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Sherwood, Brown, Fay, and Wardell present many issues and barriers Advance Practice Nurses face today.  They acknowledge that NPs have and maintain the qualifications and skills necessary to meet the needs of clients requiring primary care services.  As demand for these services increases, legislation and support to gain the necessary autonomy and practice standards are vital (Sherwood, Brown, Fay, & Wardell, (1997).  Many institutions and environments still limit APN influence and scope of practice, and various differences exist from state to state (Sherwood et al., 1997).  
NPs have consistently received extremely favorable results in regard to patient satisfaction and clinical outcomes.  Studies of patient interaction with APNs compared to physician visits show that NPs spend more time with the client, have better communication and interpersonal skills, produce better satisfaction reports from clients, and have equivalent outcomes and quality of service in relation to scope of practice (Sherwood et al., 1997).  Sherwood et al., (1997) confirms that some of these results may be due to the complexity and severity of client visits to physicians compared to NPs.  However, sufficient evidence supporting NP practice with equivalent patient presentation and complexity remains (Sherwood et al., 1997).
Many barriers to APN practice remain in many regions and states, especially in regard to financial reimbursement, prescriptive authority, and hospital admission privileges.  Due to requirements, legislation, or strict physician supervision requirements, these barriers have led to increases in cost of care, delay of treatment and care, and insufficient ability to provide primary care.  They also inhibit autonomy of practice, collaboration, and overall care.  
Initially designed as a primary care provider for underserved and rural population, the APN has broken into many other environments and locations of practice (Sherwood et al., 1997).  States with significant rural and underserved populations have provided more autonomy of practice and professional encouragement for independent practice for APNs.  Alaska, Oregon, and Washington are three such states Sherwood et al., (1997) notes.  However, from the studies mentioned, NPs have provided excellent care in numerous clinical and regional settings.  Sherwood et al. (1997) encourages all APNs to promote the advancement of their profession by influencing policy and involvement in professional organization.

Sherwood, G. D., Brown, M., Fay, V., & Wardell, D. (1997).  Defining nurse practitioner scope of practice: expanding primary care services.  The Internet Journal of Advanced Nursing Practice, 1(2).  Retrieved from