In other words, physicians authorize the nurse practitioner to prescribe certain medications -- perhaps not all but those medications that are most often required by patients -- without getting approval from a physician. It saves time and is primarily designed to make the patient more comfortable, not just to hand additional authority to the nurse practitioner. Is prescriptive authority appropriate? This question, according to Patricia Berry, a faculty member at the University of Utah, is raised often because there is in the healthcare industry a "…misapprehension about pain and addiction" (Lebo, p. 1). There are "myths about pain and pain management," Berry is quoted saying. Healthcare professionals get "…addiction, physical dependence and tolerance all mixed up," Berry continues. There are "erroneous beliefs about opioids and addiction, side effects, respiratory depression, those kinds of things," Berry explains (Lebo, p. 1).

In twenty-nine states physician collaboration is a "requirement," Lebo explains on page 2, and there are various regulations and restrictions that accompany physician collaboration. Indeed, in some states APRNs are subject to specific and even daunting restrictions on what medications they may prescribe. In West Virginia, for example, APRNs may not order Coumadin or "…more than 3 days of a benzodiazepine," Lebo continues (p. 2). And so if a patient has suffered from a general anxiety disorder, and has been responding well to Xanax for several years, what is the nurse practitioner supposed to do, "…have them come in every 3 days? Or ship that patient out to another provider?" (Lebo, p. 2).

That's not all of the tight and seemingly restrictive regulations in West Virginia. Other drugs that West Virginia APRNs cannot legally prescribe include: "schedule II controlled substances, anticoagulants, antineoplastics, radiopharmaceuticals or general anesthetics" (Lebo, p. 2). Schedule III drugs that nurse practitioners may prescribe in West Virginia are limited to a "…72-hour supply without refill," and they may not prescribe any drugs from Schedules IV and V for more than 30 days and nurse practitioners in West Virginia may not give patients "more than five refills" of Schedules IV and V medications (Lebo, p. 2).

On the other hand, the prescriptive authority of APRNs in some states and in some hospitals is "fairly loose," Lebo continues; the collaborating physician and the APRN get together and agree that the APRN may prescribe certain drugs without the doctor's immediate attention and ultimate authorization (p. 2). Nurse Practitioner Nancy Browne moved from Maine to Illinois in 2011, and she had to make an adjustment from Maine's regulations -- which allow independent prescriptive authority -- to a situation in which a collaborative agreement is reached between the nurse practitioner and the physician. This transition was not at all difficult for Browne because she had previously enjoyed a collaborative physician-APRN relationship.

Brown did say in the Lebo article that the doctors she had worked with in collaborative arrangements were cooperative and understood that "…I would only prescribe what I am comfortable with, what I feel is appropriate, and medications that go along with the broad plan of care discussed with the physician" (Lebo, p. 2). In California nurse practitioners must develop a "standard procedure with their collaborating physician, and are only allowed to prescribe" what has been agreed upon between doctor and APRN, which is reasonable and professional. Naomi Gelardi, a nurse practitioner in Redwood Valley, California, said there is "…considerable autonomy" in California, and she does not "feel constricted" albeit she believes the collaboration procedure between physician and APRN is "…confusing for many NPs (Lebo, p. 3).

The following states (and the District of Columbia) have "the most independent prescribing procedure: no requirement for physician involvement (including controlled substances schedules II through V)": Alaska, Arizona, District of Columbia, Idaho, Iowa, Maine (after two years of supervised practice), Montana, New Mexico, New Hampshire, Washington, Wisconsin (if the NP is certified as an "advanced practice nurse prescriber"), and Wyoming (Lebo, p. 5).

Evaluate participation in managed care and quality initiatives

The difference between the roles of the clinical nurse and the nurse practitioner -- though both are important components of managed care -- is significant and it is appropriate to point out those divergent roles in the healthcare field. Clinical nurses tend to zero in on "content and the application of specific knowledge" so they can make improvements on patient care, Martin Christensen...

As to nurse practitioners, they are far more interested in "…process and how they practice in providing direct patient care to specific patient groups"; they also step into the shoes of physicians and provide very competent care that patients appreciate more than what patients normally get from doctors (Christiansen, 874).
The material presented in this paper focuses on advanced practical nursing -- nurse practitioners -- and what they do, how they qualify to become APRNs, and how they collaborate with physicians in order to be able to prescribe medications for patients. What has been gleaned from the literature that was used in this piece is that the APRN is more involved in critical thinking and the "theoretical application and extensive clinical experience" that paved the way for their advancement into advanced knowledge and authority (Christianson, 875). There was a time when nurses were conditioned into believing that "a title will convey their level of authority" but not the level of competence needed for that role (Christianson, 875). That belief should be thrown out the window because nurses that are getting their Master's degrees and are becoming leaders are pushing their weight around in the sense that they are becoming more like doctors than ordinary RNs; they prescribe medication; they lead; they make judgment calls; and moreover, patients prefer getting healthcare services from a APRN rather than a physician.

The important distinction to be made in the advanced practice nurse milieu is that nurses who advance into the APRN status are engaged in a process of integration, rather than being locked into learning more about healthcare content.

Leadership -- whether a nurse practitioner intended to lead or not -- should inevitably be linked to the role the APRN plays in England. Interestingly there has been a lack of specificity in terms of evaluating the role of the advanced practitioner in England, according to Newville, et al., writing in the peer-reviewed Journal of Nursing Management. Managed care in England should be seen as on the upswing given the growth of the field of advanced practitioners there. But Newville offers three purposes for advanced practitioners that appear to devalue the potential of APRNs since they are aims that any competent RN with a four-year degree could step into and complete.

The three main aims of continuing to develop advanced practitioner roles in England include: a) improving the quality of care and to reduce costs (no one can argue with that on the face of it); b) to increase capacity and "extend the range of services" that can be made available to patients (this is questionable in terms of APRNs giving an advantage to English healthcare); and c) to "reduce the medical workload" (this is absolutely the wrong reason for training nurses to become advance practitioners) (Newville, et al., 2012). Reviewing those three aims one must wonder -- why would the healthcare industry ignore the additional education and leadership skills that advanced practitioners have gone through? Where is the information in this scholarly article about an APRN actually playing the part of a physician? One wonders why prescriptive authority is not considered a pivotal reason for training and hiring advanced practice nurses in England.

Advanced practice nursing in Singapore has been on the upswing for over ten years now but there are signs that it is not going well and one reason could be a wrongheaded approach to the project. Large amounts of money have been made available as scholarships so that RNs can continue into a Master's program and become APRNs. However, the project has been "turbulent at times" as some graduates do not want to finish the internship and do not "successfully complete the certification process" (Schober, 2010). Moreover, there is "confusion" over what the APRN can do that sets the APRN apart from the RN. The wrongheadedness of the campaign to create more APRNs is that administrators believe nurse practitioners could "…fill gaps in the provision of healthcare services" (Schober, p. 449). Fill gaps? That's patently absurd. The talented APRN can expand the ability of the healthcare sector, can provide a new level of service that patients will truly appreciate -- as opposed to having a doctor breathlessly spend 5 to 7 minutes with a patient before dashing off to his or her next 5 to 7-minute appointment.

Unlike medical administrators in Singapore, healthcare leaders in Finland are training advanced practice nurses and using those skills more wisely. "Advanced practice nurses are an important resource," according to another article in the peer-reviewed Journal of Nursing Management. One key reason…