In 2010, the Institute of Medicine (IOM) recommended states restructure their scope-of-practice guidelines for advanced practice registered nurses (APRNs) to allow for prescriptive authority and independent practice. Almost a decade later, a growing number of jurisdictions have recognized APRNs, including family nurse practitioners (FNPs), as qualified licensed clinicians who have the potential to influence the U.S. healthcare crisis.
In 2017, more than 20 states passed legislation that expanded the APRN’s scope of practice and independent prescriptive authority, bringing the total number of states that allow full and autonomous practice to 25 and the District of Columbia. In other states, APRNs practice in collaboration with or under the supervision of physicians.
At the same time, more than 40 professional medical organizations, including the American Nurses Association (ANA) and the American Association of Nurse Practitioners (AANP), recognize the APRN’s role in healthcare. They also endorse the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education, which promotes an expanded role for APRNs in healthcare.
The Robert Wood Johnson Foundation said APRNs, including FNPs, are a “big part of the solution” to the primary healthcare provider shortage. The organization said APRNs seek opportunities to practice to the fullest extent of their training and education, but often face barriers.
“Much of the public is uninformed or misinformed about what APRNs do. This lack of information can cloud decision-making about regulatory policy,” the organization said. “While their scopes of practice can overlap with those of physicians, APRNs do not practice medicine; they practice nursing.”
Continuing changes in the U.S. healthcare system signal an ongoing need for APRNs who can fill roles nationwide. Duquesne University’s online Post-Master’s Certificate in Family (Individual Across the Lifespan) Nurse Practitioner program prepares nurses to work as Certified Registered Nurse Practitioners and FNPs. Through the FNP post-master’s online certificate program, APRNs can provide primary medical care to those who need it the most.
Overcoming Barriers to Prescribing Medications
The idea of advanced practice nurse prescriptive authority is nothing new. For decades, healthcare leaders have known APRNs, including FNPs, have the education, training, and know-how needed to prescribe medications. However, in the past 20 years or so, the issue has moved to the forefront as the population ages, primary-care providers retire and access to healthcare increases.
Nurse Practitioners have prescriptive privileges of some kind in all 50 states and the District of Columbia. Currently, Nurse Practitioners working in a full-time practice write an average of 23 prescriptions a day. Advanced practice nurse prescriptive authority is designated as either independent or limited practice and depends on state regulations:
- Independent or full prescriptive authority allows APRNs to prescribe medications, devices, health and medical services, durable medical goods, and other equipment and supplies without physician oversight or collaboration.
- Limited or reduced authority requires APRNs to practice and prescribe with oversight by a physician. Depending on state law, the APRN must work within close physical proximity of a supervising doctor or can open an independent practice that is monitored remotely by a physician.
States that allow APRNs to prescribe have their own regulations. In general, however, applicants for prescriptive authority must meet these requirements:
- Have an RN license in good standing: RNs who have a license in good standing must have completed required continuing education units (CEUs), refresher courses and practical hour requirements. On average, RN licenses must be renewed every two years.
- Graduate from an accredited APRN program: RNs must complete a nationally accredited MSN program, such as the FNP program at Duquesne University. Academic preparation must include coursework in the “three Ps”—advanced physical assessment, advanced pathophysiology and advanced pharmacology—and prescribing practice hours, which can be concurrent with supervised practice hours. In many cases, FNP students must also take courses that cover illness diagnosis and management for prescriptive authority.
- Earn national certification: The online APRN program at Duquesne University prepares graduates to sit for the American Academy of Nurse Practitioners Certification Board (AANPCB) or the American Nurses Credentialing Center (ANCC) Family Nurse Practitioner certification examination.
- Apply for appropriate state prescriptive authority licensure: Each state has distinct rules and regulations regarding prescriptive authority licensure. In some cases, NPs must work under the supervision of a licensed physician throughout their career or for a limited time period. In other states, NPs are permitted to prescribe medications upon earning licensure.
- Apply for a U.S. Drug Enforcement Administration (DEA) registration number: Applying for a DEA registration number, also called a DEA license, includes providing personal information and proof of education, and undergoing a background check.
APRNs Answering the Opioid Crisis
Even with the many checks and balances that provide a clear path for APRNs to prescribe drugs, some concerns remain. In response, a large number of states have enacted new laws and regulations regarding opioid prescriptions. Among them are California and Oregon, which passed laws in 2017 that clarify APRN roles in prescribing buprenorphine, an opioid used to treat opioid addiction.
At the same time, several studies have looked at the impact of APRNs prescribing drugs with abuse potentials, such as opioids and benzodiazepines. These studies found no connection between APRN prescriptions and increased drug abuse. In fact, one notable study found “significantly less opioid and benzodiazepine prescriptions are written” in states with APRNs who have independent prescriptive authority.
The study, “State Variation in Opioid and Benzodiazepine Prescriptions Between Independent and Non-Independent APRN Prescribing States,” said possible explanations for the significant decrease in opioid and benzodiazepine prescriptions by independent APRNs may be due to education and training.
“It has been suggested that APRN training is more holistic, wellness-focused and less disease-oriented and cure-focused, so nurses may be more likely to incorporate non-opioid pharmacologic and non-pharmacologic treatment modalities to treat pain,” the study stated.
A separate study in 2016 found that NPs who have full prescriptive authority have similar prescribing patterns to physicians when prescribing mental health drugs.
“This demonstrates that nurse practitioners who have had unrestricted authority for prescribing controlled substances do not prescribe them in greater quantity or differently than their peers,” researchers told Medscape.
In addition to prescriptive authority, APRN advances include uniformity in state laws that allow for an expanded scope of practice.
Lifting Practice Restrictions on APRNs
In 2016, the U.S. Department of Veterans Affairs (VA) broke new ground by granting full practice authority to APRNs. With the new rules, APRNs are able to provide a full range of medical services across the United States, lightening the burden on the already stressed VA healthcare system.
Organizations such as the Robert Wood Johnson Foundation and the National Academy of Medicine advocate similar practice uniformity be spelled out in state laws across the country. Allowing full practice authority does not mean APRNs are trying to fill physicians’ shoes, the foundation said. APRNs are seeking to remove the regulatory, institutional and legal barriers that hamper the ability to work within their scope of practice, the foundation said.
“Even though many of their services overlap with those of physicians, APRNs do not routinely perform surgery, diagnose rare diseases, manage high-risk pregnancies or engage in a host of other complex medical interventions,” the foundation said. Instead, APRNs refer patients to specialists and other clinicians as needed.
The foundation and other professional APRN organizations say having such limitations on practice is harming healthcare in the following ways:
- Reduced access to care: Supervisory meetings between APRNs and physicians distract from necessary patient appointments and medical interventions. In most cases, physician supervision does not happen in real-time and the physicians and APRNs do not work under the same roof. That means both the physician and the APRN must take time from their days to meet face-to-face.
- Disruptions in care: If a supervising physician can no longer provide services, patients under the care of an APRN may be denied necessary medical interventions. For example, when a psychiatrist was terminated from a behavioral health clinic in Massachusetts in 2013, 10 APRNs were barred from providing care due to state laws restricting APRN practice. Patients were forced to seek medical interventions in hospital emergency departments.
- Increased costs of care: Even though states mandate APRNs work under physician supervision, APRNs still incur the costs. Overall, the payment for collaboration is unregulated and can cost APRNs thousands of dollars a year. Testimony before the Nebraska legislature in 2009 and 2014 revealed a wide variety of reimbursement costs—one NP paid her physician supervisor by covering his weekend emergency department shifts while another NP paid her supervising physician $15,000 a year.
- Undermining efforts to improve the quality of care: APRNs are poised to help millions of people who are in need of access to quality healthcare, but state and federal restrictions are standing in the way.
Even with the limitations, experts are hopeful lawmakers will blaze the trail for new legislation that opens the door to additional APRN practice.
The Future for APRNs
Susanne Phillips, FNP and author of “30th Annual APRN Legislative Update: Improving access to healthcare one state at a time” published in The Nurse Practitioner, said the coming years would bring even more positive changes to prescriptive authority, albeit slower than some would like.
“As state APRN and nursing organizations and (boards of nursing) work toward (full practice authority), incremental advances provide the opportunity to improve access over time,” she said.
Today, more than 234,000 NPs are practicing in the United States, with a majority of them licensed as FNPs. The AANP said the numbers of NPs have more than doubled since 2007. By 2024, the numbers are expected to go up another 35 percent.
Leading the way to improve access to healthcare are APRNs who advance their scope of practice. As the largest practicing group of NPs, FNPs provide care across patients’ lifespan, from birth to older adults, including pregnancy. FNPs have the education and training to provide primary care health services, conduct medical exams and diagnose illnesses.
Duquesne University’s FNP post-master’s online certificate offers students the skill and training to deliver holistic treatment for individuals, families, and communities.
About Duquesne University’s Online Post-Master’s Certificate Program—Family (Individual Across the Lifespan) Nurse Practitioner
Duquesne University’s FNP post-master’s online certificate lets APRNs advance their careers while continuing their personal and professional responsibilities. The online program melds flexible coursework with an immersive experience that prepares APRNs for the challenges and excitement that come with working as an FNP.
The program meets the standards set by the National Organization of Nurse Practitioner Faculty (NONPF) and prepares students to pursue testing for FNP certification.
Several national leaders for educational excellence have recognized Duquesne University, including U.S. News & World Report (2017 Best Online Graduate Nursing Programs), the National League of Nurses (Center for Excellence in Nursing Education), and The Princeton Review (Best 380 Colleges).
The Nurse Practitioner, APRN Legislative Update
AANP.org, Nurse Practitioner Fact Sheet
MedScape,APRN Prescribing Law: A State-by-State Summary
USDOJ.gov, Application for Registration Under Controlled Substances Act of 1970
NIH.gov, State Variation in Opioid and Benzodiazepine Prescriptions between Independent and Non-Independent APRN Prescribing States
Medscape.com, Physicians and Nurses Have Similar Prescribing Habits
VA.gov, Office of Public and Intergovernmental Affairs, VA Grants Full Practice Authority to Advance Practice Registered Nurses
Nursingald.com, Changes Coming
journals.lww.com, 30th Annual APRN Legislative Update Improving access to healthcare one state at a time