Every state differs in its rules and regulations for prescription authority for nurse practitioners, clinical nurse specialists, and nurse-midwives. Indiana allows for independent and interdependent practice, but if the advanced practice registered nurse (APRN) desires prescription authority, s/he must obtain and maintain a written collaborative agreement with a physician. As mentioned in previous posts, traditionally, prescription authority has been the domain of physicians and dentists.
Research on the practices of nonphysical providers has demonstrated conclusively that they are qualified to provide primary care.
A rather important role for primary care providers is the ability to provide pharmaceutical treatment. This is a basic pillar of providing full scope primary healthcare, as even the most nonconventional provider recognizes the need for the occasional medication. All primary care providers should therefore have the ability to prescribe medications, and all primary healthcare providers are trained in how to effectively and safely prescribe and demonstrate competency of those skills by examination.
In rural areas where providers are limited, the ability to offer a prescription is especially important, but also in rural areas with an abundance of clinicians, those with an inability to prescribe will not maintain a thriving practice. If meeting the needs of the consumer is the primary focus of providing primary care services, then providers should not be artificially restricted from meeting as many needs as possible. Doing so legislatively then, is not about improving healthcare outcomes or access to care, but rather the intent to restrict the trade for all other primary healthcare providers and creating a monopoly for the physician.
APRNs are not the only discipline seeking prescriptive authority. Physician assistants, PharmDs, optometrists, and others have had to work for their own right to prescribe throughout the country, but the largest group to find success has certainly been the nurse practitioners and physician assistants.
History of Nurse Practitioners
For many years, nursing practice was boxed into nurse practice acts that stated “nurses do not treat, diagnose, nor prescribe” because as mentioned in a prior post, physicians legislated in such broad terms that these acts defined the practice of medicine. However, the most fabulous decade for challenging the norm, the 1960s, gave birth to a population of nurses who were bored and far more educated than they were utilized. They were ready to step into roles previously encouraged only to men and because so many primary care providers were deployed to Vietnam, a need existed and nurses worked diligently to meet it.
The nurse practitioner role was shaped by the core values of nursing (which differs from physician assistants who’s profession was shaped by the medical profession). The nurse-midwife and the nurse anesthetists had already established their own roles decades prior, and even the clinical specialist was a growing profession before the nurse practitioner was initiating in the primary care setting. What they all had in common though, was that each assumed some of the functions previously exclusive to physicians (Edmunds & Mayhew, 2014).
Prescriptive Authority for Nurses
Interestingly, unlike so many other professions, because healthcare disciplines have scopes which are boxed into rules and regulations written within state statute, as educational programs advance and the skill set of nurses advance, many graduate from highly educated programs without the legal ability to implement what they have learned. In the early years of the profession, there was certainly a degree of antagonism between advance practice nurses and physicians, but that largely was mended by growing respect and relationships until the mid-1990s when the American Medical Association (AMA) began urging physicians to consciously limit further “erosions of their turf” legislatively and professionally, and to view nurses with expanded roles as true competitors for patient loyalty and money (Edmunds & Mayhew, 2014).
A physician shows his colors when he calls an advance practice nurse a midlevel provider, or nonphysician provider, or a physician extender. Each of these terms are derogatory and physician-centric.
Nevertheless, nurse practitioners have thrived and gained success across the country in passing statutes to support their expanding scope. “Clearly, all advanced practice roles have survived for longer than 40 years because the clinicians who have practiced within them were competent” (Edmunds & Mayhew, 2014, p 6). Consumers appreciate APRNs have a desire to meet the client’s needs through effective communication and educate them so they can become empowered healthcare consumers. Adding to that relationship the ability to prescribe and treat makes them a true competitor of physicians.
As nurse practitioners grew in numbers and established their own practices they acknowledge the need to expand their scope within state statutes to “treat, diagnose and prescribe” but opening up the nurse practice act for revision brought risk of unwanted and unwarranted interpretation or regulation. Nurses were afraid to upset the boat and end up in a worse scenario.
Research on the Prescriptive Practices of Advanced Practice Nurses
Nurse practitioners have been the subject of study by several researchers and have demonstrated to consistently order fewer prescriptions than are ordered by physicians. Can you imagine how a growing APRN profession might impact the pharmaceutical industry? Might the pharmaceutical company and the American Medical Association be shoulder-to-shoulder in support of rules that restrict the prescriptive authority of APRNs?
“A synthesis of the most recent prescribing data suggests that the degree of prescriptive autonomy granted by legislative statutes and administrative regulations has great variability among states and that overly restrictive regulations harness NP productivity and prevent NPs from making the full contribution to health care for which they are educated,” (Edmunds & Mayhew, 2014, p 14).
Restricting our practice LIMITS ACCESS TO CARE and DOES NOT improve outcomes for healthcare consumers. How are legislative leaders justifying these limitations on prescribing?