shutterstock 333362684Nurse practitioners (NPs) are advanced practice nurses who possess certain qualifications, licensure, and training. According to the American Association of Nurse Practitioners (AANP), NPs are licensed, independent practitioners who practice in a variety of settings while being able to assess, diagnose, treat, and manage acute and chronic illnesses. Examples of patient populations nurse practitioners are involved with include: pediatrics, adult health, gerontology, community health, critical care, psychiatric and mental health, acute care, and primary care. Once licensed, nurse practitioners are available to work in the environment in which they are licensed. Before the board exam, nurse practitioner students have pre-chosen which specialty they wish to pursue. For example, if the nurse inspires to become an acute care nurse practitioner, all schooling and clinical hours are geared toward that specialty. Once schooling and clinical hours are completed, the nurse may sit for the national licensing exam.

Nurse practitioners are experts in health promotion and disease prevention. Because nurse practitioners are experts, they can diagnose illnesses and disease processes in patients they treat. Nurse practitioners order, conduct, supervise, and interpret diagnostic and laboratory tests, prescribe pharmacological agents and nonpharmacologic therapies as well as teach and counsel patients. They are also given full prescriptive authority in some states.

The scope of practice for nurse practitioners vary state to state, but generally speaking nurse practitioners:

  • Obtain relevant health and medical history.
  • Perform a physical examination based on age and history.
  • Perform or order preventative and diagnostic procedures.
  • Identify health and medical risk factors.
  • Synthesize and analyze collected data.
  • Formulate a differential diagnosis based on the history, physical and diagnostic test results.
  • Establish priorities to meet the health and medical needs of the individual family or community.
  • Order and interpret additional diagnostic tests.
  • Prescribe or order appropriate pharmacologic and nonpharmacologic interventions.
  • Develop patient education plans.
  • Recommend consultations or referrals as appropriate.
  • Determine the effectiveness of treatment plans with documentation of patient care outcomes.
  • Reassess and modify the plan with the patient and family as necessary to achieve health and medical goals.

The scope of practice is determined by the American Association of Nurse Practitioners. Although the scope of practice is generally the same for all states, some restrictions apply. The state practice environment restricts some practice elements for nurse practitioners. NPs must have a clear understanding of how each state’s laws and regulations may impact their practice.

There are three categories of practice restrictions for nurse practitioners: full practice, reduced practice, or restricted practice. Full practice permits NPs to diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medication and controlled substances, under the exclusive licensure authority of the state board of nursing. Reduced practice permits NPs to engage in at least one element of NP practice. State law requires a career-long regulated collaborative agreement with another health provider for the NP to provide patient care or limits the setting of one or more elements of NP practice. Restricted practice permits NPs to engage in at least one element of NP practice. State law requires career-long supervision, delegation or team management by another health care provider for the NP to provide patient care. Regarding prescription authority, each state has different requirements and practice details. It is up to the NP to research each state’s laws and regulations.

Prescription restrictions  

The AANP provides a list of prescriptive authority per state for the public to review. Twenty-two states and the district of Columbia (DC) allow family nurse practitioners (FNPs) to have full legal ability to practice, including the ability to prescribe. This means that NPs in these states may practice independently without the supervision of a medical doctor. In the remaining states, FNPs must work together with a physician or go through a probationary period before practicing medicine and given the ability to prescribe.

Physician supervision law exists in states which limit the services that nurse practitioners are legally allowed to do; sometimes decreasing patient access to medical care. These restrictions include not being able to prescribe certain medications such as schedule II drugs without having an MD sign off on it; not being allowed access unless NPs enter a collaborative agreements for one or more elements of NP practice with a medical doctor; no authority given to NPs to sign Medical Orders for Scope of Treatment (MOST) forms such as a DNR forms; no recognition that NPs are primary care providers; stipulations exist when prescribing medications- such as completing an educational requirement in advanced pharmacotherapeutics; limitations for referrals to physical therapy; no authority for autonomous practice; and no clearance to sign handicap parking permits or sign death certificates.

Physician supervision laws in states such as Texas, Alabama, Oklahoma, Tennessee, Virginia, North Carolina, South Carolina, Georgia, Florida, Missouri, and California limit the services that nurse practitioners are legally allowed to do. This includes prescriptive authority. These states cannot independently prescribe medications without a medical doctor signing off. This means that they cannot write prescriptions without being in collaboration with a physician that will sign off on the orders. Furthermore, the Interactive Scope of Practice Law Guide illustrates the differences among states.

The following states are allowed to independently prescribe all medications without a medical doctor:

  • Alaska
  • Arizona
  • Hawaii
  • New Mexico
  • Nevada
  • Oregon
  • Washington
  • Idaho
  • Wyoming
  • Montana
  • North Dakota
  • South Dakota
  • Nebraska
  • Colorado
  • Minnesota
  • Iowa
  • Maine
  • New Hampshire
  • Vermont
  • Connecticut
  • Rhode Island
  • Maryland
  • DC

These states do not require a supervising physician to sign off on medication prescriptive authority. NPs in these states may practice independently.

Prescribing out of state

If you are looking to practice outside of the United States, a few options exist for Nurse Practitioners that have a current license. Guam and Northern Mariana Islands follow the same governing bodies as the USA, therefore, adhere to the same licensing credentials and regulations. Guam and Northern Mariana Islands are Full Practice, meaning they do not require a supervising physician to practice.

Other countries may require more paperwork and licensure. One option is to sign up with the U.S. Department of State as a “foreign service medical provider”. This would allow you to be employed by the U.S. State Department and work in countries across the globe. Some countries that work with the State Department include:

  • Addis Ababa, Ethiopia
  • Beijing, China
  • Quito, Ecuador

However, the U.S. Department of State informs that a Foreign Service Provider may come with some difficulty. The countries may be small or remote with little access to American amenities. There also may be unpleasant weather conditions. Some countries allow U.S citizens to apply for licensure directly as nurse practitioners. Canada allows nurse practitioners from the United States to apply for Canadian licensure. The United Kingdom also allows U.S. educated nurse practitioners to practice in the country. It can take quite a while to become certified in another country, and you may have to take the nurse practitioner certification exams again.

Legal implications for prescribing drugs

Nurse practitioners must take into consideration the legal implications for prescribing drugs. Medications are dangerous if not prescribed with purpose and critical thinking. Regardless of the scope of your prescriptive authority, one overall standard of practice is to ensure that any medication you prescribe is compatible with other medications your patient is taking. NPs must be knowledgeable about all medications prescribed, including side effects.

NPs must complete careful assessments about any medications the patient is currently taking, including side effects, black box warnings, and dosages. Nurse Practitioners are legally responsible to contact other providers who are working with the patient when there is a question about any medications. NPs must legally provide instructions to the patient regarding medications prescribed. It must be noted that NPs can face disciplinary action by your state board of nursing for a violation of your obligations under your state nurse practice act. It is advised for all practicing NPs to obtain medical malpractice insurance because of the inherent risk of prescription writing.

Not only is continuing education about new medications and specialty drugs on the market a legal requirement, but it should be a professional standard. Medications are fast changing, and NPs must stay up to date on current medications in order to stay on top of practice guidelines. Staying up to date on newly released medications also helps with managing medication side effects especially when patients take multiple medications.

Ethical implications for prescribing drugs

The ongoing opioid crisis is a serious ethical issue. The World Health Organization proposes a multi-step approach that centers on the intention of the treatment. Opioids were once a cornerstone for treating chronic and disabling pain; however, overuse and misuse has driven a drug addiction epidemic, claiming the lives of 115 people every day in the United States. Often, these drugs are not needed for chronic pain, and other pain management options can be explored.

State and federal agencies are trying to rein in opioid use by setting limits on prescriptions. Clinicians are being urged to prescribe with caution; including nurse practitioners.

When prescribing pain medication for patients, nurse practitioners need to consider the patient’s problem; determine a therapeutic objective; choose correct medications; give patients information, warnings, and instruction; keep watch of the patient; and use technology to prescribe safely.

To make sure the patient is prescribed medicine he must be examined and his needs must be determined. There are still ethical challenges from the past to consider.  Some of them include prescribing for family and friends and being knowledgeable about ingredients within medications that are contraindicated for patients’ religious or spiritual beliefs. Regarding prescribing for family and friends, there are different laws and regulations for each state. Some states expressly forbid providers from prescribing medications to family and friends, while others simply advise against it. Prescribing for a friend in a social setting could trigger legal action.

Nurse practitioners need to be mindful of patients with dietary restrictions and religious beliefs. It is ethically sound to inform patients that are vegans or vegetarians that some medications have animal-derived ingredients such as lactose and gelatin. Being honest up front will help with medication compliance and overall trust. Advise them so they can make an informed decision about treatment. Ethical and legal issues come down to doing what is best for patient outcomes and safety.

Overall, nurse practitioners can diagnose, treat, and prescribe medications to patients. Each state varies on prescription restrictions. It is a good idea to review legal and ethical state regulations before practicing as a nurse practitioner. It is also advised to get medical malpractice insurance going forward. Nurse practitioners are given a huge responsibility to provide, safe, effective, and high-quality care to those that otherwise could not have healthcare. Prescribing medications as a nurse practitioner is a privilege that can easily be taken away or given more freedom based on future state laws and regulations.

Tessa Chatham

Master of Science (M.S.), Nursing Education| Aspen University

Bachelor of Science (B.S.), Nursing| Texas Christian University

Bachelor of Arts (B.A), Psychology and English| The University of Texas at Arlington

November 2019

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