Role of an Advanced Practice

Role of an advanced practice nurse (APN) has changed and evolved over the years to the point where an APN has more authority, more respect and more responsibility -- and this paper delves into those responsibilities. The paper also reviews the intelligent use of the APRN (or APN) and the not-so-intelligent use of these well-trained healthcare professionals.

The prescriptive authority of the APRN - background

Up until a few years ago the State of Georgia was the only state in the U.S. that did not authorize APNs to prescribe medicines for their patients. Cathy Jordan, a pediatric APRN and professor in the Nell Hodgson Woodruff School of Nursing at Emory University, explains the general and the role of an APRN. The APRNs conduct physical exams as part of their routine, they take medical histories, the of course provide treatment for "…acute minor illnesses and injuries," they manage illnesses that are considered chronic, the APRNs supervise and provide interpretation for lab tests and x-rays -- and they also educate their patients and provide counsel to patients as well (Jordan, 2000). In addition, Jordan explains that APRNs do order drugs and they order diagnostic studies according to the protocol they work within.

And up until 2006, APRNs in Georgia could call a prescription into a pharmacy -- using the authority of the attending physician -- but they could not write that prescription. In her article (2000), Jordan insisted that without the prescriptive authority -- that other states give their APRNs -- the advance practice nurse is hunting down the physician to sign the prescription rather than doing it on his or her own. Time and talent are being wasted in this scenario, Jordan asserts.

Jordan references a Journal of the American Medical Association (JAMA) study that followed 1,316 adults that had been randomly assigned to "…the ambulatory care of either nurse practitioners or physicians" (p. 4). In this study the nurse practitioners had virtually the same authority and requirements as primary care physicians and, according to Jordan, "…no statistically significant difference in patient outcomes was found" (p. 4).

Moreover, research presented by Jordan reflects the fact that "…APRNs have better patient outcomes in illnesses where communication with patients is integral to recovery and wellness" (p. 4). It is not surprising that patients tend to prefer APRNs because APRNs do the "bulk of patient education," they listen more closely to patients than physicians do and have more time to counsel patients than doctors do (Jordan, p. 4). In Georgia, nurse practitioners "historically have been the significant and sometimes the only health care providers" that work with low income and elderly people in rural areas in particular (Jordan, p. 4). Hence, Jordan urged the Georgia Legislature to pass legislation to give APRNs prescriptive authority.

The prescriptive authority (and other rules that govern) APRNs in Georgia

In the State of Georgia rules for nurse practitioners were adopted on June 28, 2006. In Rule 410-12-01, the nurse practitioner (NP) has met the educational and certification requirements and has been authorized to practice according to the rules the state has produced. The advanced practice registered nurse is authorized by the George Board of Nursing to "perform advanced nursing functions" along with "certain medical acts" including (but not limited to) "…ordering drugs, treatments, and diagnostic studies…" (Georgia Board of Nursing).

In the "Rules for Nurse Practitioners" (410-12-03) the Georgia Board of Nursing does not mention prescriptive authority for the APRN but the rules generalize that the nurse practitioner must show "…evidence of advanced pharmacology within the curriculum, or as a separate course."

Meanwhile the Drugs and Narcotics Agency State of Georgia describe the Georgia Medical Practice Act OCGA 43-34-26.1 (Law) in the document "Dispensing Practitioners Georgia Laws, Rules, and Regulation" (Karsten, 2006). The document covers a number of important areas, describing what "nurse protocol," what "dispense" means and what a "controlled substance" is (Karsten, p. 11).

On page 12 of the document the law authorizes a "certified nurse practitioner" to legally order "…dangerous drugs, medical treatments, and diagnostic studies" (Karsten, 12). Moreover, a physician may "delegate to a nurse…the authority to order dangerous drugs…" in accordance with a "dispensing procedure" and under the authority of an order that was issued based on "conformity with a nurse protocol or job description."

In the Frequently Asked Questions section, the question is -- "May a…nurse practitioner dispense prescription medications?" And the answer is "Yes….a nurse practitioner may dispense prescription medications…" but that practitioner may not allow an assistant to dispense the medication to the patient without practitioner's physical presence and personal supervision" (Karsten, 2006). Also, prescription drugs dispensed by a practitioner can't be "…transferred to another practitioner or pharmacist for subsequent filing"; and while the practitioner's assistant may keep an inventory of the medications, type labels, count pills, and keep records, the assistant may not "compound prescriptions" (Karsten).

The prescriptive authority (and other rules that govern) APRNs in Indiana

The "Prescriptive Authority" to prescribe legend drugs in Indiana is based first (as it also is in Georgia) on completing at least a Master's Degree which is followed by a background check to determine if the nurse practitioner has been arrested or denied a license by another jurisdiction. The advanced practice nurse applicant in Indiana must have completed at least 2 semester hours of a graduate pharmacology course and must have "…proof of collaboration with a licensed practitioner" which amounts to a written agreement as to how the practitioner collaborates with the APRN. In fact the advanced practice nurse in Indiana must show the "time and manner of the licensed practitioner's review of the advanced practice nurse's prescribing practices" (Indiana Administrative Code, p. 2).

The advanced practice nurse in Indiana who wishes to have the authority to prescribe medications must complete a "controlled substances registration and a federal Drug Enforcement Administration registration" (Indiana Administrative Code, p. 3).

The credentialing and clinical privileges of APNs in Georgia

In Georgia the uniform application for a credential to work as an advanced practical nurse is not required; it is voluntary, and the Uniform Healthcare Practitioner Credentialing Application Form (UHPCAF) can be used by an APRN as well as by a physician (Georgia Credentialing). Once a nurse practitioner has completed the required educational steps, one of the final steps toward being able to practice is credentialing and privileging; credentialing is that process through which a healthcare professional obtains the authority to actually provide care of patients in a hospital setting (Hittle, 2010). There are examinations to take for those working in Georgia or Illinois, or other states.

Questions similar to what the American Nurses Credentialing Center (ANCC) exam expects can be studied in advance, and review courses are offered all around the United States. Georgia and Illinois offer paperwork online (Georgia Association of Health Plans, 2004, and the Illinois Department of Public Health, 2001) so the candidates can review the materials that will be included in the credentialing exam. In many states, including Georgia and Illinois, the candidate must complete an active collaborative practice agreement, which must be on the record with the employer before the candidate is credentialed. That agreement specifically describes the professional relationship between a nurse practitioner and a doctor, and as mentioned later in this paper, the collaborative agreement allows that the nurse practitioner can care for patients "independently within agreed guidelines" the physician and practitioner have agreed upon.

Once the paperwork is completed and thorough, the hospital board or governing body will credential the nurse, thereby verifying their belief that the applicant is qualified. The nurse practitioner must be re-credentialed every two years, according to Hittle; hence the skills that were documented at the time of the application are still in good working order two years down the road. Privileging is the process through which a hospital board -- the same board that gives credentials -- gives permission for the nurse practitioner to "…provide specific aspects of patient care…" such as prescribing medications, performing certain procedures and admitting as well (Hittle, p. 4).

The collaborative nature of advanced practice nurses

Sarah Lebo writes that there are only four states in 2013 that do not give APRNs authority to prescribe medications; those are Alabama, Florida, Hawaii and Missouri (Lebo, 2013, p. 1). The president of the American Academy of Nurse Practitioners -- Mona Counts -- explains that many states have stopped using the phrase "supervised" that implies a restrictive amount of authority for APRNs. Instead, the term "collaboration" is more commonly found in the language describing the relationship between physician and advanced practice nurses, Counts explains (Lebo, p. 1).

How many prescriptions does the average APRN write in a typical day? A study in 2002 shows that the typical nurse practitioner with prescriptive authority writes between 11 and 15 prescriptions daily, Lebo writes (p. 1). The American College of Nurse Practitioners conducted a survey and learned that about 37% of nurse practitioners write "…between one and 50 prescriptions per week, and 32% write between 51 and 100 prescriptions…" weekly (Lebo, p. 1).

This is the kind of collaborative effort that APRNs and physicians have when the nurse practitioner has the authority to write the prescription, and doesn't have to take time in order to locate the doctor in the hospital or clinic to get his or her approval for the prescription. 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 writes in the Journal of Clinical Nursing (Christiansen, 2011). 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.