters slightly outnumbered the opposition. However, those in opposition were more likely to be registered to vote, more likely to vote, more politically involved, and involved with more intensity than ERA supporters.
In 2015, male NPs made an average of $109,000, $9,000 more the average salary of $100,000 for female NPs. Today, gender gaps persist. An analysis of U.S. Census data conducted by the National Partnership for Women and Families (2015) reported that, on average, full-time working women in the United States are paid 21 cents less for every dollar paid to full time working men, creating an annual average wage gap of $10,762. In 2015, male NPs made an average of $109,000, $9,000 more the average salary of $100,000 for female NPs (Muench, Sindelar, Busch, & Buerhaus, 2015). The International Council of Nurses Position Statement (2009) on the socio-economic welfare of nurses also points to the challenges related to gender typing in the profession.
Comparing States Ratifying versus Opposing the Equal Rights Amendment
In this study, regulations recognizing APRN professional independence and prescribing (full professional authority) in states that ratified the ERA were compared to regulations in states that opposed the ERA passage. State support of the ERA was reflected by ratification without rescinding support for the amendment. The five states that ratified and then retracted ratification were counted among the states that did not ratify the ERA. This study used data on state regulatory environments for NPs, CNMs, CRNAs, and CNSs that was derived from NCSBN maps and scoring grids (2015a, 2015b), from a compilation of NP regulations 1998-2012 (Kuo, Loresto, Round, & Goodwin, 2013), and from a 2007 study that gave each state a numerical score based on evaluation of three domains (Rudner Lugo et al., 2007).
APRN regulations and APRN independence have not been tracked with consistent measurements over the years. Given the complexity of state regulations and nursing practice, the methodologies for assessing APRN regulatory environments have varied. APRN regulations and APRN independence have not been tracked with consistent measurements over the years. The first compilation of state regulations was the 1989 Pearson report, which did not quantify the differences or rank the states (Rudner Lugo et al., 2007). The first numerical scoring of NP practice environments was conducted with 2007 regulations (Rudner Lugo et al., 2007). That ranking scored each state on a 100 point scale reflecting the impact of NP regulations on consumers in three domains: legal capacity; NPs’ patients’ access to services; and NPs’ patients’ access to prescriptions. The legal capacity domain examined the professions (nursing and/or another profession) regulating NPs, requirements for entry into practice, and the authority to practice independent of another profession. The domain of NP patients’ access to services assessed to what extent NPs could diagnose and treat without cumbersome oversight; order tests and therapies; serve as primary care providers; be paid directly; and admit patients to the hospital. The domain of prescriptions quantified the extent to which NPs could prescribe medications their patients may need. The state scores ranged from 35 to 100 (maximum possible score).
Kuo et al. (2013) compiled data from previous studies, including the Rudner Lugo et al. (2007) state scoring and legislative updates. They assessed each state’s NP regulations for each year between 1998 and 2012. States were assigned one of three levels: a) independent practice and prescribing; b) independent practice but requiring another profession for prescribing; or c) limited, requiring physician supervision for practice and prescribing.
NCSBN identified a state as having independent practice, also referred to as full practice authority, if it had no requirement for a written collaborative agreement, no supervision, and no conditions for practice or limitations on prescribing. The NCSBN maintains data gathered from state boards of nursing. This data is used to create tables and maps reflecting progression toward full professional practice authority for nursing in each state and territory. Data for this study were taken from the most current tables, reflecting 2014 status for CNMs, CRNAs, and CNSs and 2015 status for NPs (NCSBN, 2015a; 2015b). NCSBN data from prior years were not available. NCSBN identified a state as having independent practice, also referred to as full practice authority, if it had no requirements for a written collaborative agreement, supervision, and/or limitations on prescribing. Non-independent practice states, states lacking full practice authority, require that the APRN be directly supervised in person by a physician, dentist, or/or podiatrist or that a written agreement with one of these other professions exists that specifies scope of practice and medical acts the APRN may be allowed to do.
NCSBN data identified a state as having independent prescribing if the state had no requirements for a written collaborative agreement, supervision, or conditions for the APRN to prescribe pharmacological and non-pharmacologic therapies beyond a perioperative or periprocedural period. A state was identified as not having independent prescribing regulations for APRNs if the APRN is required to have, in order to prescribe pharmacological therapies, a written agreement that specifies the scope of practice and ‘medical’ acts allowed and/or required to have supervision by a physician, dentist, or podiatrist.
Some states allow independent practice but require physician involvement for prescribing... Full APRN practice requires both professional independence and prescribing independence. Some states allow independent practice but require physician involvement for prescribing. Other states allow for independent prescribing but not independent practice. A state was identified as having full practice authority with prescribing if it was identified by NCSBN as permitting practice and prescribing independent of oversight by another profession. All other states limited full practice authority by APRNs, as they lacked independent practice, independent prescribing, or both. Full APRN practice requires both professional independence and prescribing independence.
The state information from the studies by Kuo et al. (2013) and Rudner Lugo et al. (2007), NCSBN 2014-2015 data (2015a), as well as literature on the ERA, were used to create a spreadsheet reflecting the APRN regulations (full practice or not) and ERA-ratification status of each state (ERA-supportive or ERA-opposing) as dichotomous variables. The number of states supporting the ERA, the number of states opposing the ERA, and the number in each of these groups that had full practice authority for APRNs were used to calculate Chi Squares and test for statistical significance. Since the scores in the Rudner Lugo et al. (2007) study were continuous, an independent t-test was used to compare domain and total scores in the ERA-supporting with the ERA-opposing states.
A more egalitarian view of women, as reflected in support for the ERA in the state, was found to be associated with regulations recognizing full practice authority for NPs, CNMs, and CRNAs. The relationship was not significant for CNSs. This relationship persisted in each of the three distinct assessments (Kuo et al., 2013; NCSBN, 2015a; Rudner Lugo et al., 2007) of the states’ regulatory environments for advanced practice nurses.
Table 1 shows that the differences between ERA-supporting states’ and ERA-opposing states’ 2014-2015 regulatory environments for NPs, CNMs and CRNAs. These differences were statistically significant (p <.05 for NPs and CNMs, p <.01 for CRNAs).
Table 1: ERA-Supporting and ERA-Opposing States with Full Practice Authority for Advanced Practice Registered Nurses (APRNs), 2014-2015, Number (%)
Nurse Practitioners (NPs)*
Nurse Midwives (CNMs)**
Nurse Anesthetists (CRNAs)*
Clinical Nurse Specialists (CNSs)
All States (n=50)
* p<.05 **p<.01
The ERA-supporting states were more likely than the ERA-opposing states to have full practice authority for NP regulations in 1998, 2012, and 2015 (Figure). In 1998, 27% of the 30 states that supported the ERA allowed full nurse practitioner practice authority with prescribing, compared to none of the states that opposed the ERA (p<.05). In 2012, the gap between the two sets of states continued; 14 (47%) of the ERA-supporting states had full NP practice authority with prescribing, while only two (10%) of the 20 ERA-opposing states had recognized NPs’ full practice authority with prescribing (p<.01). As of July 2015, among the 30 ERA-supporting states, 16 (53.3%) have full practice authority with prescribing. In contrast, only four (20%) of the 20 ERA-opposing states have full practice authority with prescribing for NPs (p<.05). The trends over the three time periods are shown in the bar chart.
Figure: Percent of States with Full NP Practice, with Prescribing, 1998, 2012, 2015 in ERA-Supporting and ERA-Opposing States
*p<.05 ** p<.01
Additionally, the t-test of the ERA-supporting and ERA-opposingstates’ earlier scores from the Rudner Lugo et al. (2007) study showed a statistically significant (p <.01) difference (Table 2) between the two groups of states in the total scores, as well as in the domains of legal capacity and NPs’ patients’ access to services, but not for NPs’ patients’ access to prescriptions.
Table 2: Average Nurse Practitioner Regulatory Scores in ERA-Supporting and ERA-Opposing States, 2007
Domain of state regulatory environment
Legal c apacity**
NP patients’ access to services**
NP patients' access to prescriptions
Total State Score**
All states (n=50)
ERA-supporting states (n-30)
ERA-opposing states (n=20)
The relationship between ERA ratification and NP regulations persisted in the test of the 2007 state scores (Table 2). The average scores of the ERA-supporting-states were higher than the all-states averages and the ERA-opposing-state averages for each of the three domains and the total scores. The total scores on the 100 point scale for the ERA-supporting states averaged 77, compared to 64 for the ERA-opposing states (p<.01). The ERA-supporting states average score for legal capacity was 22, compared to 17 for the ERA-opposing states (p<.01). The score for NP patients’ access to services (maximum possible was 40 points) was an average of 33 in ERA-supporting states and 27 in the ERA-opposing states (p<.01). In the domain of prescribing, which could have a maximum of 30 points, the ERA-supporting states averaged 23, compared to 20 in the ERA-opposing states. This approached statistical significance, p=.06.
The ERA vote indicated the state’s perception of women’s equality. Multiple social, economic, and cultural factors influence both a state’s view of women and its vote on gender equality. Similarly, multiple factors, including resistance from other professional groups, healthcare situations, manpower needs, and legislative leadership may be factors in determining APRN regulations. For example, Massachusetts ratified the ERA but limits APRN practice, while Idaho did not support women’s equal rights but does have full APRN practice authority. The fact that Massachusetts has the highest number (421.5) of primary care physicians in the nation per 100,000 people and Idaho has the second lowest (184.1) may play a role in determining the extent of APRN practice privileges (Association of American Medical Colleges Center for Workforce Studies, 2013). The analysis reported here considered ERA ratification; it did not address other factors that may influence the APRN regulations.
No quantification of the APRN regulatory environments during the time states voted on the ERA (1972-1982) exists; many states did not recognize the APRN role at that time. The advanced practice nurse roles were developing across the nation during the years of ERA ratification votes (1972-1982). Pioneers Dr. Loretta Ford and Dr. Henry Silver trained the first APRNs in 1965. In 1982, the NCSBN produced the first model nurse practice act for states to consider but this act did not include language for APRNs. That same year the NCSBN appointed a committee to study the issues related to nurse practitioner regulations (Hartigan, 2011).
The findings of this study show a consistent relationship between ERA-supporting or ERA-opposing states and their state APRN regulations, both historically and currently. The findings of this study show a consistent relationship between ERA-support or ERA-opposition and state APRN regulations, both historically and currently. ERA-supporting states were more likely to have full APRN practice with prescribing rights, in 1998, 2007, 2012, and 2015. While the ERA votes occurred over 40 years ago, it is likely that these social and cultural perspectives on women’s roles persist today and influence current APRN regulations.
The relationship between attitudes towards women’s equality and the regulation of advanced nursing aligns with the comparisons of ERA-supporting and ERA-opposing states by Crowley (2006), Nice (1986) and Daniels and Darcy (1985). States supporting the ERA have more women in the legislature and more pro-female policies than the ERA-opposing states. They are also more likely to be earlier adopters of policy innovations (Daniels & Darcy, 1985). The largest group of APRNs, specifically the NPs, have been identified by the Harvard Business Review as a positive ‘disruptive innovation’ in healthcare (Christenson, Bohmer, & Kenagy, 2000).
Demeaning images of nurses, often having sexual connotations, have persisted and been detrimental to the nursing profession (Summers & Summers, 2009). Other work has shown the undervaluation of women and women’s work remains an important contributor to the gender pay gap and discrimination (Bobbitt-Zeher, 2011). The findings in this study suggest that state-specific perceptions of women and the role of women may contribute to the variation in nursing regulations among the states. Undervaluing of women and of predominately female professions can be a barrier to recognizing the qualifications, abilities, and quality of care of APRNs and the potential contributions of APRNs’ full practice authority.
The relationship between the ERA and full CNS practice in this study was not found to be significant. This may be related to the lower prevalence of CNSs in the nation and other characteristics of the CNS role. For example, in three states, the CNS role is still not recognized as an advanced practice role (NCSBN, 2015b). While the relationship with the prescribing domain for NPs in the 2007 state scorings approached but did not meet significance (p=.06), the relationship between the overall scores for the two sets of states, reflecting both professional autonomy and prescribing as recommended by the IOM and NCSBN, was strongly significant (Rudner Lugo et al., 2007). Prescribing authority without independent practice authority is still a practice that is limited.
The ERA-supporting states are making greater progress than the ERA-opposing states toward full implementation of the model nurse practice act and the IOM Future of Nursing (2010) recommendations. The relationship between perceptions of women, as reflected in ERA support or opposition, persisted in 1998, 2007, 2012, and 2014-2015, using three different assessments of APRN professional autonomy with prescribing (Kuo et al., 2013; NCSBN, 2015a; Rudner Lugo et al., 2007). The ERA-supporting states are making greater progress than the ERA-opposing states toward full implementation of the model nurse practice act and the IOM Future of Nursing (2010) recommendations.
The American Association of Colleges of Nursing (AACN) has stressed, in its ‘Essentials’ documents which address essential content to be included in nursing programs, the importance of nursing education including, at all levels, an understanding of political forces and advocacy skills (AACN, 2006; AACN, 2011). The association between the ERA and full practice authority for APRNs suggests that these skills are very much needed and that nursing regulations are influenced by the social and political environments of each state.
Nurses seeking to update nursing regulations require a diversity of partners. The success of the anti-ERA movement provides valuable lessons in this regard. For example, the success of anti-ERA forces’ emotional appeals to voters and the power of popular opinion reinforce the benefits of both promoting the positive health benefits of APRN care and also collaborating with a range of grass-rootgroups. Just as the anti-ERA forces appealed to emotions, professionals opposing full practice authority appeal to fear and danger of low quality care, comparing years of education of APRNs to that of physicians, rather than looking at the evidence showing high quality care provided by APRNs. Forces encouraging full practice authority for APRNs can also use emotional appeals to grass-root groups, such as healthcare consumers, for improved access and personal relationships with APRNs, while also demonstrating decades of evidence of safety and outcomes.
Building partnerships with organizations promoting women’s equality and improved healthcare access may bolster APRN regulatory reform. The ERA battle has also highlighted how policy issues become valuable tools for politicians in contested elections. The ERA became a rallying point for increasing voter participation, especially in competitive elections. ERA supporters and opponents could leverage their activism to gain candidates’ support of their positions on the issue. While the failure of ERA ratification shows the passion for maintaining the status quo, it also shows the impact of a relatively few but effective advocates, as ERA history has shown that the ERA opponents were fewer in number but stronger in their engagement on the issue. No policy issues occur in a vacuum. Building partnerships with organizations promoting women’s equality and improved healthcare access may bolster APRN regulatory reform. Strengthening perceptions of APRNs as strong, competent, independent, and full-peer collaborators with other professionals may counter some gender stereotyping that currently blocks full implementation of the IOM recommendations. Strong, forthright, male and female APRN advocates, along with a diversity of consumer and business partners, calling for aligning state regulations with the IOM recommendations and the NCSBN Model Practice Act, may further diffuse some of the gender bias limiting full practice authority for NPs.
Projecting the image of APRNs as male and female professionals who are strong and competent can help build support for full utilization of APRN skills. Attitudes toward women influence APRN regulations. The data presented above has demonstrated that ERA-supporting states have been more likely to have APRN regulations that allow for full practice authority. The states that did not support the ERA tended to also have other limited policies, such as limited domestic violence protections, that are less favorable for women, and to have fewer females in local and state office. An understanding of the relationship between perceptions of women and nursing regulations can guide broader strategies that will help to update state nursing regulations and secure full practice authority for APRNs that is in alignment with each state’s social and political values. Projecting the image of APRNs as male and female professionals who are strong and competent can help build support for full utilization of APRN skills. Progress toward full deployment of APRNs will require partnerships and grass-roots efforts to build political support, along with framing the updating of APRN regulations to be in alignment with each state’s political values for the good of all citizens.
Nancy Rudner Lugo, DrPH, APRN
Dr. Rudner Lugo serves as an Adjunct Professor at George Washington University School of Nursing in Washington, D.C., where she teaches health policy, quality, and population health. She also has a workplace, health-coaching practice, works as a health care consultant with HealthAction.biz, and serves as an APRN in a local free clinic. She was a co-author of the first ranking of state nurse practitioner regulations and a co-author of a study assessing factors associated APRNs’ likelihood to be engaged in influencing policy. She serves on the Florida Action Coalition to implement the recommendations of IOM report, The Future of Nursing: Leading Change, Advancing Health, and has been an active leader with the League of Women Voters. Her state, Florida, has opposed the Equal Rights Amendment and has limited practice authority for APRNs.
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