Scope of practice for advanced practice registered nurses (APRNs) is a controversial, complex, and constantly evolving topic amongst health care practitioners, policymakers, and the public. Health care spending in America is projected to increase 5.6 percent each year between 2016 and 2025, amounting to about $3.35 trillion for 2016 alone, or $10,345 per person, according to the Department of Health and Human Services (PBS NewsHour). Coupled with this increasing cost of healthcare is the growing demand for medical services in America, as the baby boomer population ages and health conditions such as obesity, diabetes, and asthma steadily increase. With the extremely high cost of healthcare in the country, and its concerning upward trajectory, many are calling for ways to reduce health care costs without sacrificing quality of care.
Granting full practice authority to APRNs is one way to help address this rise in health care costs, while also increasing accessibility to medical services in underserved areas, such as rural regions that do not have hospitals or physician private practices close by. There has been a gradual increase in the number of states that grant APRNs the authority to practice independently. Currently, 22 states and the District of Columbia grant APRNs full practice authority. However, the majority of states still do not allow APRNs to practice independently: 16 states grant APRNs reduced practice authority and 12 states grant APRNs restricted practice authority.
In the face of the documented public health and economic benefits of granting APRNs full practice authority, why has the movement to empower APRNs progressed so slowly? The answer to this question is complicated, and involves multiple interrelated factors, ranging from misconceptions about the role of APRNs in medical settings to special interest groups lobbying to maintain the status quo. This article explores the issue of APRN scope of practice, how full practice authority benefits both the public and the medical community, and what barriers are preventing more widespread adoption of legislation that expands APRNs’ rights and privileges to practice to the full extent of their training. It also outlines the ways in which nursing students and APRNs can advocate for their profession and help to accelerate the movement to allow APRNs full practice privileges nationwide.
Scope of Practice for APRNs: Important Concepts and Definitions
APRN scope of practice is governed primarily by state nurse practice acts, which are developed by regulatory agencies such as a state’s board of nursing, board of advanced practice nursing, and/or board of medical examiners. States that do not grant APRNs full practice authority may limit one or more elements of advanced nursing practice, such as the ordering of certain diagnostic tests, the provision of emergency medical services, the dispensing of certain medications and other treatments, and medical referrals. While nurse practice acts are specific to each state, several common elements outlined in them include collaborative agreements between APRNs and physicians, protocols and procedures for APRN practice, prescriptive authority, and signature recognition on elements of patient care.
Collaborative agreements are written contracts between a physician and an APRN, which outline the practice privileges granted to the APRN, how often the supervising physician will review patient records, whether and to what extent the physician will oversee the APRNs’ daily work with patients, and how both the physician and the APRN should interact with patients in the case of one or the other’s absence. Collaborative agreements typically outline certain protocols that APRNs must abide by–for example, what types of medical services APRNs can provide in certain situations, when APRNs should consult with their supervising physician, and in what situations they are able to dispense certain medications.
Federal regulations through the Drug Enforcement Administration (DEA) as well as state regulations dictate what types of controlled substances APRNs are allowed to prescribe, procure, administer, and dispense to patients, and in what situations. The DEA divides drugs into different classes according to their addictive potential and effects on the human body. Schedule 2/2N controlled substances have the highest addictive potential of the drugs approved for medical use, and can have severe physical and mental side effects. Schedule 3/3N, 4/4N, and 5/5N controlled substances have less abuse potential (with Schedule 5/5N substances being the lowest abuse risk).
APRNs’ prescriptive authority varies widely across different states. For example, some states allow APRNs to prescribe, procure, and dispense medicines from all four medically viable drug classes without physician oversight, while other states only allow APRNs to prescribe drugs from classes 3/3N, 4/4N, and 5/5N. Some states only require physician oversight for the first 2000 or more hours of an APRN’s practice, while others mandate that limited prescriptive privileges be included as a protocol in a physician and APRN’s collaborative agreement. States may also have academic and continuing education requirements that outline how many course credits APRNs must take in pharmacology and pharmacokinetics before they are allowed to prescribe medications to patients.
Signature Recognition on Items of Patient Care
State legislation also controls whether APRNs can sign off on certain items of patient care, such as physical therapy referrals and other types of referrals, proof of a disability for parking permits, death certificates, Do Not Resuscitate (DNR) orders, and Provider Orders for Life Sustaining Treatment (POLST) forms. APRNs’ privileges in this area also vary considerably–some states may allow APRNs to sign off on death certificates and physical therapy referrals, but do not allow them to sign DNR orders, while other states require a physician’s signature or clearance on all these items. To add to the complexity of patient care signature recognition, the ability for APRNs to sign off on these different items does not directly correlate with the full, reduced, and restricted classifications of practice authority. Some states that grant APRNs full practice authority may not allow them to sign off on one, several, or all of these items of patient care.
The AANP’s Categories of APRN Scope of Practice Legislation
Full practice authority, reduced practice authority, and restricted practice authority are definitions developed by the American Academy of Nurse Practitioners (AANP) to describe the degree to which APRNs can practice in alignment with their advanced academic and clinical training within their state of residence. These categories are useful in assessing the degree of practice autonomy an APRN has in a given state. Below are descriptions of what these definitions mean:
- Full Practice Authority: State practice and licensure laws permit APRNs to evaluate patients, make diagnoses, order and interpret labs and other diagnostic tests, and prescribe medications and other treatment measures independently of physician oversight. Current and prospective APRNs should note, however, that even in states that grant APRNs full practice authority, local laws and even regulations at the health care system and hospital levels affect their ability to practice. In addition, APRNs’ certification specialization may also limit their ability to practice in certain medical contexts.
- Reduced Practice Authority: State practice and licensure law limits APRNs from engaging in one or more elements of advanced practice nursing. What elements of practice are restricted vary from state to state, but may include prescribing certain medications or completing certain medical procedures. APRNs are also required to enter collaborative agreements with physicians in order to complete certain medical tasks.
- Restricted Practice Authority: As with reduced practice authority, restricted practice authority is when state practice and licensure law restricts APRNs’ ability to engage in one or more elements of advanced practice nursing. States with restricted practice authority also tend to require collaborative agreements between APRNs and physicians. Furthermore, according to the AANP, APRNs in restricted practice states are required to operate under the supervision of an outside health discipline or organized health care system, which include health care facilities, home health agencies, physicians’ private practices, and community health centers.
Nurses and nursing students should note that the above definitions are necessarily quite broad, and that states within the same category of full, reduced, or restricted practice often have very different laws and regulations around APRN scope of practice. President of the National Association of Pediatric Nurse Practitioners (NAPNAP) Laura Searcy, MSN, PPCNP-BC explained the complex nature of APRN practice regulations nationwide in an exclusive interview with OnlineFNPPrograms.com. “Currently, there is no uniform model of regulation of APRNs across the states,” she said, “Each state independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry into advanced practice, and the certification examinations accepted for entry-level competence assessment.”
Furthermore, on top of state-level nursing legislation, local governments and regulations at the health care system and hospital levels can influence what rights APRNs have to work with patients. “[E]ven in states that have achieved full practice authority per AANP or NCSBN evaluation, there are still differences in state laws and regulations,” Ms. Searcy added, “In addition, health care systems, institutions, and practice sites can impose additional restrictions on practice, even in states that have ‘full practice authority.’”
The Benefits of Full Practice Authority for APRNs
Granting APRNs full practice authority has been shown to increase accessibility to care, especially in rural areas and regions that have a dearth of physicians and need more medical practitioners who can provide preventative health care services. The benefits of granting full practice authority to APRNs extend beyond medical outcomes as well. Studies have shown that allowing APRNs greater scope of practice privileges and autonomy leads to lower rates of malpractice suits and significantly lower health care costs at the individual, state, and national levels. For example, in their research article “Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics,” Joanne Spetz et. al estimated that the cost savings of granting full practice authority to nurse practitioners nationwide could amount to $810 million per year solely at retail clinics (this estimate does not include the potential cost savings in other medical settings).
In her interview with OnlineFNPPrograms.com, Ms. Searcy explained how the expanding APRNs’ scope of practice privileges positively impacts many interrelated elements of society. “Improving patients’ access to care from qualified providers improves states’ healthcare outcomes while also improving the business and economic climate within states,” she said. By increasing access to care while decreasing medical costs, APRNs who practice independently can benefit state and local economies (not to mention the national economy), reduce the inflated pricing of medical services, improve public health outcomes, and increase the quality of life of patients and their families.
The Challenges Facing APRN Scope of Practice Expansion
In recent years, there has been a push on the part of APRNs and nursing associations to expand APRN scope of practice to meet the growing health care demands of the American population. Both the Institute of Medicine and the National Council of State Boards of Nursing (NCSBN) have officially recommended a movement towards granting APRNs full practice authority in all states. However, despite years of advocacy on the part of APRNs for the expansion of APRN practice privileges, many states remain resistant to the idea of allowing APRNs more autonomy.
Why has adoption of full practice authority for APRNs not spread nationwide, given the nation’s need for qualified health care professionals? Three main factors that are preventing this progress are physician practice groups that argue that APRNs lack sufficient medical training to practice independently, lack of public and legislative awareness of APRNs’ qualifications to practice autonomously, and the fact that APRNs in each state face different regulations and legislative barriers to expanding their scope of practice privileges.
The fight to expand scope of practice for APRNs has been a decades-long endeavor, and one of the primary opponents to full practice authority for APRNs has been physicians and physician associations. These physician groups have been adamant in their argument that physician-led medical practices are the safest option for patients, and that staff nurses and APRNs lack the intensive training to make difficult medical decisions without the expertise of a supervising doctor.
For example, the American Medical Association (AMA) released a statement in May of 2016 stating their disappointment at the Department of Veterans Affairs’ (VA) proposal to expand APRNs’ practice privileges to include practicing without physician supervision. Dr. Stephen R. Permut, MD, JD, who is the Board Chair of the American Medical Association, wrote on behalf of the AMA, “While the AMA supports the VA in addressing the challenges that exist within the VA health system, we believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country’s veterans. We feel this proposal will significantly undermine the delivery of care within the VA.”
Dr. Permut also cited the fact that physicians are uniquely qualified for the role of independent practitioner due to the volume and intensity of their medical training hours. “With over 10,000 hours of education and training, physicians bring tremendous value to the health care team. All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine,” he stated.
Finding a point of agreement between APRNs and physicians on the subject of non-physician scope of practice privileges has proven very difficult, yet Ms. Searcy encourages both APRNs and physicians to view each other as all part of a larger medical care team, and to find ways to work together on the shared goal of improving patient health outcomes. “We practice in collaborative teams with leadership of the team determined by the patients’ needs at that time. It’s all about patient access and improving health outcomes, not about ’us‘ (APRNs) vs ’them‘ (physicians),” she said.
Lack of Public and Legislative Awareness of APRNs’ Qualifications
Another significant barrier preventing APRNs from achieving greater scope of practice privileges is the general lack of awareness among state and local governments, as well as the general public, regarding the medical qualifications and capabilities of APRNs. Ms. Searcy explained to OnlineFNPPrograms.com, “Barriers preventing APRNs from obtaining full practice in certain states include opposition from organized medicine and poor understanding by the public/legislators about nursing titles and authority. Most stakeholders do not understand the advanced education and training that APRNs have and the high level of care they are qualified to provide.”
Studies on the impact of granting APRNs full practice authority, such as the ones mentioned above conducted by UCSF and Columbia University, are slowly working to counter the misconceptions around APRNs’ ability to practice medicine without physician oversight. Using the evidence from these and other studies in both articles and advocacy materials that reach the general public can be very helpful in correcting misconceptions around advanced practice nursing that hinder APRNs’ progress in lobbying for changes in scope of practice legislation.
“There is a continual need to educate and inform both legislators and the public about the competencies, skills and 40 years of research that has shown APRNs to be high quality, safe and cost effective providers of care,” Ms. Searcy said in her interview with OnlineFNPPrograms.com. She also encouraged nursing students and practicing APRNs to get involved in state-level politics, and to serve as an educator of legislators who might not be aware of the positive impact that full practice authority for APRNs can have on community health outcomes. “More students and APRNs need to participate in the basic grassroots work of developing ongoing relationships/communication with their elected officials at both the state and federal levels. They must educate and inform these officials about their advanced education and training and the contributions they make to the elected official’s constituents’ health. They should join the professional association(s) of their choice to have the networking and resources in order to accomplish this outreach,” she advised.
Lack of Uniformity in Nursing Legislation
The third primary barrier to granting more APRNs full practice authority is the complexity and lack of uniformity in state legislation concerning APRNs’ licensure requirements and scope of practice privileges. As mentioned previously, even within the broad definitions of full practice authority, reduced practice authority, and restricted practice authority, a wide range of APRN practice regulations exist. For example, both California and North Carolina are “Restricted Practice” states, according to the AANP. Yet what “restricted practice” means in both states differs, at least from the legislative standpoint, and are dependent on each state’s board of nursing:
California: According to the California Board of Registered Nursing, APRNs residing in this state are required to operate under the supervision of an organized health care system, which include health care facilities, home health agencies, physicians’ private practices, and community health centers. These organized health care systems develop “standardized procedures” that outline what specific practice privileges APRNs can have in certain patient circumstances if they meet particular medical training and competency requirements. APRNs must prove their eligibility to complete these standardized procedures, and receive approval prior to beginning their practice at a health care facility.
North Carolina: According to the North Carolina Board of Nursing, APRNs must work under a collaborate practice agreement with a physician, and this agreement must include explicit protocols dictating how an APRN should interact with patients, fulfill responsibilities in and out of the presence of a physician, how many prescriptions an APRN can refill for a patient, whether and what controlled substances the APRN can dispense and under what circumstances, and other items. Furthermore, the collaborative agreement must outline what emergency care the APRN is authorized to provide in certain situations. APRNs are also required by state law to meet with their supervising physician a minimum of once every six months.
Due to the variance between state nurse practice acts and other regulations governing scope of practice for APRNs, APRNs face a complicated task when trying to combat laws that seek to limit their practice privileges. Rather than simply fighting to change one law at the federal level, APRNs in states with reduced or restricted practice policies must understand and potentially advocate against numerous complex laws and codes that are specific to their state. The complexity of these laws can make it difficult for graduate nursing students and new APRNs to understand how to best advocate for their profession. Nurses interested in becoming advanced practice providers should contact their state board of nursing to learn about the specific rules surrounding APRN scope of practice in their state. In addition, they should seek the support of APRN organizations that can help them better understand the legislation that impacts nurses in their state, and speak with APRNs in their field of interest to get a firsthand description of how scope of practice laws affect APRNs on a daily basis. Ms. Searcy recommends that students and APRNs join nursing associations at the national, state, and local levels, all of which can provide educational resources, policy toolkits, and helpful infrastructure around advocacy measures. “When students and APRNs join professional associations, they can amplify their voices with the support of a much broader group of like-minded professionals,” she said.
The APRN Consensus Model
Ms. Searcy also recommended that APRNs try and get a basic understanding of the federal and state laws that affect their practice, and to stay up-to-date on the latest changes in health care legislation. “Students and APRNs need to understand the basics of APRN regulation. They need to understand the APRN Consensus Model, the uniform model of regulation for the future of advanced practice nursing that is designed to align the interrelationships among licensure, accreditation, certification, and education,” she said, “The model provides guidance for states to adopt uniformity in the regulation of APRN roles. They need to understand their individual state nurse practice acts and other state laws and regulations that control their practice.”
The APRN Consensus Model is the NCSBN’s response to the lack of uniform standards for APRN licensure and practice privileges. This model seeks to streamline and standardize state regulations around APRN licensure and practice. On its website, the NCSBN described the purpose of the Model:
Today, many states have adopted portions of the Model elements but there still may be variation from state to state. APRNs moving from state to state need to ask themselves, “Have I met the requirements to practice in this state? Do I have the appropriate certification required to practice in this state? Does my training/experience match within the scope of practice required to practice? As long as regulatory requirements differ from state to state, each state border represents an obstacle to portability—potentially preventing access to professionals and access to care.
By lobbying for the adoption of the APRN Consensus Model by their state legislatures, APRNs can help move their states closer to expanding practice privileges for APRNs. Developing a clear and uniform standard of APRN qualifications and privileges can help remove some of the misconceptions about APRNs’ ability to practice independently, while also enabling APRNs to move between states with the confidence that they will be held to the same medical standards across state lines.
How APRNs Can Impact the Future of Their Profession
Despite the slow progress to expand APRNs’ scope of practice privileges in more states, APRNs have the power to influence state and national legislation impacting APRNs’ right to practice to the full extent of their intensive medical training and qualifications. They can do so by joining nursing associations that can provide them with the knowledge and the tools to advocate effectively, contacting state and federal policymakers, and educating the public about the compelling public health and economic reasons for expanding APRN full practice authority nationwide.
The positive public health outcomes that result from granting full practice authority to APRNs are well documented in literature, and serve as powerful evidence of the level of advanced knowledge and clinical competence that APRNs bring to their work with patients. Bringing the facts to the people who impact legislation, and framing the truth in a way that illustrates the widespread benefits of independent APRN practice, is imperative. In her interview, Ms. Searcy said, “APRNs at the state level need to involve other stakeholders as allies in reducing barriers to practice to prevent the perception that discussions about scope of practice are merely turf battles between the medical and nursing professions.”
As the President of NAPNAP, Ms. Searcy also recommends joining professional nursing organizations that prioritize advocacy, and explained how her organization helps APRNs who wish to get more involved in their professional community and advance their profession. “NAPNAP members have access to our Advocacy Center to research state or federal laws and quickly contact elected officials, as well as numerous resources related to advocacy including our Child Health Coalition Building Toolkit,” she said, “Our Child Health Policy Learning Collaborative provides topical policy speakers on a monthly basis and allows members to ask questions and get assistance with their advocacy efforts.” When APRNs join organizations whose primary mission is to advance the profession and support APRNs and nursing students, they can benefit from the expertise of people whose job is to understand the legislation impacting APRNs’ daily practice, and to fight for the expansion of APRN rights and privileges.
In addition to NAPNAP, resources for APRN advocacy are available through reputable organizations, including (but certainly not limited to):
- The American Academy of Nurse Practitioners: The AANP provides members with a Federal Policy Toolkit, State Policy Toolkits, Government Affairs Updates, and detailed information about legislation impacting nurse practitioners at the state and federal levels.
- The Association of Advanced Practice Psychiatric Nurses: AAPPN provides its members with connections to lobbyist groups that advance their professional interests, continuing education courses and resources, and updates on legislation that impacts psychiatric APRNs’ scope of practice.
- The Gerontological Advanced Practice Nurses Association: GAPNA provides its members with information about the APRN Consensus Model, leadership resources and professional development toolkits, and support for APRN students and preceptors.
- Nurse Practitioners in Women’s Health: NPWH conducts research on best practices in women’s health, with the aim of improving quality and accessibility of women’s health services, and removing scope of practice barriers for APRNs in this field. NPWH offers members continuing education opportunities, regular conferences, and a network of fellow WHNPs.
In addition, state and local APRN associations can be powerful centers of advocacy, and also places where APRNs and graduate nursing students can join a community that benefits them personally and professionally. Through collaboration with nursing associations and their professional peers, steady and targeted advocacy, and continued excellence in their practice of nursing care, APRNs may be able to secure a future in which they can enjoy full autonomy and truly practice to the full extent of their training and abilities.
Nurse Practitioner Practice Authority by State: Full, Reduced and Restricted Scope of Practice Environments
Laws governing APRN practice authority are complicated and vary widely from state to state. We sought to help APRNs better understand their scope of practice privileges by creating this table, which provides a list of how the AANP currently classifies each state in terms of full, reduced or restricted practice. We also provide a state-by-state summary of important practice privileges, such as prescriptive authority and patient care signature recognitions. For more information, click on the state name for links to that state’s board of nursing and nursing practice act.
Disclaimer: Information in the following table should be used for educational purposes only. While we have done our best to ensure that all the data included below is accurate at time of publishing, we do not guarantee the accuracy of the information, as nursing laws do change over time. Interested parties should confirm all information with State Boards of Nursing, State Boards of Pharmacy, and other relevant legislative and regulatory parties for the most up-to-date information.
|State||Practice Authority||Prescriptive Authority||Physical Therapy||Disability Parking Permits||DNR||Death Certificates|
|Arkansas||Reduced||more info||Yes||No||No||In Hospice Only|
|District of Columbia||Full||more info||Yes||Yes||No||No|
|Illinois||Reduced||more info||Yes||Yes / No||Yes||No|
|New Hampshire||Full||more info||Yes||Yes||Yes||Yes|
|New Jersey||Reduced||more info||Yes||Yes||No||Yes / No|
|New Mexico||Full||more info||Yes||Yes||No||Yes|
|New York||Reduced||more info||Yes||Yes||No||Yes|
|North Carolina||Restricted||more info||Yes||No||No||Yes|
|North Dakota||Full||more info||Yes||Yes||-||Yes|
|Rhode Island||Full||more info||Yes||Yes||Yes||Yes|
|South Carolina||Restricted||more info||-||No||No||No|
|South Dakota||Full||more info||Yes||No||Yes||Yes|
|West Virginia||Reduced||more info||Yes||Yes||Yes||Yes|
green= Full Practice Authority
yellow= Reduced Practice Authority
red= Restricted Practice Authority
- “AMA Statement on VA Proposed Rule on Advanced Practice Nurses,” ama-assn.org, American Medical Association, https://www.ama-assn.org/ama-statement-va-proposed-rule-advanced-practice-nurses
- “An Explanation of Standardized Procedure Requirements for Nurse Practitioner Practice,” rn.ca.gov, State of California Board of Registered Nursing, http://www.rn.ca.gov/pdfs/regulations/npr-b-20.pdf
- “APRN Consensus Model,” ncsbn.org, National Council of State Boards of Nursing, https://www.ncsbn.org/aprn-consensus.htm
- “Does Independent Scope of Practice Affect Prescribing Outcomes, Healthcare Costs, and Utilization?” healthcostinstitute.org, Health Care Cost Institute, http://www.healthcostinstitute.org/wp-content/uploads/2016/08/HCCI-Issue-Brief-Independent-Prescribing-Outcomes.pdf
- “Issues At-A-Glance: Full Practice Authority,” npamonline.org, Nurse Practitioner Association of Maryland, http://www.npamonline.org/associations/9774/files/Full%20practice%20authority.pdf
- “Mid-Level Practitioners Authorization By State,” deadiversion.usdoj.gov, Drug Enforcement Administration, https://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf
- “NHE Fact Sheet,” cms.gov, Centers for Medicare and Medicaid Services, https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html
- “NP Laws and Rules,” ncbon.com, North Carolina Board of Nursing, http://www.ncbon.com/dcp/i/nursing-practice-nurse-practitioner-np-laws-rules
- “Quality of primary care by advanced practice nurses: a systematic review,” academic.oup.com, International Journal for Quality in Health Care, https://academic.oup.com/intqhc/article-lookup/doi/10.1093/intqhc/mzv054
- “Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics,” content.healthaffairs.org, Health Affairs: At the Intersection of Health, Health Care, and Policy, http://content.healthaffairs.org/content/32/11/1977.abstract
- “State Law Chart: Nurse Practitioner Prescriptive Authority,” ama-assn.org, American Medical Association, https://www.ama-assn.org/sites/default/files/media-browser/specialty%20group/arc/ama-chart-np-prescriptive-authority.pdf
- “$10,345 per person: U.S. health care spending reaches new peak,” pbs.org, PBS NewsHour, http://www.pbs.org/newshour/rundown/new-peak-us-health-care-spending-10345-per-person/