Broadening the scope of nursing practice.

n engl j med 364;3 nejm.org january 20, 2011 193 phase of reform must slow the growth of health care costs and improve value through payment reforms, including bundling of payments and payments for episodes of care. Some savings will derive from implementation of innovative models of care, such as accountable care organizations, medical homes, transitional care, and community-based care. We believe that if we are to bridge the gap in primary care and establish new approaches to care delivery, all health care providers must be permitted to practice to the fullest extent of their knowledge and competence. This will require establishing a standardized and broadened scope of practice for advanced-practice registered nurses — in particular, nurse practitioners — for all states. Nurses’ role in primary care has recently received substantial scrutiny, as demand for primary care has increased and nurse practitioners have gained traction with the public. Evidence from many studies indicates that primary care services, such as wellness and prevention services, diagnosis and management of many common uncomplicated acute illnesses, and management of chronic diseases such as diabetes can be provided by nurse practitioners at least as safely and effectively as by physicians.1 After reviewing the issue, an Institute of Medicine (IOM) panel recently reiterated this conclusion and called for expansion of nurses’ scope of practice in primary care.2 Some physicians’ organizations argue that physicians’ longer, more intensive training means that nurse practitioners cannot deliver primary care services that are as high-quality or safe as those of physicians. But physicians’ additional training has not been shown to result in a measurable difference from that of nurse practitioners in the quality of basic primary care services.1,2 We are not arguing that nurse practitioners are substitutes for these physicians, but rather that we should consider how primary care services can be more effecBroadening the Scope of Nursing Practice