"If you don't seek out that approval, then you're going to be fighting an uphill battle the entire way," says Knybel.
"There's a whole hierarchy level that controls what a practitioner can do—but it all comes down to how you're restricted by the boards within the hospitals. They control who can work there, what they can do and how they can practice," says Smolenski.
"But most of these boards are run by physicians. Some are more progressive, but it really varies from place to place or where there are less physicians and physicians have more authority they don't want to give that up. It really depends on the physicians on these boards."
3. State licensing standards limit their mobility
State nurse practice acts still vary from state to state. In 2006, the Consensus Model for APRN Regulation brought together the accreditation programs, state boards, and nursing bodies to come to some agreement on what the APRN standards should be across states. This was meant to improve nurse practitioners' mobility across states as well as provide some consistency to their licenses because every state was, and still is, handling APRNs differently.
But according to the AANP, out of the 155,000 nurse practitioners in the United States, only 43% hold hospital privileges. "Now the issue is that the states are going to have to relook at their nurse practice acts so everyone is more consistent across state lines, which will make it easier for people who are hiring," says Smolenski.