How nurse practitioner scope of practice regulations impact nursing home staffing and quality

The National Institute on Aging awarded Miami University $314,640 on September 1, 2026, under the Aging Research program (CFDA 93.866) to examine how state-level nurse practitioner scope of practice regulations affect staffing patterns and resident outcomes in nursing homes.

The research employs sequential explanatory mixed methods across three aims: determining how changes to state NP scope of practice regulations affect NP staffing patterns in nursing homes; examining the effect of different NP staffing patterns and expanded NP scope of practice on nursing home resident outcomes; and exploring qualitatively the factors influencing nursing homes' employment of NPs and service impact on resident outcomes. The study uses state regulatory changes between 2019 and 2024 as a natural experiment, comparing states that changed regulations against a control group of states that had granted NPs full practice authority prior to the study period. Aim 1 and Aim 2 utilize a difference-in-differences framework to analyze NP staffing levels and resident outcomes.

The award period runs September 1, 2026, through June 30, 2030, with performance taking place in Oxford, Ohio. This is a Project Grant, the standard assistance type under the Aging Research program.

Abstract

The quality of care provided in nursing homes has been of concern for several decades and inadequate clinical staffing is associated with many quality issues. Nurse practitioners (NPS) can be a one solution to the staffing and quality issues that are plaguing the nursing home industry as NPS may be better able to identify issues with residents earlier. Our preliminary analysis shows there is significant variation in the use of NPS across states, and this is related to how state-level scope of practice regulations dictate whether NPS are able to practice independently, known as full practice authority, or must work under the supervision of a physician. Sequential explanatory mixed methods are proposed to better understand how NP scope of practice regulations impact the employment of NPS and quality outcomes of nursing home residents. The specific aims are: aim 1) to determine how changes to state NP scope of practice regulations affect NP staffing patterns in nursing homes; aim 2) to examine the effect of different NP staffing patterns and the expansion of NP scope of practice on nursing home resident outcomes; and aim 3) to explore qualitatively the factors that affect nursing homes' employment of NPS and their service's influence on resident outcomes. In 2020, 14 states temporarily granted NPS full practice authority and then reverted back to their previous regulations and five states permanently granted NPS full practice authority. Aim 1 and 2, will utilize these changes as a "national experiment." states that changed scope of practice regulations will be treated as multiple "treatment" groups that will be compared to a "control" group of states that had given NPS full practice authority prior to the study period of 2019 to 2024. Aim 1 will examine NP staffing patterns (e.g., staffing levels) utilizing a difference-in-differences framework. Data indicate an ability to examine approximately 8,780 nursing homes per quarter. Aim 2 will use resident assessments (n=850,000-900,000 per quarter) to measure resident quality outcomes (e.g., pressure injuries, falls). Difference-in-differences analysis will be used to identify the effect of NP scope of practice expansion, decomposing the effect into the expansion of practice authority VS. Changes in NP staffing patterns. Finally, aim 3 will consist of qualitative interviews with nursing home administrators and will yield valuable insights into the barriers nursing homes face in employing NPS and the steps some nursing homes have taken to overcome these barriers as well as insights into the mechanisms through which NP services affect care quality.