Published December 1, 2025
In 1965, a nurse and a pediatrician in Colorado devised a novel plan: With some extra training, registered nurses could deliver desperately needed care to children in rural communities where physicians were in short supply.
Their vision gave rise to the world’s first nurse practitioner (NP) program—a practice that has since gone global, with roughly 70 countries adopting or considering some version of an advanced practice nurse with the authority to write prescriptions. NPs are now the third fastest-growing occupation in the United States, and yet they remain widely underutilized, according to Joshua Porat-Dahlerbruch, PhD, RN, an assistant professor in the University of Pittsburgh School of Nursing’s Department of Acute and Tertiary Care.
“Each state restricts or allows nurse practitioners to function differently through scope of practice laws,” Porat-Dahlerbruch said. “But in many cases, it doesn’t matter if an NP has the fullest legal autonomy possible—if their organization doesn’t recognize their full set of abilities, patients suffer at the end of the day.”
Porat-Dahlerbruch is recognized as a global expert on NP integration, a multi-level process that he and his co-authors defined in a recent paper as “incorporating NPs into a care model to the extent that they can function to their full scope of practice and education, which leads to improved patient, health system and population needs.” His research has helped identify barriers that NPs frequently face—such as policies that limit the kinds of patients they can see or requirements that physicians sign off on their tasks—as well as practical solutions.
As patients live longer but also experience more chronic conditions, demand rises for health care professionals at all levels. Porat-Dahlerbruch explained this makes it “particularly important” for decision-makers to let NPs practice to their utmost potential.
“Nurse practitioners need autonomy,” Porat-Dahlerbruch said. “If they're not practicing to the full extent of the scope of practice and education, then they aren't able to provide their best care.”
Though Porat-Dahlerbruch is a community care nurse by trade, he has been interested in the essential services that NPs provide ever since he started nursing school at the University of Pennsylvania.
“From my early days in nursing school, I’ve believed that nurse practitioners are really the key to solving a lot of our issues in health care access,” he said. “NPs are known to be very communicative and good at developing deep connections with patients, and they also tend to work in more underserved areas compared to physicians and physician assistants.”
Alarmed by some of the issues he saw in clinical practices, Porat-Dahlerbruch started exploring policies that could increase the flow of NPs into health care facilities and support work environments conducive to their success. After earning his PhD, he received a Fulbright postdoctoral fellowship to continue exploring this issue in Israel. The country established its equivalent of the NP role in the early 2010s and was still in the process of expanding the program when Porat-Dahlerbruch arrived in 2021.
After interviewing scores of nurse practitioners, physicians, health care leaders, policymakers and national organizations to better understand NP integration, Porat-Dahlerbruch realized the U.S. is not alone in its struggle to define and incorporate nurse practitioners into health systems. In one instance in Israel, a group of physicians stood up and left a meeting in a huff when a health care policymaker suggested that NPs could share some of their workload.
“It stems from distrust and fear that they might be substituted,” Porat-Dahlerbruch said. “As one nurse practitioner told me, ‘People like grandma’s schnitzel the way she makes it, and the same goes for the health care system. Change takes a long time.’”
Porat-Dahlerbruch started looking into NP programs in other countries and learned that they all shared a common thread.
“There is not a single country that has gotten an overarching agreement—from the public, physicians or others in the health system—that nurse practitioners are part of the team and not just part of a hierarchy working under physicians,” Porat-Dahlerbruch said.
Since returning to the U.S. and joining Pitt Nursing in 2023, Porat-Dahlerbruch has led eight studies that aim to define and improve NP integration through policies implemented at all levels of governance. Last year, he led a study that proposed a new way of classifying policy interventions, including “macro” policies at the national, jurisdictional or regional level (such as providing financial incentives for organizations to hire NPs) down to “micro” policies in individual units or care teams (such as creating mentorship relationships between senior and junior NPs).
More recently, he surveyed 10,000 primary care nurse practitioners across the U.S. to understand the extent to which they are practicing “to the top of their licensure and education,” Porat-Dahlerbruch said. Those results have not yet been published, but his hope is that health care leaders will eventually bring this survey back to their institutions to measure NP integration in the U.S. and beyond.
Ultimately, Porat-Dahlerbruch believes the entire health care system will benefit from ensuring NPs are granted greater authority, with patients standing the most to gain at the end of the day.
“As a nurse, you see how much your own autonomy and work environment affect your ability to provide care to patients,” Porat-Dahlerbruch said. “Take that to the nurse practitioner level where they're prescribing care, and you can see how important it is for them to freely practice to the full extent of their education and how much that helps patients in the long run.”