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Pennsylvania is one of 28 states that has not expanded the scope of practice in its licensure laws for certified registered nurse practitioners (NPs), who must maintain formal collaborative agreements with physicians to practice. For many years, proposals to update licensure and adapt it to make it more compatible with current models of collaborative care could not overcome legislative logjams. Often, these proposals were seen as primarily “turf wars” between NPs and physicians, without full consideration of the impact on patients and public health. Growing evidence indicates that these legal oversight requirements impair professional entry to practice, increase costs of care, impose administrative and cost burdens on health systems and NPs, and impede access to high-quality, cost-efficient health care.

Both chambers of the Pennsylvania General Assembly acted to expand scope of practice during the 2019-2020 session—although to different extents. S.B. 25 would have expanded opportunities for NPs across the state, while a compromise amendment to H.B. 100 proposed a six-year pilot program that would have removed physician oversight requirements for NPs in primary care shortage areas only. Neither piece of legislation passed both chambers before session expired. A University of Pennsylvania analysis showed that H.B. 100, as amended, would have affected fewer than 50 NPs who now practice in these shortage areas, which have a combined population of more than 200,000 people. It would not have changed the practice restrictions on the vast majority of more than 11,000 NPs practicing across the state, often in rural and high-poverty areas.

Since the legislation was introduced in 2019, the landscape for reform has shifted, as the COVID-19 pandemic rapidly transformed health care and revealed striking health disparities. Recognizing an opportunity to break the logjam, the University of Pennsylvania held a virtual workshop on November 20, 2020, bringing together researchers, health professionals, and consumers to chart a new path forward. This policy brief summarizes their recommendations to update scope of practice regulation to better meet the primary care needs of Pennsylvanians.


In breakout sessions, workshop participants delved into three intersecting themes: lessons learned from rapid changes in practice due to the pandemic; ways to foster collaborative relationships among NPs, physicians, and other health professionals; and options to move legislation forward in the next legislative session. Each recommendation individually represents a tangible and feasible approach to improve access to care and achieve public health goals. Together, they represent a “symbiotic opportunity” to change the narrative that has produced political stalemate.

Lessons from COVID-19 Changes

In response to the pandemic, many states relaxed or suspended their requirements for physician oversight of NPs, allowing them to expand their practice capabilities — all within the scope of their education and training. Pennsylvania relaxed certain restrictions during the declared emergency, such as limiting NP practice to a specific clinical specialty or prohibiting NPs from prescribing drugs outside of an established formulary.

While there is extensive evidence about the benefits of full SOP and access, quality, and cost of care, workshop participants noted that temporary expansions in NP practice in Pennsylvania and other states could yield state-specific information on quality and efficiency of NP care. They recommended that we see this as an opportunity to update regulation by codifying the temporary changes and further develop, spread, and scale innovative models of care. To apply the lessons of the pandemic, and build consensus among stakeholders, participants recommended that:

Fostering Collaborative Relationships

In a session jointly led by an NP and a family physician, participants discussed the nature of collaborative practice. While current Pennsylvania regulation calls for a collaborative practice agreement, participants noted that real professional collaboration involves more of a process and relationship than a “check box” or payment for a contract. These contracts often require the NP, or health system employing NPs, to pay significant fees to the collaborating physician to fulfill the legal requirement. As presently structured, collaborative practice agreements impose administrative burdens and costs upon the health system, without adding value or delineating services that foster robust interprofessional relationships. Participants recommended that:

Moving Scope of Practice Legislation Forward in Pennsylvania

In a session focused on the most promising steps to take advance scope of practice reform, participants considered the years of legislative impasse and the polarizing dynamics of a “trade war” between entrenched professional interests. They called for changing the narrative by engaging the public around how the public interest can best be served by future legislation. They recommended that:

This policy brief was authored by Janet Weiner, PhD, MPH and reflects rich discussions at the November 20, 2020 virtual workshop sponsored by Penn LDI and Penn Nursing. We thank all workshop participants for their insight; the recommendations herein do not imply endorsement by each participant nor a consensus statement among them.