If your institution has an abundance of physicians, you may think nursing scope-of-practice issues don't concern you. But health reform and provider shortages may make an increased role for advanced-practice nurses—particularly nurse practitioners—inevitable, even in physician-rich areas. Susan Reinhard, chief strategist of the AARP-funded Center to Champion Nursing in America, points to the push to reduce readmissions. "This is where NPs will become very valuable in urban hospitals," she says. "They will provide transitional care and interventions almost as soon as complicated patients are admitted—hospitals already doing this have shown significant reductions in their rehospitalization rate."

Additionally, change is coming at the state level. "States are incrementally expanding scope-of-practice laws for nurse practitioners, and the pace is accelerating," says Catherine Dower, associate director of research at the Center for the Health Professions at the University of California, San Francisco.

According to the 2010 Pearson Report, which is published annually in the American Journal for Nurse Practitioners, 15 states and the District of Columbia permit independent practice for NPs. Seven other states require physician collaboration to prescribe; the rest require physician collaboration to diagnose, treat and prescribe. But these cut-and-dried categories mask a lot of variation, says Dower, noting that definitions like "supervision" and "prescriptive authority" vary widely.

Getting an exact read on legislative changes is difficult. Last April, the Associated Press noted that 28 states were considering expanding the authority of nurse practitioners. But during the summer months, nearly all states adjourn their legislatures, killing any pending bills. "We know there's a fair amount of activity around the advanced-practice nurse issue," Reinhard says.

Hawaii, Maryland and Pennsylvania all passed legislation in their most recent sessions. Ohio, one of seven states whose legislatures are in session nearly year-round, has a bill that has passed the House and is pending in the Senate.

The American Medical Association opposes such legislation. "With a shortage of both physicians and nurses in the U.S., increasing the responsibility of nurses is not the answer to the physician shortage," J. James Rohack, M.D., AMA immediate past president, wrote in a published letter responding to the April AP article.

CEOs should not underestimate their roles in welcoming advanced-practice nurses on staff. "Hospital cultures don't change so fast, but the CEO's attitude makes a big difference in how accepting staff will be," Dower says.

Credentialing is another key area. "CEOs should smooth the credentialing process for non-physician providers," Reinhard says. "CEOs should focus on quality and the mix of providers that help them drive value and, increasingly, that will include APNs."