Advanced Practice Nurses and Prescriptive Authority

Introduction

The "Nurse Practitioner" is a relatively new American medical role. First conceived in the 1960s as a restricted diagnostic/nursing hybrid, the discipline has developed within a patchwork of varying state and federal regulations and legislation. The modern Nurse Practitioner is at once empowered and hampered by state and federal authorities across several vital areas. Fortunately, the sheer number of American Nurse Practitioners gives them the political clout to significantly influence their roles toward eventual autonomy and financial equity.

Historical Development of Prescriptive Authority

Though non-physicians have filled medical care gaps created by a lack of physicians for hundreds of years, the formal category of "Nurse Practitioner" is relatively young. During the 1960s, Dr. Henry Silver and a nurse educator named Loretta Ford created an educational program to prepare nurses for responding to the lack of physicians in rural areas of Colorado. Taught at the Master's level, this program required a nursing license and patient care experience for admission, and was innovative in that it combined traditional nursing care with the ability to diagnose. The first Nurse Practitioners began practicing in the late 1960s. Though the nursing profession was initially skeptical of this "physician extender" that seemed to militate against its patient-care focus, as the profession became more defined and as educational programs developed and spread across the country, nursing eventually welcomed this new role.

While Nurse Practitioners enjoyed some autonomy and greater privileges in their roles, the issue of prescriptive authority proved to be a separate battle that took years and even decades to win. By the mid-1970s, state legislatures began considering the possibility of granting prescriptive authority to Nurse Practitioners. Some states eventually granted prescriptive authority through their regulatory bodies, while others did so through their legislative bodies. By 2006, all 50 states and the District of Columbia had granted at least some degree of prescriptive rights to Nurse Practitioners (Buppert, 2012, p. 7).

As of the year 2000, approximately 95,000 Nurse Practitioners practiced in every state and the District of Columbia, with varying requirements and authority granted by each state. According to the National Center for Health Workforce Analysis, the 95,000 Nurse Practitioners working in 2000 represented an increase of more than 240% in the number of American Nurse Practitioners since 1992. By 2011, the number of Nurse Practitioners in the United States exceeded 135,000 (Crane, 2011), and the American Academy of Nurse Practitioners estimates that 656 million prescriptions per year are written by Nurse Practitioners (Brown, 2010, p. x). Today, Nurse Practitioners fill numerous roles in nearly every health care setting, fulfilling the nursing profession's primary focus on the patient's total well-being while exercising the authority to prescribe medication and to order, perform, and interpret some laboratory tests. A recent multidisciplinary health care study found that "Nurse Practitioners demonstrate a high level both of collaboration and high levels of autonomy" (Klein, 2011, p. 80). Nurse Practitioners are able to practice autonomously in many states, though a number are supervised by physicians in some capacity (National Center for Health Workforce Analysis, 2010, pp. 7–9).

The Family Nurse Practitioner specialty is more flexible than areas specializing in neonatal or acute care. Consequently, Family Nurse Practitioners can practice in a number of health care specialties, including family medicine, urgent care, internal medicine, pediatrics, women's health, cardiology, gastroenterology, and urology. While the Family Nurse Practitioner is limited in acute care or neonatal complications, this specialty is often chosen precisely because it allows practice across many areas (Advanced Practice Recruiters, 2012). Most closely resembling the general practitioner of earlier medicine, Family Nurse Practitioners are in ever greater demand due to the shortage of family practice physicians — particularly in rural and inner-city areas — the increasing number of Baby Boomer patients, and the demands created by uninsured patients accessing the health care system through government programs (Advanced Practice Recruiters, 2012). Family Nurse Practitioners are normally found in clinics providing family medicine to patients of any age and are capable of providing care across patients' lifetimes. Depending on their geographic and clinical areas, they may concentrate on any age group, typically from toddlers through older adults. Their prescriptive authority is governed by state legislation, and all 50 states currently allow Family Nurse Practitioners to prescribe medications (Advanced Practice Recruiters, 2012).

Today's Nurse Practitioner faces significant legal, ethical, financial, role acquisition, and political issues, particularly regarding prescriptive authority. Perhaps the most daunting concern involves legal regulation. Regulations governing Nurse Practitioners, including their prescriptive authority, still vary from state to state: "For NPs in 2 states, though, authority to prescribe any schedule of controlled substances is not allowed. Two other states are waiting for final rulemaking before their legislative acts enabling NPs to prescribe controlled substances become effective. For NPs in several states, a variety of restrictions on controlled substances prescribing remain" (Byrne, 2011). Nevertheless, some general rules apply to the prescriptive authority of Nurse Practitioners in every state and the District of Columbia:

Issues and Challenges Facing Nurse Practitioners

Any prescription written for a controlled substance must include the NP prescriber's federal Drug Enforcement Administration (DEA) number, denoting the NP's independent or plenary authority to prescribe in accordance with state scope of practice. Every prescription is expected to include standard information such as the prescriber's name, title, license or specialty, ID or Rx number as applicable, practice address, and phone number; the patient's name; the date of the prescription; and the name of the drug, strength, dosage, route, specific directions, quantity, number of refills, and instructions regarding generic substitution. The cosignature of a collaborating physician is not required in any state on any prescription that an NP is authorized to write (Byrne, 2011).

Nurse Practitioners in federal facilities, such as Veterans Administration hospitals, are governed by a separate set of regulations. As an advisory ruling from the Commonwealth of Massachusetts illustrates, federal regulations borrow some aspects of state legislation but are not identical to it (Health and Human Services, 2010).

The modern Nurse Practitioner also faces serious ethical concerns, particularly due to legal restrictions on practice. The limitations placed on Nurse Practitioners pose an ethical problem in providing the highest quality of care for patients. One Nurse Practitioner noted that every day she is "forced to negotiate around practice restrictions that interfere with my ability to deliver optimal care to my patients" (as cited in Mills, 2009). In addition, 46% of Nurse Practitioners reportedly delivered care that they deemed subpar due to insufficient prescriptive authority (Peterson & Simpson, 2010, p. 7). The very regulations that empower Nurse Practitioners also restrict their abilities so severely that they create serious ethical concerns about the quality of patient care.

Nurse Practitioners are also faced with significant role acquisition and closely related political issues, particularly regarding prescriptive authority. Role acquisition varies from state to state, and some state regulations make full acquisition of the Nurse Practitioner role next to impossible. For example, in Texas, Nurse Practitioners must be supervised by physicians in order to practice. A 2010 Texas Tribune article described a psychiatric Nurse Practitioner who could not open a practice in Georgetown, Texas, because she could not find a physician willing to supervise her. As she stated, she essentially had to continue seeking a single local doctor who would allow her to petition — and pay the doctor — to grant her prescriptive authority, while that doctor could also be held liable for her work (Ramshaw, 2010).

Political issues involving physicians also pose significant challenges. The dramatic increase in Nurse Practitioners has given rise to questions about their impact on the incomes of other health providers, including physicians. Researchers have found that in areas with greater numbers of Nurse Practitioners, NP incomes are higher while the incomes of physicians in the same geographic areas are decreased (Perry, 2009, p. 509). Perhaps partially due to this economic impact, physicians have resisted Nurse Practitioners' quest for full practice and prescriptive authority, expressing concern that unsupervised NPs will misdiagnose patients, miss potentially life-threatening problems, make prescribing errors, lack the skill to manage complex patients with multisystem diseases, order unnecessary tests, and drive up health care costs. However, none of these concerns has proven to be true in the 40-year history of Nurse Practitioners, and resistance by physician associations remains a major obstacle (Mills, 2009).

Nurse Practitioners also face restrictive limitations on authority and inequitable payment and reimbursement policies. According to Safriet (2011), Nurse Practitioners' efforts to provide the highest level of care are frustrated by two factors: "state-based limitations on the licensed scopes of practice which prevent them from practicing to the full extent of their abilities, and payment or reimbursement policies (both governmental and private) that either render them ineligible for payment, or preclude their being paid directly for their services, or pay them at a sharply discounted rate for rendering the same services as physicians" (p. 446). In order to fully realize their potential, Nurse Practitioners must work to change these restrictive laws and unfair payment policies.

Medical insurance is another significant challenge. As Nurse Practitioners' authority increases, so do their insurance concerns. Insurance companies sometimes act differently in different states — contracting with a Nurse Practitioner in one state but not in another. According to Carolyn Buppert, a Nurse Practitioner and attorney specializing in NP representation, an insurance company's refusal to contract may depend on the degree of autonomy granted by the state: the less autonomy given, the less likely an insurance company is to contract directly with a Nurse Practitioner (Buppert, 2012). Additionally, California is the only state that separates "medical corporations" — requiring physician ownership of a percentage — from "nursing corporations," and some insurance companies have a policy of contracting only with "medical corporations" (Buppert, 2012). This illustrates the difficulty that some Nurse Practitioners face: without a contract with an insurance company, there are instances in which a patient may not be treated or the Nurse Practitioner may not be paid.

A further challenge related to insurance is the greater exposure to liability in the form of a medical malpractice suit. With greater authority and exposure comes greater risk, and Nurse Practitioners are not immune. Consequently, they must obtain medical malpractice insurance. Even if a Nurse Practitioner wins a malpractice suit, the experience may cause the NP to doubt her decision-making ability, resort to over-referring and seeking unnecessary consultation, face increased insurance rates, miss days of work while testifying, incur legal expenses, and be required to mount a defense before the state licensing board (Buppert, 2012, p. 256). The impact on the Nurse Practitioner's ability to provide a high level of care is thus significant regardless of the suit's outcome.

Conclusion

Initially conceived as a hybrid diagnostic/nursing role to fill a gap in medical care due to limited numbers of physicians, the role of Nurse Practitioner has dramatically expanded over its 40-plus year history. The estimated 135,000 currently practicing American Nurse Practitioners are now granted prescriptive authority to varying degrees by every state, the District of Columbia, and the federal government. This development has occurred by patchwork design, resulting in legislation and regulations that simultaneously empower and impede Nurse Practitioners in their quest to provide the highest quality of patient care.