Why is it that some staes don’t allow NPs to practice in their full capacity without a practicing physician involvement?
Why is it that some staes don’t allow NPs to practice in their full capacity without a practicing physician involvement?
One of the most pressing issues in the nurse practitioner community is the fight to modernize practice regulations. In some states, NPs cannot provide healthcare to the full extent of their education and credentialing. As a result, NPs in states with limited practice authority cannot always fulfill their patients’ needs without a “collaborative agreement” with a supervising physician. This impedes the NP from operating autonomously (fpa, 2021, p. 1).
Although some may not realize, the mission of our Boards of Nursing (BONs) were developed to protect the public not the nurse. The Boards in each state regulate nursing practice and define requirements for licensure and scopes of practice in their particular geographical area. When it comes to the advance practice nurse, the scope of practice varies widely dependent upon the location and the specialty.
Before January of 2021, only 22 states (and DC) allowed NPs to practice to the full extent of their scope, education, and practice without physician involvement. 24 states required a formal, written relationship with a physician. The buck as they say, doesn’t stop there, because even within these parameters, there are further obstacles because the “relationship requirement varies from state to state and could call for supervision, delegation, authorization, or more general direction and collaboration” (ncsbn.org., n.d., para 6). 4 States—CT, IN, MN and PA, “require some form of relationship” but nothing needs to be formally documented—further confusing the issue! When it comes to prescribing, only 13 of 23 jurisdictions that allow autonomous practice by NPs allow them to prescribe without benefit of physician involvement. “The remaining 38 states all require documented physician involvement for NPs to be able to prescribe medications” (ncsbn.org., n.d., para 6).
I have to say, this was not an easy assignment. You would think it would be cut and dried. This is what you can and this is what you cannot do. Add COVID to the mix, and the waters are further muddied, as so many states adopted “Emergency” or “Executive” orders. Some “waived” or “suspended” certain requirements. Still others—like Massachusetts, made permanent changes.
On March 25th, 2020, Governor Charles D. Baker declared a state of emergency in Massachusetts due to COVID-19. At that time, he announced any APRN with at least 2 years supervised practice experience—or equivalent, would be exempt from requirements of physician supervision and prescriptive practice. Ten months later, on January 4th, 2021, Massachusetts became the 23rd state allowing nurse practitioners to practice independent of a supervising physician. When the Governor —Charlie Baker, signed the legislation into law (Japsen, 2021).
“This decision aligns with the evidence and recommendations for NP licensure from leading health policy groups like the National Academy of Medicine. Research shows that states with Full Practice Authority maintain strong safety and quality outcomes and improve both access to care and cost savings” (Japsen, 2021, p. 3).
Two of the biggest obstacles I can see against autonomy are the need for a collaborating physician and prescriptive authority.
As of January 1st, 20201, NPs in Alaska have full practice authority (fpa), and they have the right to prescribe Schedule II to V controlled substances. In Arizona, they too have full prescriptive authority; however “a Controlled Substance Prescription Monitoring Program (CSPMP) application must be submitted” (Maryville, 2020) with the DEA before they will be allowed to begin prescribing. In Colorado, NPs are considered having fpa. They can achieve full prescriptive authority once they have completed 1,000 hours of practice with a provisional prescriptive authority—either an MD or a mentoring NP. In Massachusetts, after 2 years of qualifying supervised prescriptive practice NPs can earn independent fpa.
It seems every state and every BON has their own sets of rules and regulations. Although it is to keep the public safe, with the changing landscape with regard to the shrinking availability of primary care physicians in this country, is it truly in the public’s best interest? According to Phoenix & Chapman in Institute of Medicine, 2011, Nurses should practice to the full extent of their education and training” (2020, p. 376). That’s all we are asking!
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