Moving can be a hassle. For health care providers, moving to another state raises complications to a whole new level. As a nurse practitioner, you must untangle new scope-of-practice guidelines and possibly a different level of prescriptive authority.
Keeping track of what you can and can't do when prescribing is no easy task. State legislation on the issue is introduced regularly, as nurse practitioners in Georgia, Kentucky and Virginia can attest. Those states passed laws to broaden prescriptive authority for NPs in 2006. Now only four states have no controlled substances (CS) authority: Alabama, Florida, Hawaii and Missouri.
Twelve states and the District of Columbia allow NPs to prescribe independently (including controlled substances). The majority of states (28) require physician collaboration for CS prescribing, and the rest (10) mention physician supervision in their guidelines. Several states have specific formulary requirements as well.
"I am looking forward to the day that NPs are licensed independent providers in every state," said Mona Counts, NP, president of the American Academy of Nurse Practitioners, who holds a doctorate degree in educational administration. "Most states have removed the restrictive language of the past, i.e., 'supervised,' and are utilizing the term 'collaboration,' which is a step forward. However, I do believe the need for quality health care providers and improved access to health care will move all states to eventually recognize NPs as licensed independent providers."
A 2002 study found that the average nurse practitioner writes between 11 and 15 prescriptions per day, and that number continues to climb.1 A poll by the American College of Nurse Practitioners found that 37% of NP respondents write between one and 50 prescriptions per week, and 32% write between 51 and 100 prescriptions per week. 2 NPs also are becoming a more sought-after audience for pharmaceutical companies. A recent report by Verispan, a health care informatics corporation, showed that NP retail prescriptions increased 22% in the first 8 months of 2006 (compared with the same time period a year earlier), while physician retail prescriptions increased at a significantly slower rate: only 2%.
|Opposite Ends of the Spectrum
The terminology for physician involvement in NP prescriptive authority spans a continuum including on-site physician supervision, professional collaboration, collaboration with agreed upon protocols or delegation, or no involvement whatsoever.
Twelve states and the District of Columbia have the most independent prescribing procedure: no requirement for physician involvement (including controlled substances schedules II through V):
District of Columbia
Maine (after first 2 years of supervised practice)
Wisconsin (if NP is certified as an "advanced practice nurse prescriber")
While most states have collaborative terminology, 13 states still use the term "supervise." NPs in these states are allowed to prescribe from schedules II through V unless otherwise noted:
Florida (no controlled substances)
Georgia (schedules III through V)
Hawaii (controlled substance rules not yet drafted)
Oklahoma (schedules III through V)
South Carolina (schedules III through V)
Texas (schedules III through V)
Along with increased NP prescribing comes a long, heated debate on how much prescriptive authority is appropriate. This stems largely from a misapprehension about pain and addiction, said Patricia Berry, NP, a nursing faculty member at the University of Utah. Berry, a doctorally prepared researcher, has analyzed state regulations governing CS prescribing by NPs.
"The one thing that really impedes prescriptive authority change, particularly around controlled substances, is all the myths about pain and pain management," Berry told ADVANCE. "We get addiction, physical dependence and tolerance all mixed up. We make all these assumptions based on erroneous beliefs about opioids and addiction, side effects, respiratory depression, those kinds of things."
Michigan is making the latest headlines on the subject with a push for independent practice and prescribing authority. Right now, NPs have prescriptive authority as a delegated act.
"Without prescriptive authority, we can't even prescribe cough medicine with codeine under our own name," said Juliet Santos, NP, president-elect of the Michigan Council of Nurse Practitioners and owner of Early Solutions Clinic in Burton and Taylor, Mich. "We're unable to prescribe stimulants for adult and pediatric patients with attention deficit-hyperactivity disorder. Patients experience a delay in pain control management for chronic and acute problems, and physicians experience liability issues with prescriptions written under their names with no previous patient encounter or documentation."
With this legislative push and others around the country, nurse practitioners hope to decrease confusion for patients, decrease costs for health insurance companies, and create a smoother path for safe and effective medication dissemination.
"We feel this legislation will give us rightful accountability for all the medications NPs prescribe," Santos said. "NP names need to be on all prescriptions filled. Their names should appear on all records kept at the pharmacies, insurance companies and prescription bottles in homes. NPs have been invisible for so long."
Working Within Restrictions
Physician collaboration is a requirement that many NPs are accustomed to, since 29 states mandate it for controlled substances prescribing. Although these states can be lumped together in the "collaboration" language, some states have much more confusing regulations than others.
"Several states have restrictive formularies that lead to patient care being compromised," Counts said. "Some restrictions mean the patient who had chosen an NP as his or her provider would have to see several different providers or do multiple visits to have his or her medications ordered. For example, in West Virginia, NPs cannot order Coumadin or more than 3 days of a benzodiazepine. If someone with general anxiety disorder has been doing well for years on Xanax, what do you do, have them come in every 3 days? Or ship that patient out to another provider?"
The regulations don't end there for West Virginians. NPs there cannot prescribe schedule II controlled substances, anticoagulants, antineoplastics, radiopharmaceuticals or general anesthetics. In addition, the restriction list expands to spell out that the prescribing of drugs on Schedule III is limited to a 72-hour supply without refill. NPs may not prescribe drugs from Schedules IV and V for more than 30 days and for no more than five refills, they can prescribe no parenteral preparations except insulin and epinephrine, and so on.
In other cases, prescriptive authority restrictions are fairly loose, allowing an initial agreement with a collaborating physician to outline which drugs will be prescribed by the NP and then a fair amount of independence after that (depending on the physician's level of collaboration).
When Nancy Browne, NP, moved from Maine to Illinois 2 years ago, she traded a relatively independent prescriptive authority for one that is delegated and limited by what is written in a collaborative agreement between physician and NP. The transition wasn't overly difficult since Browne is used to collaborative guidelines set by her employer, not by law.
"As an NP in a hospital, it's a challenge to try to make sure what you are practicing lines up with facility restrictions and legal restrictions," said Browne, a pediatric nurse practitioner in the pediatric surgery division at the University of Illinois Medical Center. "If the law said I could prescribe independently, but the hospital didn't want to have that liability and said I couldn't, I would have had to accept that."
Browne's prescribing requirements were outlined in the collaborative agreement with the hospital from the start.
"That delineated what class of medications I could prescribe, and the language in the collaborative agreement was from a physician in my specialty," she said. "My interpretation was 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."