Professional Nursing and State-Level Regulations Main Post
Comparing Advanced Practice Registered Nurse (APRN) board of nursing regulations between California (CA) and Texas (TX) reveals significant differences in terms of practice authority and supervision requirements. These variations have a direct impact on the legal authority of APRNs to practice within the full scope of their education and experience. This comparison will highlight the regulatory distinctions and their implications for APRN practice.
California APRN Regulations
In California, APRNs operate under restricted practice, meaning they must work in collaboration with a physician to perform specific duties. According to the California Board of Registered Nursing (BRN), APRNs, including Nurse Practitioners (NPs), must enter into a written collaboration agreement with a physician, detailing the scope of their practice and areas where physician oversight is required. These agreements dictate prescriptive authority and the performance of certain medical functions (California BRN, 2021). California’s SB 1375, passed in 2022, allows APRNs to practice independently under specific conditions after meeting additional experience requirements, but the majority still practice under the oversight model.
For example, an NP working in a primary care setting in California must consult a supervising physician for prescription approvals or certain diagnoses, limiting their autonomous decision-making capacity despite having advanced education and clinical experience.
Texas APRN Regulations
Texas also mandates restricted practice for APRNs, but the nature of physician collaboration differs slightly. The Texas Board of Nursing (TBON) requires APRNs to work under a delegation agreement with a supervising physician, which is similar to California’s collaboration agreement. However, Texas regulations are stricter in terms of proximity; physicians must be available for consultations and oversight but are not required to be onsite (Texas Board of Nursing, 2023). Furthermore, in Texas, the NP’s prescriptive authority is specifically linked to controlled substances, requiring oversight for Schedule II drugs and higher.
For instance, an NP in Texas may be responsible for managing chronic conditions such as diabetes or hypertension but cannot independently prescribe certain medications without physician approval, limiting their ability to practice fully within their scope.
Key Differences Between California and Texas
Supervision Requirements: In both states, APRNs must collaborate with physicians, but California’s rules focus more on the documentation of collaboration (through written agreements), while Texas emphasizes supervision through a delegation model and restricts certain prescriptive practices more stringently, especially for controlled substances.
Practice Authority Pathways: California allows for some APRNs to gain full practice authority after fulfilling experience requirements through the implementation of SB 1375. Texas does not have such a pathway, maintaining permanent restrictions on APRN independence, even for experienced practitioners.
Application of These Regulations to APRNs with Full Practice Authority
For APRNs with full practice authority, like those in full practice states such as Colorado or Arizona, the regulations in California and Texas would impose significant limitations. For example, in a full practice state, an NP could independently open a clinic and provide comprehensive care, including prescribing medications without physician oversight. If that same NP moved to California or Texas, they would need to establish a collaborative or supervisory agreement with a physician, limiting their autonomy.
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Adhering to Regulations: Practical Examples
California: An NP in California working in a dermatology clinic may develop treatment plans for patients with chronic skin conditions but would need a collaborating physician to sign off on prescriptions for medications such as isotretinoin, even though they are trained to manage such cases independently.
Texas: A Texas NP in a pain management clinic may independently assess and manage patients but must consult with a physician before prescribing certain controlled substances like opioids. They would adhere to this regulation by ensuring that all such prescriptions are reviewed and approved by their supervising physician.
Conclusion
The regulations governing APRNs in California and Texas place significant constraints on their ability to practice independently, affecting their ability to apply their full range of education and expertise. While both states require some form of physician collaboration, Texas’ rules are stricter concerning prescriptive authority, particularly for controlled substances. APRNs must navigate these legal frameworks carefully to adhere to state regulations while still providing effective patient care.
References
California Board of Registered Nursing. (2021).
Advanced Practice Registered Nurse: Scope of practice for nurse practitioners
.
https://www.rn.ca.gov/pdfs/regulations/apn.pdf
Texas Board of Nursing. (2023).
Licensure & practice for APRNs
.
https://www.bon.texas.gov/aprn-overview
National Council of State Boards of Nursing. (2022).
APRNs in the U.S.: Current practice authority by state
.
https://www.ncsbn.org
Links to an external site.
Professional Nursing and State-Level Regulations
Boards of Nursing (BONs) exist in all 50 states, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, and the Virgin Islands. Similar entities may also exist for different regions. The mission of BONs is the protection of the public through the regulation of nursing practice. BONs put into practice state/region regulations for nurses that, among other things, lay out the requirements for licensure and define the scope of nursing practice in that state/region.
It can be a valuable exercise to compare regulations among various state/regional boards of nursing. Doing so can help share insights that could be useful should there be future changes in a state/region. In addition, nurses may find the need to be licensed in multiple states or regions.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
To Prepare:
Review the Resources and reflect on the mission of state/regional boards of nursing as the protection of the public through the regulation of nursing practice.
Consider how key regulations may impact nursing practice.
Review key regulations for nursing practice of your state’s/region’s board of nursing and those of at least one other state/region and select at least two APRN regulations to focus on for this Discussion.
By Day 3 of Week 5
Post
a
comparison of at least two APRN board of nursing regulations
in your state/region with those of at least one other state/region. Describe how they may differ. Be specific and provide examples. Then, explain how the regulations you selected may apply to Advanced Practice Registered Nurses (APRNs) who have legal authority to practice within the full scope of their education and experience. Provide at least one example of how APRNs may adhere to the two regulations you selected.
By Day 6 of Week 5
Respond
to at least
two
of your colleagues
* on two different days
and explain how the regulatory environment and the regulations selected by your colleague differ from your state/region. Be specific and provide examples.
*Note:
Throughout this program, your fellow students are referred to as colleagues.
Reply from xx
Advanced practice RN’s give patients access to providers who are more readily available, resourceful and as knowledgeable as PCP’s. Appointments to see a primary care provider are scheduled out for months leading to saturation in the ER and urgent care. “Lack of full practice authority (FPA) for advanced practice registered nurses (APRNs) is a barrier to the provision of efficient, cost-effective, high quality, and comprehensive health care services for some of our most vulnerable citizens (Bosse J. et al., 2017). Nurse Practitioners scope of practice has a wide set of rules according to the state. Scope of practice refers to the professional activities that each state authorizes nurses or other clinical staff to perform (Clark, E., 2023).
I will be comparing the APRN board of nursing in California to Arizona as both of these states offer full practice authority. APRN’s attend graduate school to obtain a master’s degree, post-master’s certification or doctorate in their intended specialty. Per Assembly Bill 890 signed by Governor Newsome, California has two categories of NP’s. The 103 NP works in a group setting with at least one physician and surgeon within the population focus of their National Certification. The 104 NP may work independently within the population focus of their National Certification. The 103 NP must work in good standing for three years prior to applying to become a 104 NP (California Board of Registered Nursing, 2022).
Arizona Board of Nursing allows APRNs or RNP’s full prescriptive authority by submitting a controlled substance prescription monitoring program (CSPMP) application and registering with the DEA before prescribing medication to patients (Ridenour, 2021). Arizona does not require nurse practitioners to be supervised or collaborate with a physician. They are allowed to practice independently, as long as they follow the guidelines given by the state (Ridenour, 2021). This gives APRNs the ability to care for patients without limitations as long as it is within their scope.
References
Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Poghosyan, L. (2017). Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care.
Nursing Outlook
,
65
(6), 761–765.
https://doi.org/10.1016/j.outlook.2017.10.002Links to an external site.
Links to an external site.
California Board of Registered Nursing. (2022).
Assembly Bill 890
. California Board of Registered Nursing.
https://www.rn.ca.gov/practice/ab890.shtml
Links to an external site.
Clarke, E. (2023, November 10).
Nurse practitioner practice authority: A State-by-state guide
. NurseJournal.
https://nursejournal.org/nurse-practitioner/np-practice-authority-by-state/
Links to an external site.
Ridenour, J. (2021).
Doug Ducey APRN Questions & Answers SCOPE OF PRACTICE: Nurse Practitioners Board
. https://www.azbn.gov/sites/default/files/2021-07/APRN%20Scope%20of%20Practice%20Q%26A%20FINAL.pdf
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Main Discussion Post
Advanced practice registered nurses (APRNs) are subject to laws and regulations for the safety of their patients. The Nurse Practice Act (NPA) is the legislation that states the scope of practice for nurses while the Board of Nursing is what ensures that this legislation is upheld through processes such as licensure, certification of academic completion, and disciplinary actions when necessary (American Nurses Association, n.d.). Each of these sets of regulations are specific to each state so this results in varying scopes of practice which can be confusing.
In Arkansas, APRNs with Prescriptive Authority are required to have a Collaborative Practice Agreement (CPA) in order to prescribe drugs (Arkansas State Board of Nursing, n.d.). Anything else in the scope of practice for APRNs does not require a CPA or oversight from a physician. The CPA must include what schedules of drugs the APRN is allowed to prescribe, the protocols set in place, a plan for when both the physician and APRN are unavailable, and the availability of the overseeing physician. After the APRN has completed six thousand two hundred hours of practice within a CPA, they can apply for full practice authority (FPA) which would mean they no longer require any oversight. Kansas, on the other hand, has less restrictive regulations and does not require a collaborative practice agreement (Kansas State Board of Nursing, n.d.). APRNs have full practice authority upon licensure to work and prescribe within their defined scope of practice without any oversight of a physician. For example, an Arkansas nurse practitioner treating a patient with a UTI can only prescribe antibiotics if they have a collaborative practice agreement with a physician who would review the patient’s chart and prescriptions, whereas a Kansas nurse practitioner can prescribe antibiotics on their own with no need for a physician to review the patient’s information.
Additionally, there are no limitations on opioid prescriptions outside of the already established drug enforcement agency requirements (DEA) which is a major contrast to Arkansas’s many restrictions concerning opiates (Arkansas State Board of Nursing, n.d.; Kansas State Board of Nursing, n.d.). Arkansas recommends that the “lowest effect dosage” be prescribed and suggests careful contemplation on increasing a dosage to above ninety MME/day (Arkansas State Board of Nursing, n.d.). The Arkansas NPA also defines a standard of documentation that must be in the patient’s medical record if opioids are prescribed at a level of over fifty MME/day. Lastly, any patient being prescribed opioids for chronic malignant pain, pain that has required opioid management for at least three months, must have an in-person assessment completed by the APRN every three months and every sixth months by the overseeing physician. According to the DEA’s substance control act, a practitioner can prescribe a controlled substance in the instance of “legitimate medical purpose” with no federal limit on the quantity of schedule II substances (United States Department of Justice, 2023). In addition, a practitioner may issue multiple prescriptions to the patient as long as the practitioner believes the multiple prescriptions will not lead to patient abuse, each is on a separate prescription, and that they are all prescribed for legitimate medical reasons. That being said, the biggest difference here is that opioid prescriptions by nurse practitioners in Arkansas are monitored more strictly than in Kansas.
With over 244,000 estimated nurse practitioners estimated to enter the workforce by 2025, the profession is rapidly growing to replace the estimated physician deficit of 200,000 (Felber Neff et al., 2018). Although full practice authority APRNs could have a highly positive impact on healthcare accessibility in the United States, I do think that oversight until experience is gained is very important. This may be controversial, but I think that having to complete a certain number of practicing hours under a collaborative practice agreement before having full practice authority helps the nurse practitioner be more confident in decisions and safer when it comes to patient care. From what I have seen, I do appreciate the detail that the Arkansas Nurse Practice Act has in place in regards to prescriptive authority and overall patient care Professional Nursing and State-Level Regulations.
References
Arkansas State Board of Nursing. (n.d.).
Nurse practice act: Chapter 4.
https://healthy.arkansas.gov/wp-content/uploads/Rules.Chapter04-_Effective_05-15-2022.pdf
Links to an external site.
Felber Neff, D., Hee Yoon, S., Steiner, R. L., Bejleri, I., Bumbach, M. D., Everhart, D., & Harman, J. S. (2018). The impact of nurse practitioner regulations on population access to care.
Nursing Outlook 66
(4), 379-385.
https://doi.org/10.1016/j.outlook.2018.03.001
Links to an external site.
Kansas State Board of Nursing. (n.d.).
Nurse practice act statutes & administrative regulations.
https://ksbn.kansas.gov/wp-content/uploads/NPA/npa.pdf
Links to an external site.
United States Department of Justice. (2023).
Practitioner’s manual: An informational outline of the controlled substances act
.
https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-071)(EO-DEA226)_Practitioner’s_Manual_(final).pdf
Links to an external site.
Reply from
Comparison of APRN Board of Nursing Regulations: Texas vs Illinois
Prescriptive power
In Texas regulations for Advanced Practice Registered Nurses (APRNs) there is a requirement for a written agreement with a physician to prescribe medications known as a “Collaborative Practice Agreement”. This agreement defines the scope of authority and mandates that APRNs must undertake 20 hours of pharmacology continuing education every two years to uphold their prescribing privileges as, per Texas Board of Nursing guidelines in 2023.
Illinois regulations state that the
advanced practice nurses (APRNs) are allowed to prescribe medications
once they have acquired a license and met educational criteria without needing an agreement, with a physician for controlled substances prescribing rights but they must obtain a “Controlled Substance License.” Additionally in Illinois APRNs need to fulfill continuing education requirements but do not have to undergo training in pharmacology as, per the Illinois Department of Financial and Professional Regulation in 2023.
In Texas and Illinois there are distinctions, in how Advanced Practice Registered Nurses (APRNs) function due to the need for agreements in Texas and independent prescribing permissions in Illinois.The ability of APRNs, in Texas to prescribe medication may be restricted if they do not have a Collaborative Practice Agreement (CPA) whereas APRNs in Illinois enjoy independence in this aspect.
In Texas regulations pertain to Advanced Practice Registered Nurses (APRNs) their scope of practice is outlined by the Texas Nursing Practice Act. It is subject to restrictions established in the Collaborative Practice Agreement (CPA). Although APRNs have the capability to conduct procedures independently, there may be circumstances where they are required to seek guidance or make referrals to physicians based on the terms specified in their agreement as stated by the Texas Board of Nursing in 2023.
In Illinois Regulations regarding healthcare professionals known as Advanced Practice Registered Nurses (APRNs) there is a scope that allows them to conduct assessments and treatments independently without needing a collaborative agreement with other healthcare providers. The Illinois Nurse Practice Act acknowledges APRNs capabilities to practice according to their education and training levels (Illinois Department of Financial and Professional Regulation report, in 2023).
In Texas agreement limits the use of APRNs education and skills unless specified in their agreement with a physician. In contrast in Illinois APRNs can work independently making decisions and delivering care without the need to consult with a physician. This allows for autonomy.
Applying for Advanced Practice Registered Nurses (APRNs)
Regulations concerning authority and practice scope have an impact, on how advanced practice registered nurses (APRNs) carry out their duties in the field of healthcare provision. For instance an APRNs practicing in Texas who is authorized to prescribe medications is required to have a Collaborative Practice Agreement (CPA) in place. This requirement may limit their ability to promptly respond to patient needs. In situations where an APRNs is treating a patient with pain they might need to seek guidance from their partner before making any changes to the medication regimen potentially leading to delays, in providing care.
In Illinois a nurse practitioner treating a patient has the ability to evaluate the situation on their own and recommend a course of treatment without having to seek advice, from a doctor thus improving the efficiency of patient care.
Example of Commitment
In Texas an advanced practice registered nurse (APRN) could follow the rules, on prescribing medicine by keeping in touch with the doctor they work with in an agreement. They would have to make sure that any changes in medication for a patient with diabetes are communicated and documented as, per state laws.
In Illinois nurse practitioners can show they follow their guidelines by doing extra training, in managing chronic diseases This helps them stay skilled and make decisions independently.
References
Texas Board of Nursing. (2023).
Advanced Practice Registered Nurses
. Retrieved from
Texas Board of Nursing website
.
Illinois Department of Financial and Professional Regulation. (2023).
Advanced Practice Registered Nurse Licensure
. Retrieved from
Illinois Department of Financial and Professional Regulation website
Links to an external site.
.
Hain, D. J., & Fleck, L. M. (2020).
The evolving role of the nurse practitioner: Implications for advanced practice nursing and health policy
.
Journal of Professional Nursing
, 36(4), 231-237. doi:10.1016/j.profnurs.2020.04.004.
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Jasmine Daniels
(She/Her)
Sep 25, 2024 9:18pm
|
Last reply Sep 27, 2024 8:55pm
Reply from Jasmine Daniels
Advanced practice nurses are registered nurses with additional education and certification whose scope of practice, like that of a registered nurse, is dictated by a regulatory body. Nursing regulatory bodies (NRBs) exist to regulate nursing practice in the interest of public safety. Each state has its board of nursing (BON) made up of experts in the field and chosen members of the public (Short, 2022). While the
purpose
of nursing boards is the same from state to state, the regulations within the practice acts proposed by their respective nursing boards tend to differ. The differences in the rules for APRNs by boards of nursing in the states of Mississippi and Tennessee are of particular interest to me, as I live in the Memphis metro area.
APN or APRN?
The differences between Mississippi and Tennessee regulations begin with the title given to the advanced practice nurse. In Mississippi, nurse practitioners are considered APRNs or advanced practice registered nurses (Mississippi Board of Nursing, n.d.). Tennessee refers to advanced practice nurses as APNs or advanced practice nurses (Tennessee Board of Nursing, 2019). Both boards consider certified nurse midwives (CNM), certified nurse anesthetists (CRNA), and certified nurse practitioners (CNP) as advanced practice registered nurses. Both states require advanced practice nurses to obtain a minimum of a master’s degree, pass boards, and receive certification from the DEA to prescribe controlled substances (Mississippi Board of Nursing, n.d.; Tennessee Board of Nursing, 2019).
APRNs Practice Authority
In the state of Mississippi, APRNs have reduced practice authority. This requires a “collaborative agreement” where a physician is available for collaboration and communication. The physician must review 10-20% of charts monthly and meet with the APRN quarterly. Additionally, APRNs may not practice independently until they have had 1,000 monitored practice hours during which a physician was physically present (Mississippi Board of Nursing, n.d; American Medical Association, 2017). Another practicing APRN with three or more years of experience in the same field as the APRN they oversee may also fulfill this duty (Mississippi Board of Nursing).
APRNs have restricted practice authority in the state of Tennessee. This rule requires physician oversight for prescriptive authority. The clinician supervising the APRN must always be available for collaboration, physically be onsite once every 30 days, and review 20% of charts monthly (American Medical Association, 2017; Tennessee Board of Nursing, 2019).
Full Practice Authority
As someone who lives in an area rich with health disparities, full practice authority is a topic of interest to me. Full practice authority can enable advanced practice nurses to answer the call for equitable healthcare access in rural areas (Neff et al., 2018). According to studies conducted by Empower Mississippi, the state of Mississippi has a physician shortage, with half of Mississippi serving just four major metro areas (Norris, n.d.). This leaves people living in rural areas of Mississippi with minimal access to primary care. Legislation aimed at solving this problem by giving APRNs full practice authority died in committee hearings on January 1, 2023, citing concerns for APRN’s ability to diagnose with perceived less education compared to that of a physician. However, research in this area shows that malpractice cases against nurse practitioners did not increase in states where APRNs have full practice authority (Empower Mississippi, 2023). Additionally, APRNs are more likely to serve in rural areas and provide more affordable, holistic care, bridging the gap in access to quality healthcare (Bosse et al., 2017).
References
American Medical Association. (2017).
State law chart: Nurse Practitioner Practice Authority
. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/specialty%20group/arc/ama-chart-np-practice-authority.pdf
Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Poghosyan, L. (2017). Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care.
Nursing Outlook
, 65(6), 761–765.
Empower Mississippi. (2023). SB 2796: Full practice authority for nurse practitioners – Empower Mississippi.
Empower Mississippi – Ideas to Action
. https://empowerms.org/sb-2796-full-practice-authority-for-nurse-practitioners/
Mississippi Board of Nursing. (n.d.). Title 30: Professions and Occupations. In
Part 2840: ADVANCED PRACTICE
.
https://www.msbn.ms.gov/sites/default/files/Part%202840%20Advanced%20Practice.pdf
Links to an external site.
Neff, D. F., Yoon, S. H., Steiner, R. L., Bumbach, M. D., Everhart, D., & Harman J. S. (2018).
The impact of nurse practitioner regulations on population access to care
Links to an external site.
.
Nursing Outlook
, 66(4), 379–385.
Norris, C. (n.d.). NURSE PRACTITIONERS AND THE QUALITY OF CARE. In NURSE PRACTITIONERS AND THE QUALITY OF CARE (pp. 1–4).
Short, N. M. (2022).
Milstead’s health policy and politics: A nurse’s guide
(7th ed.). Jones & Bartlett Learning.
Tennessee Board of Nursing. (2019). Rules of the Tennessee Board of Nursing.
Advanced Nursing Practice and Certificates
. https://publications.tnsosfiles.com/rules/1000/1000-04.20190329.pdf
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Thabasum Abraham
Sep 25, 2024 8:54pm
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Reply from Thabasum Abraham
Introduction
As shortages in care providers is becoming an issue, especially during the post-COVID burnout of clinicians, many physicians are leaving healthcare for good. In order to meet the needs of the community, we as nurses are stepping up into clinical leadership and executive leadership roles across the United States.
Professional Nursing Regulations (State vs. Federal)
Advanced practice registered nurses (APRNs) are categorized as nurse practitioners (NPs), certified registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), and clinical nurse specialists (Kleinpell et al, 2023). APRNs brings a holistic approach to health care system. Studies shows primary care provider shortage can be somewhat managed by nurse practitioner workforce expansion.
Key Regulation Impact on Nursing Practice
The physician lobby is strong and in many cases is pushing back on the scope of practice creep that our nursing lobby is advocating across the nation, but their lobby historically tends on focus more on reimbursement policies, research and issues not directly related to scope of practice (Landers, 2000). However, the nursing lobby has more numbers and tends to be more organized. As we expand our scope, and increase our qualifications, nurses would like to get to the level of equal providers with physicians (Chiu et al, 2021). This will only happen with appropriate changes to regulations and legislation that will allow us to work at the peak of our training, education and licensure. By expanding the scope of licensure through updated policies, we can ensure the advancement of our APRN training.
Comparison of Texas with other states
There are three different types of APRN roles in United States: full, reduced and restricted authority. More than half of the U.S states are Full Practice Authority (FPA) states. FPA states permit to evaluate, diagnose, order and interpret diagnostic tests and initiate management and treatment including prescribing medications and controlled substances (Neff et al, 2018).
The scope of practice in the state of California is more of a full scope of practice with much more flexibility and freedom to practice than in Texas. Texas requires a very large percentage of notes be co-signed by a supervising physician and in many facilities and health systems the requirement can be almost 100% (Practice – APRN Scope of Practice, 2024).
On the contrary in California the laws used to say that a supervising physician must only “peruse occasionally” the documentation and does not mention that they have to be present on-site during the care of a patient. As such in California a nurse practitioner has almost 100% autonomy with very little supervision of their scope of practice. Over the last decade or 2 California has made a move towards more restrictive practice policies as well (Nurse Practitioner, 2024).
Perhaps one of the more restrictive states is Florida where advanced practice nurse practitioners can only practice in a primary care setting and have a limited scope of the drugs they are allowed to prescribe. They are also required to be supervised by a physician and the arrangement must be documented in writing (Updated Standards for Protocols: Physicians and ARNPs, 2016). Professional Nursing and State-Level Regulations
In practice, having worked with nurse practitioners in California, even though the law is restrictive, practical applications have a lot of loopholes and nurse practitioners tend to get away with a lot more freedom in California.
APRN Scope of Practice
As I mentioned before, scope of practice can vary from state to state, and based on the policies of the healthcare organization where an APRN works (Short, 2022). Physicians are wary of granting full practice privileges to APRNs in many specialties. In Texas, APRNs are expected to work under a supervising physician, and that physician is ultimately responsible for the decision making and outcomes of the APRN. In spite of this, there are many physicians who overstretch and take on more APRNs than they can reasonably supervise. This results in physicians who in some cases never see patients, and APRNs who round daily and practice almost autonomously. These APRNs cannot bill for 100% of the charges of the physicians according to billing regulations, so when this occurs, physicians are limiting the income of the hospitals and facilities where these APRNs see patients.
While this is good to offset physician burnout and reduce physician workloads, it is not appropriate to replace a specialty physician with an APRN completely. In some cases with capitation and bundled payment systems, such as with the Medicare and Medicaid Diagnosis Related Groups (MS-DRG and APR-DRG) system, increased utilization of APRNs does not affect the payment for an Inpatient stay, and as such this is where APRNs need to pave a road for increased scope as demand will increase in the coming decades as payment structures continue to tighten (Zhang, 2022).
Conclusion
As physician shortages become more apparent, nurses need to expand in practice and we need to expand from primary care into more specialty care to meet the needs of patients and healthcare organizations. As physician more and more move into administrative and leadership roles, remote and work from home supervisory roles, APRNs can fill that void and meet the demands on the healthcare system for bedside care professionals. If we lobby successfully, APRNs can provide a valuable cost saving service to the healthcare system in the United States.
References
Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Poghosyan, L. (2017). Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care. Nursing outlook, 65(6), 761–765. https://doi.org/10.1016/j.outlook.2017.10.002
Chiu, P., Cummings, G. G., Thorne, S., & Schick-Makaroff, K. (2021). Policy Advocacy and Nursing Organizations: A Scoping Review. Policy, politics & nursing practice, 22(4), 271–291.
https://doi.org/10.1177/15271544211050611
Links to an external site.
Kleinpell, R., Myers, C. R., & Schorn, M. N. (2023). Addressing Barriers to APRN Practice: Policy and Regulatory Implications During COVID-19. Journal of nursing regulation, 14(1), 13–20.
https://doi.org/10.1016/S2155-8256(23)00064-9
Links to an external site.
Landers, S. H., & Sehgal, A. R. (2000). How do physicians lobby their members of Congress?. Archives of internal medicine, 160(21), 3248–3251. https://doi.org/10.1001/archinte.160.21.3248
Neff, D. F., Yoon, S. H., Steiner, R. L., Bejleri, I., Bumbach, M. D., Everhart, D., & Harman, J. S. (2018). The impact of nurse practitioner regulations on population access to care. Nursing outlook, 66(4), 379–385. https://doi.org/10.1016/j.outlook.2018.03.001
Short, N. M. (2022). Milstead’s health policy and politics: A nurse’s guide (7th ed.). Jones & Bartlett Learning
Unruh, L., Rutherford, A., Schirle, L., & Brunell, M. L. (2018). Benefits of Less Restrictive Regulation of Advance Practice Registered Nurses in Florida. Nursing outlook, 66(6), 539–550. https://doi.org/10.1016/j.outlook.2018.09.002
Updated Standards for Protocols: Physicians and ARNPs
. (2016, 1 12). Retrieved 9 2024, from Florida Board of Nursing: https://floridasnursing.gov/standards-for-protocols-physicians-and-arnps/
Nurse Practitioner
. (2024). Retrieved 9 2024, from California Board of Registered Nursing: https://www.rn.ca.gov/practice/np.shtml
Practice – APRN Scope of Practice
. (2024). Retrieved 9 2024, from Texas Board of Nursing: https://www.bon.texas.gov/practice_scope_of_practice_aprn.asp.html
Zhang, A. D., & Anderson, T. S. (2022). Comparison of Industry Payments to Physicians and Advanced Practice Clinicians. JAMA, 328(24), 2452–2455. https://doi.org/10.1001/jama.2022.20794
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Nche Mou Bayong
Sep 25, 2024 6:43pm
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Last reply Sep 28, 2024 10:32am
Reply from Nche Mou Bayong
Professional Nursing and State-Level Regulations
APRNs are a critically important profession in healthcare, especially in an
environment where the need for quality care is high. However, there exists a vast difference
in the extent of practice and the regulatory capacity of APRNs from one state to another. The
Board of Nursing (BONs) in every state is mandated to set policies regarding practice to
protect the public’s health, but these policies also establish the framework in which APRNs
are required to work. This paper aims to compare the APRN regulations in Minnesota and
Florida with openness to differences in the practice authority of APRNs, supervisory rules,
and prescriptive authority. This is very important for APRNs to learn, especially for those
planning to gain a license in other states or those planning to switch to new rules and
regulations. Understanding the meaning of these regulations helps to decode the impact of the
current legislation on the APRN’s practice and their practice jurisdiction across different
states.
Overview of APRN Regulations
Minnesota
In Minnesota, APRNs practice on the FPA, which permits the complete practice of
diagnosing and treating different ailments without collaboration with physicians. This
encompasses assessing a patient, an admitting diagnosis, request, and interpretation of
investigations, as well as formulating and implementing treatment regimens, including
writing prescriptions for drugs without consulting a physician. Minnesota Board of Nursing
controls APRNs; more so, APRNs are required to possess a current registered nurse license
and pass through an accredited advanced practice nursing program (Minnesota Board of
Nursing, 2016). Also, APRNs need to register with the national certification relevant to the
field; these include the Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified
3
Nurse-Midwife (CNM), or Certified Registered Nurse Anesthetist (CRNA). The state
requires APRNs to renew their certification in order to meet the continuing education and
keep abreast with clinical practice. It is intended to improve primary health care, especially in
areas where physicians and other primary care practitioners might be hard to come by.
Minnesota APRN legislation has changed markedly since the Advanced Practice
Nurse Act was enacted in 1999 and the amendments. For instance, Senate Bill 511, enacted in
2014, enabled separate practice autonomy for APRNs, provided they had accumulated not
less than 2080 hours of practice under the supervision of a physician. This collaborative
management plan must not be written but between the APRN and a physician with the same
population focus. For example, when an APRN is certified in pediatrics, they work alongside
a pediatrician. Although the CRNAs, in specific ways, are limited in their ability to prescribe
pain medication independently, the overall APRN regulatory model is founded on the ability
to provide quality care independently. This approach not only improves the quality of
healthcare services delivery but also acknowledges that APRNs are instrumental in
promoting the improvement of the health world across different settings in Minnesota.
Florida
In Florida, all APRNs practice under the Restricted Practice model, which sets
particular supervisory conditions for the APRN’s practice. Although APRNs are mandated to
possess a Master’s degree in nursing and must sit for a national certification exam in their
chosen specialty, they legally practice under the physician’s protocols. This is because their
scope of practice permits an aspiring APRN only to accomplish tasks or make clinical
judgments that are stipulated by the written supervisory plan. For example, if an APRN is
practicing under the provisions of a physician who has a specialty in delivering family
medicine, then the rights of the APRN concerning the ability to prescribe some sorts of drugs
4
or concerning the method of managing the patients would depend on the conditions under
which APRN works with the physician. However, Florida law requires that APRNs provide a
minimum of 3,000 supervised clinical hours before applying for independent practice, and
those granted independent licenses are restricted to primary care practices only.
Nonetheless, changes to legislation enacted over the past few years have started to
alter the situation of APRNs in Florida. The passage of House Bill 1067 provided essentials
of the autonomous practice of some qualified APRNs, but they must follow particular
guidelines. This includes having clocked adequate clinical hours for the specialty, in addition
to having their national certification. Still, even with these levels of autonomy, the population
density of practice is limited to primary care consisting of chronic illness management as well
as preventive care (floridanursing.gov, 2024). According to the reports, around 8,185 APRNs
have applied for independent practice before the beginning of the year 2023. This transition
marks a big move in pulling Florida regulations closer to parity with those in other states for
the benefit of patients. The change in the regulatory framework is indicating a growing
appreciation for the critical roles that APRNs perform in providing health care to varied
populations of Floridians.
Differences Between Minnesota and Florida Regulations
The major differences between Minnesota and Florida regarding APRNs are the
practice authority, supervisory, and prescription authority. MN APRNs are privileged to
practice under FPA, where they are allowed to diagnose conditions, order diagnostic tests,
and prescribe medications as well as treatment regimens all by themselves (Kleinpell et al.,
2022). This autonomy, coupled with the passage of Senate Bill 511 in 2014, permits APRNs
to practice independently on the condition that they have no less than 2,080 hours of
collaborative practice with a physician. Hence, Minnesota APRNs can work without any
5
supervisory clause, and this also optimizes healthcare services delivery since the APN can
contribute towards the delivery of healthcare services, especially in rural stations that require
few physiologists. This regulation framework allows APRNs to practice as educated and
trained to take care of the patients.
Unlike other states, Florida is considered to fall under the Restricted Practice model
under the condition that APRNs have to enter a supervisory agreement with a physician. This
means that despite the fact that Florida APRNs and Minnesota APRNs are educated at the
master’s level and are certified identically, they are bound by the details outlined in the
supervisory contracts. For example, they can only prescribe some medicines or perform some
operations when they are under the direction of their immediate boss- the physician.
Furthermore, Florida requires setting and registering APRNs for at least 3000 hours of
supervised clinical experiential practice before eligibility for the autonomous practice. This
requirement can become a hindrance to providing early patient care since participating
APRNs have to refer to their supervising physician first when coming up with important
decisions about a patient’s care.
The other apparent variation is in the extent of administrative, autonomous, and
prescriptive power provided to APRNs in every state. Currently, all Minnesota APRNs have
the right to independent prescribing of medications upon fulfillment of education and
certification requisites. This encompasses the privilege of issuing controlled drugs without
entering into a practice collaboration with a medical practitioner. It is via this process that the
Minnesota Board of Nursing assesses whether the APRNs are well placed to provide the
patients’ care as required. On the other hand, Florida rules require prescriptive authority to be
based on the supervisory agreement with a physician. After getting a professional license in
Florida, APRNs are still supervised in some ways, such as by prescribing medication under
6
specific guidelines. This limitation can have the consequence of limiting the A PRNs in
Florida's ability to act promptly to patients’ needs compared to the APRNs in Minnesota.
Implications for APRN Practice
The difference in regulation between Minnesota and Florida has a substantial
potential impact and repercussions for APRNs. As an independent APRN in Minnesota, a
practice state with FPA, one can diagnose and treat patients independently, thus improving
the capacity to deliver a full range of care at the appropriate time. It is most suitable for use in
rural areas where the shortage of skilled human resources in health care is most acute. For
instance, if an APRN is practicing in Minnesota, entry, diagnosis, treatment, and handling of
a disease like diabetes or hypertension without requiring a doctor’s direction will increase
patient satisfaction and reduce cost. The freedom to prescribe medication autonymously also
allows APRNs to time match by eradicating time that might be spent consulting a doctor to
sign the prescription or grant approval. The regulations provide the systems model of
healthcare; APRNs may work collaboratively with physicians, yet they have the competence
to exercise independent clinical judgments based on their mandates.
On the other hand, the Restricted Practice model of APRNs in Florida has the
following working challenges that can likely influence the conduct of APRNs care. The
compulsory presence of a supervisory agreement with a physician restricts the practice
providing range and can introduce potential delays in patients’ treatment. For instance, an
APRN in Florida is expected to consult the collaborating physician anytime they wish to alter
the client’s treatment plan or order for medicines, a time-consuming processes in the delivery
of care. This means that to allow novice APRNs to practice, they would still have to complete
3,000 hours of supervised practice, which could discourage some nurses from pursuing the
APRN role. These restrictions can thus result in bare places in handling a disease in the
7
preliminary stages in the affected population. Consequently, regarding the APRNs’ choices,
Florida could be less efficient in adapting its rules and regulations to the advanced training of
these practitioners compared to the states, including Minnesota, which allow broader
independent practice.
Conclusion
Therefore, comparing the regulations of Minnesota and Florida APRNs, significant
disparities are evidenced concerning their access to practice and, the delivery of care to the
populace. Minnesota’s Full Practice Authority means that APRNs can practice independently
to provide optimum patient care, especially in rural areas. This independence improves the
healthcare possibilities and lets APRNs use their complete training and preparation to the full.
Instead, Florida’s Restricted Practice model includes regulatory requirements for supervision,
which can restrict APRNs’ range of practice and the rate of treatment provision, thus
threatening patients’ needs. Continuing complexities in healthcare requirements make these
provisions of regulatory discrepancies valuable for APRNs willing to transverse state borders
or adapt to the changing practice spheres. Finally, the appropriate management of regulations
on APRNs will enhance the healthcare delivery system and benefit everyone.
References
floridanursing.gov. (2024). Florida Board of Nursing» Autonomous Advanced Practice
Registered Nurse – Licensing, Renewals & Information. Floridasnursing.gov.
https://floridasnursing.gov/licensing/autonomous-advanced-practice-registered-nurse/
Kleinpell, R., Myers, C. R., Likes, W., & Schorn, M. N. (2022). Breaking Down Institutional
Barriers to Advanced Practice Registered Nurse Practice. Nursing Administration
Quarterly, 46(2), 137–143. https://doi.org/10.1097/naq.0000000000000518
8
Minnesota Board of Nursing. (2016). Advanced Practice Registered Nurse (APRN) License
General Information / Minnesota Board of Nursing. Minnesota Board of Nursing.
https://mn.gov/boards/nursing/advanced-practice/advanced-practice-registered-nurse-
%28aprn%29-licensure-general-information/
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Alicia Prentler
Sep 25, 2024 6:05pm
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Last reply Sep 28, 2024 10:18pm
Reply from Alicia Prentler
Week Discussion 5
Full practice APRN’s are essential to providing low-cost care and increase access to preventive care (Bosse et al., 2017). Each state has different regulations that regulate the care that can be provided by APRN’s. In Michigan APRN’s needs to have the supervision of a physician in order to practice. When it comes to prescribing APRN’s in Michigan can prescribe any non-scheduled medication but any scheduled medication 2-5 must be done in the delegated act of a physician, (Michigan Compiled Laws, 2024). When it comes to rounds in Michigan, APRN’s can complete rounds at the frequency they determine necessary without the approval or supervision of a physician (Michigan Compiled Laws, 2024). Having limitations in APRN’s is proven to decrease ER visits and hospitalizations within patients (Bosse et al., 2017).
Ohio has the ability to prescribe all scheduled medications with proper education, to prescribe schedule II drugs there has to be proof of completion of instruction of advanced pharmacology, (Ohio Laws and Administrative laws, 2018). This is essential in providing a whole health model to our patients. The ability for APRN’s to practice within the full scope of their education and training has proven to reduce health disparities and lower cost of care. The Department of Veteran’s Affairs has determined that allowing APRN’s full practice has only had positive impacts on care to include a whole health approach to care, increased patient satisfaction and overall improvement on patient satisfaction scores (National Council of State Boards of Nursing, n.d.). Encouraging more states to participate in the APRN Compact Act are steps that need to be taken to encourage a nationwide acceptance of APRN’s practicing within the full scope of their training.
Resources:
Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Poghosyan, L. (2017).
Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care
Links to an external site.
. Nursing Outlook, 65(6), 761–765.
Michigan Compiled Laws. (2024) Public Health Code (Excerpt) Act 368 of 1978. Retrieved from :
https://www.legislature.mi.gov/(S(b4vwmsi2u4sluf45ttuck4n5))/documents /mcl/pdf/mcl-368-1978-15-172.pdf
Links to an external site.
.
National Council of State Boards of Nursing (NCSBN)
Links to an external site.
. (n.d.). Retrieved September 20, 2018, from https://www.ncsbn.org/index.htm
Ohio Laws and Administrative Laws. (2018) Rule 4723-9-02 Requirement for a Course of Study in Advanced Pharmacology. Retrieved from: https://codes.ohio.gov/ohio-administrative-code/rule-4723-9-02
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Cody Ross Newton
Sep 25, 2024 5:40pm
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Last reply Sep 28, 2024 7:54am
Reply from Cody Ross Newton
New York
Scope of Practice
: In New York, Nurse Practitioners (NPs) can practice independently after completing 3,600 hour collaborative agreement with a physician in the specialty involved and in accordance with a written practice agreement and written practice protocols. After this period, they do not require ongoing supervision.
Prescriptive Authority
: NPs in New York can prescribe medications, including controlled substances, once they obtain a New York State prescriptive authority. In order to do this, the NP must obtain New York State Official Prescription Forms or authorization to prescribe controlled substances from the New York State Department of Health
,
o
btain a Federal Drug Enforcement Administration number issued by the US Department of Justice-Drug Enforcement Administration
and then o
btain a National Provider Identifier issued by the US Center for Medicaid and Medicare Services.
Licensing
: NPs must hold a Master’s or Doctoral degree in nursing, pass a national certification exam, and fulfill continuing education requirements for license renewal. New York also mandates specific coursework in pharmacology for prescriptive authority.
Arkansas
Scope of Practice
: Arkansas NPs must have a collaborative agreement with a physician if they do not meet independent practice qualifications. NPs that have completed a minimum of 6,240 hours of practice under a collaborative practice agreement and hold an active prescriptive authority certificate can apply to practice under full independent authority.
Prescriptive Authority
: Unless NPs in Arkansas have full prescriptive authority, they will need to have a collaborative practice agreement. If the NP has full practice authority, they are exempt from needing the collaborative agreement. They must complete a pharmacology course but do not need any formal agreement with a physician to prescribe. According to the Arkansas State Board of Nursing website, NPs will “provide documentation of successful completion of pharmacology coursework which shall include pharmacokinetics principles and their clinical application and the prescription of pharmacological agents in the prevention and treatment of illness, and the restoration and maintenance of health” (Arkansas State Board of Nursing Rules p. 8, 2020).
Licensing
: Like New York, Arkansas requires NPs to have a Master’s or Doctoral degree and to pass a national certification exam. Continuing education is also required for renewal. APRNs with prescriptive authority shall complete five contact hours of pharmacotherapeutics continuing education in the APRN’s area of certification each biennium prior to license renewal.
Allowing nurse practitioners to practice with full authority is one way to help serve our communities in a more comprehensive way. Nurse Practitioners (NPs) primarily serve younger, more diverse, and vulnerable populations. Studies indicate that NPs are cost-effective, providing care comparable to physicians while reducing hospital complications and costs, particularly through the application of evidence-based practices (Dillon & Gary, 2016). An example of how APRNs may adhere to the two regulations I selected would be adhering to their continuing education that is required to continue practicing. According to Wright et al. (2023), “continuing education programs for advanced practice nurses should be rigorously developed, implemented and evaluated to support the quality and effectiveness of patient care”.
References
Arkansas State Board of Nursing Rules. (2015). In
ARKANSAS STATE BOARD OF NURSING RULES
. https://www.healthy.arkansas.gov/images/uploads/pdf/Rules.Chapter04-_Effective_05-15-2022.pdf
Dillon, D., & Gary, F. (2016). Full Practice Authority for Nurse Practitioners.
Nursing Administration Quarterly
,
41
(1), 86–93. https://doi.org/10.1097/naq.0000000000000210
Part 64, Nurse Practitioners | Office of the Professions
. (n.d.). https://www.op.nysed.gov/professions/nurse-practitioners/laws-rules-regulations/part-64
Wright, M., Kvist, T., Imeläinen, S., & Jokiniemi, K. (2023). Continuing education for advanced practice nurses: A scoping review.
Journal of Advanced Nursing
,
80
(8), 3037–3058. https://doi.org/10.1111/jan.15911
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Brianna Renee Cole
Sep 25, 2024 9:13am
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Last reply Sep 28, 2024 10:36pm
Reply from Brianna Renee Cole
Discussion 3
NURS 6050
Brianna Cole
September 25, 2024
Advanced Practice Registered Nurses (APRN) are nurses with post-graduate education and training in one of the following areas: Nurse Anesthetist, Nurse Midwife, Nurse Practitioner, or Clinical Nurse Specialist. (Boehning & Punsalan, 2023) Like a Registered Nurse license, an APRN license is regulated by the perspective State Board of Nursing.
Regulations of an APRN vary
from state to state. Some states allow APRNs to practice independently, some have reduced practice, and some are fully restricted.
The purpose of the Board of Nursing is to protect the public’s welfare. Each state determines the rules and regulations of how the APRN can practice. Before being able to practice as an APRN in any state, one must graduate from a credible school that the board acknowledges and pass the state boards.
Texas APRN Regulations
Texas falls under the restricted practice model, meaning the APRN cannot practice independently. The APRN must collaborate with a medical doctor using the Collaborative Practice Agreement, defining the roles and expectations. (Texas Board of Nursing, 2024) This means that even though the APRN works within their scope of practice, they still need to consult a physician.
Another difference in Texas is the topic of prescriptions. In Texas, the APRN must file a prescriptive authority agreement. According to the Texas Board of Nursing (2024), the prescriptive authority agreement is a mechanism by which an APRN is delegated the authority to order or prescribe drugs or devices by a physician. The APRN can enter the contract after obtaining licensure, a prescriptive authorization number, and a physician. Professional Nursing and State-Level Regulations
California APRN Regulations
California recently passed AB 890 on January 1, 2023, which allows APRN to practice independently. Once an APRN obtains their license, they must practice for a minimum of three years under a physician’s supervision or obtain 4,600 hours before practicing independently. (California Association for Nurse Practitioners, 2024) However, California is still considered a restrictive state. When starting as a new APRN, I found California is very similar to Texas. The APRN must collaborate with a physician when diagnosing, treating, and prescribing patient medications.
Adhering To Regulations
Texas: If working at a clinic in Texas, the Nurse Practitioner (NP) would have to work under the physician’s supervision. The NP gives the provider a brief overview of the assessment findings and then reviews the treatment plan with the provider before initiating the treatment.
California: In California, the NP would follow the same steps as a new, inexperienced NP. Once the NP gains the hours of experience or has worked under the supervision of a physician, they can apply to practice independently.
There are pros and cons to the regulations set by the state. One of the pros is collaborating with another professional when having difficulties diagnosing a patient. However, time is one of the major cons of following these strict regulations. It will take longer to treat patients, possibly leading them to have longer clinic appointment times.
Conclusion
Every state has a Board of Nursing that regulates how an Advanced Practice Registered Nurse can practice. Although these two examples exemplify two states with restrictions, many states allow APRNs to practice at total capacity within their scope right after graduating. It is vital to regularly visit your state’s Board of Nursing to be aware of any updates and changes that can affect your practice.
References
Boehning, A. P., & Punsalan, L. D. (2023, March 1).
Advanced Practice Registered Nurse roles
. StatPearls – NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK589698/
Links to an external site.
California Association for Nurse Practitioners
AB 890 Implementation
. Retrieved September 2024
https://canpweb.org/Advocacy/AB-890-Implementation
Links to an external site.
Texas Board of Nursing. Retrieved September 25, 2024.
Texas Administrative Code
.
https://www.bon.texas.gov/rr_current/222-5.asp.html
Links to an external site.
Texas Board of Nursing. (2024).
Advanced practice registered nurses: Rules and regulations.
Texas Board of Nursing. Retrieved from
https://www.bon.texas.gov
Links to an external site.
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Rebecca Carico
Sep 25, 2024 7:57am
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Last reply Sep 29, 2024 1:17am
Reply from Rebecca Carico
The mission of state and regional boards of nursing is backed by regulations that are meant to protect patients and ensure the safety of the public regarding health care (Short, 2022). Short (2022) also mentions that health care education programs can vary greatly based on the information and methods of teaching they provide, making the need for laws and regulations even more necessary to ensure a certain standard of practice is being upheld by all educational facilities. A topic that I have seen frequently debated and discussed within nursing regulations is whether the nurse practitioner should have autonomy in their practice. With the primary care physician shortage in rural areas actively worsening, nurse practitioners are becoming more and more sought-after because they help bridge the gap in providing access to primary care (Neprash, 2021).
Currently in Virginia, a nurse practitioner must have 9,000 hours (5 years) worth of experience before being able to apply for an autonomous license, which would allow him or her to work autonomously without physician oversight. North Carolina, however, does not allow the nurse practitioner to ever have autonomy no matter how experienced they may be. Neprash et al (2021) compares different rural and urban areas in multiple states and the ability for nurse practitioners to conduct autonomous practice. For instance, where Virginia allows autonomous practice after 5 years of patient care, the state of North Carolina requires a collaborative practice agreement to always be in place between the nurse practitioner and a supervising physician.
Virginia Board of Nursing Regulations:
According to the Virginia Board of Nursing (2018), the criteria for eligibility to apply for a Nurse Practitioner license includes: holding a current and active RN license, evidence of a graduate degree in nurse practitioner specialty from an accredited program, evidence of certification in chosen specialty (FNP, Midwives, Psychiatric, etc.), filing the board of nursing application, paying the application fee, and passing the applicable board of nursing exam. A nurse practitioner that has not reached the 9,000 hours of practice, or has chosen not to obtain full practice authority, must enter and stay in a practice agreement with a supervising physician. The physician is required to perform chart reviews of the nurse practitioner periodically throughout the year, and there is currently no minimum requirement for the number of chart reviews required of the supervising physician. Supervising physicians are limited to 10 nurse practitioners in one practice setting.
North Carolina Board of Nursing Regulations Criteria:
Requirements to receive a Nurse Practitioner license in NC according to the North Carolina Board of Nursing (2024) include: holding a current and active RN license in North Carolina (or from another compact state), completing the appropriate degree requirements from an accredited school, meet registration requirements and apply for one-time registration according to the NCBON, submit an application for approval to practice, and have a collaborative practice agreement in place with a supervising physician (North Carolina Board of Nursing, 2024). Unlike Virginia, North Carolina does not set a limit on the number of nurse practitioners that a supervising physician can oversee in one practice setting.
APRN Full Scope of Practice
The most significant difference between Virginia and North Carolina that I have found is the ability for nurse practitioners to obtain full autonomy after 9,000 hours (5 years) of full-time practice (Virginia Board of Nursing, 2018). In North Carolina, there is no legal authority for a nurse practitioner to practice within their full scope of education and experience without physician oversight due to the limitations set forth by the NC Board of Nursing (North Carolina Board of Nursing, 2024). Nurses in Virginia can adhere to their regulation by ensuring they have a collaborative agreement with a physician for the first consecutive 5 years of full-time practice before attempting to branch out and apply for their autonomous license. Nurses in North Carolina can adhere to their regulations by ensuring that they find a physician to enter a collaborative practice agreement with prior to applying for their nurse practitioner license, and ensuring that they stay in a practice agreement during their time practicing as a nurse practitioner.
References
Virginia Board of Nursing. (2018, July 6).
Advanced Practice Registered Nurse (APRN)
. https://www.dhp.virginia.gov/Boards/Nursing/PractitionerResources/AdvancedPracticeRegisteredNurse/
Neprash, H. T., Smith, L. B., Sheridan, B., Moscovice, I., Prasad, S., & Kozhimannil, K. (2021). Nurse Practitioner Autonomy and Complexity of Care in Rural Primary Care.
Medical Care Research and Review
: MCRR
,
78
(6), 684–692.
https://doi.org/10.1177/1077558720945913
Links to an external site.
North Carolina Board of Nursing. (2024, April 24).
Nurse Practitioner
. North Carolina Board of Nursing. https://www.ncbon.com/nurse-practitioner-0
Short, N. M. (2022).
Milstead’s health policy and politics: A nurse’s guide
(7th ed.). Jones & Bartlett Learning.
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Lucia Almeida
Sep 25, 2024 2:54am
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Last reply Sep 25, 2024 7:28am
Reply from Lucia Almeida
The Boards of Nursing (BONs) play a crucial function in providing guidance to registered nurses and the public to make sure its members adhere to state laws, the most important of which is to protect the public. Like most states, the BON in Virginia regulates the licensure and the scope of practice for the nurses, to ensure that the nurses practice according to a set level of competence, to enable them to discharge their responsibilities as expected. Licensure processes as defined by the VBN include education, passing the NCLEX-RN examination, and continuing education for an active license (Virginia Department of Health Professions (.gov), n.d.). These criteria make sure that nurses are qualified to handle the job and will not put the lives of their patients at risk by practicing without proper knowledge and understanding of their job. Also, state laws demand that licenses be renewed as frequently as possible to make sure that nurses practice in conformity with new practice and technological advancements in the health sector.
The Virginia BON also establishes and identifies the practice of nursing and its boundaries with regards to public protection while also providing for the dynamic healthcare systems environment. The VBN defines the roles and scopes of practice for RNs, LPNs, and NPs that indicate which tasks the professionals can perform while excluding unauthorized persons from practicing in a manner beyond their certification. These regulations are important in imposing order on the delivery of health care and to ensure that each healthcare worker or provider is legal in his practice to prevent causing harm to the patient. Research shows that clearly outlined scopes of practice improve patient outcomes due to clear and accountable practice (Blanchard et al., 2021). The role of NPs has evolved in Virginia, and the practice authority has increased over the years in terms of the ability of NPs to diagnose and treat patients without necessarily reporting to physicians especially in rural settings.
The differences are not very distinct, and yet they are significant enough to have an impact on the practice of nursing in Virginia as compared to other states with different BON regulations. For instance, some states like New York has very limiting laws that call for collaborative practice between a nurse practitioner and a physician while Virginia has been more liberal on the same issue. Nurse practitioners in Virginia can practice independently if they have had five years or more of clinical practice; this was passed in 2018 (Virginia Department of Health Professions (.gov), n.d.). Hence the need for such regulatory flexibility in meeting growing healthcare needs especially in the rural areas where there is a relative shortage of physicians. These variations call for the need for nurses to acquaint themselves with laws in the neighboring states if they intend to transfer to another state.
References
American Nurses Association. (n.d.).
ANA enterprise.
http://www.nursingworld.org
Blanchard, C. M., Yannayon, M., Sorge, L., Frail, C., Funk, K., Ward, C., Livet, M., Sorensen, T., & McClurg, M. R. (2021). Establishing a common language for the comprehensive medication management patient care process: Applying implementation science to standardize care delivery.
JACCP: JOURNAL of the AMERICAN COLLEGE of CLINICAL PHARMACY
,
4
(9), 1070–1079.
https://doi.org/10.1002/jac5.1496
Links to an external site.
Virginia Department of Health Professions (.gov). (n.d.).
Virginia Board of Nursing – RN/LPN
. Virginia Board of Nursing.
https://www.dhp.virginia.gov/Boards/Nursing/PractitionerResources/ContinuedCompetency/RNLPN/
Links to an external site.
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Lovepreet Kaur
(She/Her)
Sep 24, 2024 11:22pm
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Last reply Sep 25, 2024 7:28am
Reply from Lovepreet Kaur
Professional Nursing and State-Level Regulations
I
n
tr
od
uct
io
n
Advanced Practice Registered Nurses (APRNs) are essential healthcare professionals in the United States because they provide super-specialized nursing care in a variety of sectors. The degree of an APRN’s freedom and the progress of patient care, however, may vary based on their state, duties, and responsibilities (Schirle et al., 2020). The two portions of the
APRN regulations
in Texas and California are highlighted in this discussion, along with their distinctions and implications for APRN practice.
Professional and State-Level Regulations
In the two states under comparison, the Texas Board of Nursing Regulations is located in Texas, while the California Board of Nursing Regulations is located in California. All regulations pertaining to the practice of nursing in the state of California are under the jurisdiction of the California Registered Board of Nurses. For example, the first regulation covers nursing education, license issuing, nurse registration, and many more regulations.
Each state’s board of nursing oversees advanced practice nurses. They establish and uphold the parameters and rules governing each nursing license. Advanced Practice Nurses, Licensed Practical Nurses, Registered Nurses, and Nursing Assistants are all governed by these nursing boards. In addition, state legislatures and the NCSBN (National Council of State Boards of Nursing) oversee professional nurses. It is referred to as the Nurse Practice Act. Describing the parameters of practice, legal requirements, and standards that each profession must follow, serves as a guide for professionals in the protection and care of each population (Jusino, 2024).
Comparison between two Selected States Regulations on Advanced Nurse Practice
Regulation 1: Scope of Practice
California, which has a lax approach to healthcare regulations, supports APRNs’ role as primary care physicians (PCPs) by allowing them to prescribe medications independently. The research by Schirle et al. (2023), addresses the obstacles and regulations related to optimal APRN practice and how they affect APRN practice in California and nationwide. Nonetheless, current laws in California mandate that APRNs work in conjunction with physicians and receive guidance or supervision in particular specializations (Schirle et al., 2020). Future APRN rules are shaped by an understanding of these interactions, which incorporate independence and dependency to maintain healthcare and consumer health outcomes in diverse situations as highlighted by Jusino (2024). However, the Texas Board of Nursing has said that the state is more restrictive regarding APRN practice. NPs and CNSs included, APRNs are important members. Texas does, however, have restrictions on independent prescription (Plemmons et al., 2023). For example, in rural health clinics and telemedicine programs, doctors are required to confer with APRNs before prescribing drugs. Incorporating the suggested principles of patient safety and constituent practice care models, together with Texas regulatory rules, is guaranteed by this cooperation.
Regulation 2: Licensure Requirements
California requires completion of an authorized graduate degree in nursing, national certification in the position of APRN and a specialty, and fulfillment of continuing education criteria for license renewals to provide general APRN licensing. California NPs are required to complete 30 hours of continuing education credits every two years to renew their license. This comprehensive method ensures that advanced practice registered nurses (APRNs) possess the necessary educational background and recognized professional training to practice independently and at a high quality as highlighted by Plemmons et al. (2023). In the same way, Texas requires
APRNs to fulfill clinical practice hour requirements for licensure by finishing recognized academic programs and passing the national certification test. The demographic emphasis, such as pediatric or mental health, is one example of an optional specification that ensures APRNs have the knowledge and expertise relevant to their field of interest and employment. Regarding APRN licensure, both states have equally strict regulations that emphasize certification, ongoing competency, and educational requirements. That being said, Texas offers an additional level of qualification in the form of clinical practice hours that deviate from the criteria, which may persuade any APRN from California to follow the clinical requirements when working in Texas (Plemmons et al., 2023).
Implications for APRN Practice
It is necessary for APRNs who are employed in California or Texas, or who want to work there, to be aware of these variations in regulatory rules. For example, an APRN who is moving to Texas from California and has completed certification as a Family Nurse Practitioner must adjust to the collaborative prescribing approach in the new state to comply with all legal requirements. According to Poghosyan et al., (2022), to fulfill clinical hour requirements during this transition, one must establish a working connection with physicians, comprehend local guidelines, or enroll in an alternative program. These regulatory differences, however, provide APRNs and other healthcare providers the ability to advocate for greater independence or coloration in certain areas. Encouraging access to care, promoting mobility throughout states, and improving the progress or results of APRN treatment are all made possible by standard licensing regulations (Schirle et al., 2020).
Adhering to State Regulations
The advanced practitioner has to be well-versed in the rules and their scope to follow them and stay within their area of expertise. Joining a professional association in their state is one method to keep informed about changes to the scope of practice as well as updates to these rules. According to Poghosyan et al., (2022), updates on new laws, modifications to outdated rules, and much more may be found on the websites of state-run institutions. It’s possible to join national advanced practice groups in addition to state ones. By continuing education, APRNs and CRNPs can remain current on the discussed regulations in addition to all additional changes to scope and regulations (Jusino, 2024).
Conclusion
Different degrees of independence and systemic integration are seen in the APRN legislative frameworks in Texas and California. In Texas, team-based treatment with physicians is encouraged, but California permits APRNs to prescribe independently. Particularly for remote and virtual services, these differences have an impact on patient outcomes, APRN responsibilities, and overall access to healthcare. In light of this, the unification of APRN licensing regulations across state lines may enhance labor mobility and promote uniformity in practice, both of which benefit patients. To advocate for legislation that would allow for a uniform and integrated healthcare model across the nation, advanced practice registered nurses (APRNs) who intend to work in many states must be aware of these trends (Jusino, 2024).
References
Jusino, L. (2024).
Exploring Regulatory Frameworks in Nursing Education and Practice: A Policy Analysis
(Doctoral dissertation, Jacksonville University). https://search.proquest.com/openview/913ce042d2bf80b894c2641c5ae508e3/1?pq-origsite=gscholar&cbl=18750&diss=y
Plemmons, A., Shakya, S., Cato, K., Sadarangani, T., Poghosyan, L., & Timmons, E. (2023). Exploring the relationship between nurse practitioner full practice authority, nurse practitioner workforce diversity, and disparate primary care access.
Policy, Politics, & Nursing Practice
,
24
(1), 26-35. https://journals.sagepub.com/doi/abs/10.1177/15271544221138047
Poghosyan, L., Stein, J. H., Liu, J., Spetz, J., Osakwe, Z. T., & Martsolf, G. (2022). State‐level scope of practice regulations for nurse practitioners impact work environments: Six state investigation.
Research in nursing & health
,
45
(5), 516-524. https://onlinelibrary.wiley.com/doi/abs/10.1002/nur.22253
Schirle, L., Norful, A. A., Rudner, N., & Poghosyan, L. (2020). Organizational facilitators and barriers to optimal APRN practice: An integrative review.
Health Care Management Review
,
45
(4), 311-320. https://journals.lww.com/hcmrjournal/fulltext/2020/10000/Organizational_facilitators_and_barriers_to.5.aspx
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Regina Candice Shaw
Sep 24, 2024 10:51pm
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Last reply Sep 27, 2024 1:07pm
Reply from Regina Candice Shaw
Regina Candice Shaw
Discussion week 5
Access to a primary care service in the United States is still a myth, despite the expansion of health care coverage, over 15% of Americans still don’t have access to these services (Bosse et al., 2017). Advanced Practice Registered nurse practitioners (APRNs) have the potential to remedy the shortage in primary care services. According to Bosse et al., some states do not allow APRNs to work independently they require physician supervision. APRNs have the education, experience, and training to confidently fulfill this role, but unfortunately, federal states operate independently. APRNs’ scope of practice varies by state I will compare Illinois, which is the state I am living in right now to Oregon, as I will probably move there once, I am done with my master’s program.
In the state of Illinois, according to the Illinois Board of Nursing APRNs, it is within their scope of practice to diagnose, order diagnostic, therapeutic tests, and procedure tests. They are also allowed to perform the tests and subsequently interpret them and treat the patient based on their findings. Furthermore, they can request that therapeutic tests be conducted and run diagnostics when employing health care devices. Additionally, they can offer counseling services, educate their patients, and proffer health education as well as advocate for their patient’s care and treatment. Moreover, they can be granted the authority to practice without an explicitly written collaborative agreement. Next, there are some restrictions regarding prescribing controlled substances; they must be reviewed monthly by a collaborating physician. Finally, the APRNs must meet the proper education on the Controlled Substance Act (
PART 1300 NURSE PRACTICE ACT : Sections Listing
, n.d.).
In the state of Oregon, APRNs are allowed to practice autonomously; they are responsible and accountable for the management of their patient plan of care, including prescriptive privileges (
Oregon Secretary of State Administrative Rules
, n.d.). They can manage patients during acute and chronic phases of their medical condition, which is important when it comes to managing patients who need palliative or hospice care. Next, APRNs in Oregon have the capability to initiate and collaborate with other healthcare practitioners regarding consultation, initiation, and evaluation of education plus other programs, refer patients to another healthcare provider or community resources, and even transfer a patient.
APRNs in the state of Oregon are more autonomous and have full prescriptive capability. Thus, they do not mandate a collaborative agreement with a physician. This independence allows them to work independently. As mentioned above, the lack of access to primary care services due to a shortage of physicians can be resolved by allowing APNRS to be independent. Conversely, in Illinois, limiting the prescription authority can delay patient care as physicians have to review the prescription. Finally, this can drastically change the outcome of a palliative care patient who needs chronic pain management, for example, or a hospice patient who needs controlled substances more frequently. Suffice it to say APRNs cannot make a quick adjustment to medication without consulting with a physician.
To conclude, this assignment was very informative as it revealed that the scope of practice of APRNs varies from state to state. Illinois state restricts the prescriptive power of APRNs and requires a collaborative agreement with a physician and a monthly review on controlled substances. As a consequence, this restriction can delay care and negatively affect patient outcomes. Finally, in Oregon, they are more autonomous and do not need a physician overseeing their job and can fully practice to the extent of their training, knowledge, and experience thereby enhancing the patient experience and quality of care, and empowering them to serve their community more efficiently.
References
Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Poghosyan, L. (2017). Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care.
Nursing Outlook
,
65
(6), 761–765. https://doi.org/10.1016/j.outlook.2017.10.002
Oregon Secretary of State Administrative Rules
. (n.d.). Retrieved September 24, 2024, from https://secure.sos.state.or.us/oard/displayDivisionRules.action?selectedDivision=5986
PART 1300 NURSE PRACTICE ACT : Sections Listing
. (n.d.). Retrieved September 24, 2024, from https://www.ilga.gov/commission/jcar/admincode/068/06801300sections.html
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Pawandeep Kaur Dhaliwal
Sep 24, 2024 10:29pm
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Last reply Sep 28, 2024 2:35pm
Reply from Pawandeep Kaur Dhaliwal
Main Post
Professional Nursing and State-Level Regulations
Advanced Practice Registered Nurses (APRNs) play a critical role in delivering comprehensive healthcare services, and their ability to practice autonomously or under certain restrictions varies across regions.
These regulations impact the scope of practice and the legal authority that APRNs
possess in managing patient care. By comparing British Columbia’s full-practice model with Texas’s restricted practice model, it becomes evident how regional differences in board of nursing regulations influence APRNs’ autonomy.
In British Columbia (BC), Nurse Practitioners (NPs) operate under a full-practice model that grants them considerable autonomy (Contandriopoulos et al., 2023). This regulation, governed by the British Columbia College of Nurses and Midwives (BCCNM), allows NPs to diagnose, treat, and prescribe independently (BCCNM, 2024). For example, an NP in BC can initiate a treatment plan, prescribe medications, including controlled substances, and manage patient care without requiring physician oversight. This model allows APRNs to fully utilize their education and clinical expertise, promoting efficient, patient-centered care. Texas, on the other hand, employs a restricted practice model under the authority of the Texas Board of Nursing (TBON), which requires APRNs to engage in a collaborative practice agreement with a physician (Texas Board of Nursing, 2024a). The agreement stipulates the scope of APRN practice and places limits on independent prescriptive authority. For instance, in Texas, an APRN cannot prescribe certain medications, particularly controlled substances, without a physician’s supervision or approval, which can delay patient care (Texas Board of Nursing, 2024b).
Regarding prescriptive authority, BC NPs enjoy independent authority, enabling them to prescribe medications, including controlled substances, without the need for physician consultation, allowing them to manage pharmacological treatment plans efficiently (BCCNM, 2024). Conversely, in Texas, APRNs have restricted prescriptive authority, meaning they must operate under a prescriptive authority agreement (PAA) with a supervising physician. This restriction limits the medications they can prescribe independently, particularly controlled substances, and requires compliance with specific terms set out in the PAA (Texas Board of Nursing, 2024b). These terms may vary, but often result in the APRN needing physician approval for more complex medications.
The differences in these regulations have significant implications for APRNs who are authorized to practice within the full scope of their education and experience. In BC, the full-practice authority means that an NP can provide comprehensive care across various settings, from rural to urban communities, without waiting for physician input. For example, an NP working in a remote BC community can manage a patient with chronic pain, including prescribing narcotics if necessary, without delay. This is particularly beneficial in areas where access to physicians is limited (Hitay & Whitehead, 2021). In contrast, an APRN in Texas must maintain a collaborative relationship with a physician, which may hinder their ability to act promptly in certain situations, especially in underserved areas where physician availability is scarce. For example, in rural Texas, an NP may be limited in addressing a patient’s needs swiftly due to the mandatory physician oversight for certain medications (Hitay & Whitehead, 2021).
In British Columbia (BC), an Advanced Practice Registered Nurse (APRN) may adhere to the regulation of independent prescriptive authority by conducting a comprehensive assessment of a patient with diabetes and initiating insulin therapy without requiring physician input. The APRN would evaluate the patient’s history, perform diagnostic testing, and prescribe the appropriate type and dosage of insulin based on the patient’s individual needs. This ability to prescribe without restrictions enables the APRN to manage the patient’s condition in a timely manner, ensuring continuity of care without delays caused by waiting for physician approval.
In Texas, adherence to the regulation of a collaborative practice agreement would involve an APRN working in a rural clinic managing a patient with chronic pain. While the APRN could independently assess and provide general care, they would need to consult with their supervising physician to prescribe opioids for pain management. The APRN would review the patient’s condition, propose a treatment plan, and seek the physician’s approval for prescribing the necessary medication, ensuring that all actions comply with the PAA in place between the APRN and the supervising physician.
Conclusion
The regulatory differences between British Columbia and Texas illustrate how regional governance can impact the scope of APRN practice. BC’s full-practice model enables NPs to exercise complete autonomy in patient care, enhancing healthcare access and efficiency. In contrast, Texas’s restricted model imposes limitations that necessitate physician collaboration, potentially creating barriers to timely care.
References
BCCNM. (2024). F: Prescribing Drugs. Bccnm.ca.
https://www.bccnm.ca/NP/ScopePractice/part2/prescribing/Pages/Default.aspx
Links to an external site.
British Columbia College of Nurses and Midwives (BCCNM). (2024).
RN Scope of Practice
. Www.bccnm.ca.
https://www.bccnm.ca/RN/ScopePractice/Pages/Default.aspx
Links to an external site.
Contandriopoulos, D., Bertoni, K., Duhoux, A., & Randhawa, G. K. (2023). Pre-post analysis of the impact of British Columbia nurse practitioner primary care clinics on patient health and care experience.
BMJ open
,
13
(10), e072812.
https://doi.org/10.1136/bmjopen-2023-072812
Links to an external site.
Htay, M., & Whitehead, D. (2021). The effectiveness of the role of advanced nurse practitioners compared to physician-led or usual care: A systematic review.
International Journal of Nursing Studies Advances
,
3
, 100034.
Texas Board of Nursing. (2024a). Authority to Order and Prescribe Controlled Substances. Texas.gov.
https://www.bon.texas.gov/rr_current/222-8.asp.html
Links to an external site.
Texas Board of Nursing. (2024b). Texas Board of Nursing – Practice – APRN Scope of Practice. Texas.gov.
https://www.bon.texas.gov/practice_scope_of_practice_aprn.asp.html
Links to an external site.
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Domonique Yates
Sep 24, 2024 7:36pm
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Last reply Sep 25, 2024 9:25am
Reply from Domonique Yates
Hi colleagues,
Advanced Practice Registered Nurses (APRN) hold important positions within our healthcare system. The services they can provide hinges on the state in which they practice. APRNs are certified to be completely empowered to prescribe medications and do other procedures outside of a doctor’s direction. The state board of nursing is in charge of the administration features of nursing licensing for each state. Every state has their own individual board of nursing committee.
I live in NJ and the two ARPN board of regulations I chose to discuss are (1) prescriptive authority: APNs are permitted to prescribe medications to their patients without the doctor’s participation, including III-V controlled substance which are examples of drugs that are moderate to low potential for physical and psychological dependence and they can also prescribe schedule II controlled substance which are a high potential for abuse. An agreement outlining their joint association must be documented and signed every year by the nurse and physician (Incredible Health Staff, 2023). The nurse is not required to work with the doctor in the physician’s office, but they can connect by phone or email, and (2) pursue professional education. Every year ARPNs must complete the course for renewal of a registered professional nurse license and the continuing education requirements of the national certify agency. This consists of a one hour of content about prescription opioid drugs, and two hours on subjects regarding end-of-life. An additional 6 contact hours in pharmacology linked to restrained substances is required to prescribe medicine.
In the state of Texas, their prescriptive authority stipulations are the same as New Jersey except for controlled substances. It is mandatory for APRNs to maintain authority agreement or protocol with the doctor (TBON,2024). For the purpose of prescribing addictive drugs, it is imperative for nurse practitioners to file a separate application with the State Department of Public Safety for controlled substance registration.
APRNs can adhere to the two regulations I selected because they have the learning, knowledge, practice, and discipline to prescribe medication. 96.2% of NPs prescribe medications and write an average of 21 prescriptions per day (AANP, 2024). As the public ages and health care providers are retiring more NPs are needed to replace these positions. Nurses are advancing their careers by attending adaptable on-line programs to continue their education. These courses meet national standards for which prepares nurses for challenges and to help them to learn more ways to provide the best health outcomes for patients.
Reference
American Association of Nurse Practitioners(AANP). (February 2024). AANP National Nurse Practitioner Database. NP Fact Sheet. Retrieved from
https://www.aanp.org/about/all-about-nps/np-fact-sheet
Links to an external site.
Incredible Health Staff. (November 08,2023). Incredible Health. Can Nurse Practitioners Prescribe Medication? Retrieved from
Can Nurse Practitioners Prescribe Medication?
Links to an external site.
.
Texas board of nursing (TBON). (2024). Texas board of nursing. Advance Registered Nurse With Prescriptive Authority. Retrieved from
https://www.bon.texas.gov/rr_current/222-8.asp.html
Links to an external site.
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Stella Chinelo Ukakogu
Sep 24, 2024 4:44pm
Reply from Stella Chinelo Ukakogu
Main Discussion Post Week 5
The Board of Nursing exists in many States and endeavors to exercise supervision and authority over nursing practice to protect public health and comply with professional duties in the various States in the United States of America. The Board of Nursing sets rules for regulating Advanced Practice Registered Nurses (APRNs). Each regulation varies from state to state and thus influences the practice of APRNs. An analysis of BON regulations in Texas and California shows the main differences concerning APRN independence and prescriptive privileges.
Comparison of APRN Regulations: Texas vs. California
According to the Texas BON (2023), APRNs must be nationally certified in the specialty practice, possess at least an advanced degree, and collaborate with a physician to practice Radiopharmacy. This agreement entails partial or complete supervision depending on the environment; for instance, the physician may not be on-site in rural areas but must be accessible for consultation. Texas APRNs must practice for 400 hours within two years and complete 20 continuing education hours, five of which must be in pharmacology and this is need to retain the license.
Interestingly, California’s regulations extend much greater freedom to APRNs. Effective 1 January 2023, Assembly Bill 890 provides APRNs with full practice after 4,600 hours of supervised practice or three years of practice under a physician (California BRN, 2023). Once all these conditions have been met, APRNs licensed in California can diagnose, treat, and prescribe without physician collaboration and thus offer more practice authority than in Texas. California expects national certification and annual continuing education for license renewal; however, independent practice endorsement significantly categorizes California as one of the most progressive states regarding APRN practice (California BRN, 2023).
Differences in APRN Regulations
The significant difference, therefore, is the level of decentralization. Texas is far more decentralized than California. Texas regulates APRNs and only allows them to practice independently to some extent, as they have to work with physicians on matters such as the prescription of medicines and clinical practice. This team can decrease the rate of health delivery since physicians in rural areas or areas of low density are already limited. However, Chapman et al. (2019) support that Californian laws permit APRNs to achieve full practice exemptions through the transitional practice period. Such a discrepancy may enhance the effectiveness of managing patients in California, where APRNs can practice freely without the intervention of physicians.
For instance, an APRN from Texas practicing in a primary ambulatory clinic would establish practice under the supervision of a physician and would be prohibited from prescribing narcotics or controlled substances except under the physician’s directive. When the transition period in California is over, an APRN in a similar position can prescribe similar medications themselves, which will save time for the patients.
Application of Regulations to APRN Practice
These regulatory differences significantly affect APRN practice. The collaborative agreement requirement in Texas may limit access to healthcare in the rural or underserved areas of the state because there are fewer physicians in these areas. This may cause a healthcare provider to delay prescribing a medication, delay a treatment plan, or fail to follow the recommended action plans. Consequently, California policies improve patient comprehensiveness, as APRNs with full practice autonomy can treat patients without collaboration with physicians, thus optimizing care.
For example, an APRN in California could establish a rural clinic, treat patients, prescribe medicines, and monitor patients with steady illness, such as diabetes or congestive heart failure, without writing a letter to a physician for permission. On the other hand, a Texas APRN exercising in a similar role would require a collaborative practice medical doctor crippling their capacity to perform independently. They may slow down the rate at which care services are rendered.
Conclusion
A
comparison of Texas and California states indicates the differences in APRN regulations
, especially on autonomy and physician collaboration issues. By regulating APRN practice through the program collaborative agreement, Texas restricts the ability of APRNs to practice independently to the extent allowed by their training and education; on the other hand, California opens the way to full practice through the APRN education profile. These differences show the significance of state-centered rules as they inflict upon the general APRNs’ practice and the potential to enhance access to care in underserved contexts.
References
California Board of Registered Nursing. (2023).
AB 890 and NP Scope of Practice.
https://www.rn.ca.gov
Links to an external site.
Chapman, S. A., Phoenix, B. J., Hahn, T. E., & Strod, D. C. (2019). Utilization and economic contribution of nurse practitioners in federally qualified health centers.
Medical Care Research and Review
, 76(3), 295-308.
https://doi.org/10.1177/1077558717732415
Links to an external site.
Texas Board of Nursing. (2023).
Advanced Practice Registered Nurse Licensure and Renewal.
https://www.bon.texas.gov
Links to an external site.
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Nellie Garcia Monarrez
Sep 24, 2024 11:36am
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Last reply Sep 24, 2024 10:09pm
Reply from Nellie Garcia Monarrez
Main Response to Discussion
Comparison of APRN Regulations in West Texas and North Central New Mexico
Regulation 1: Scope of Practice
West Texas: In Texas, APRNs must practice under a physician’s autonomy by requiring physician oversight for diagnosing, treating, and prescribing, particularly for controlled substances; for example, an APRN in West Texas needs a signed protocol with a collaborating physician detailing specific treatments and medications they can prescribe. The Texas Board of Nursing does not have a list of tasks that every APRN can or cannot perform (Texas Board of Nursing. 2022). The physician must regularly review a certain percentage of patient records, impeding timely care decisions.
North Central New Mexico: APRN Certified Nurse Practitioners (CNP) in New Mexico enjoy full practice authority, meaning they can independently evaluate, diagnose, interpret diagnostic tests, and initiate treatment plans without physician collaboration or oversight. For example, an APRN in North Central New Mexico can operate independently, managing patient care and making decisions in real-time. This is especially beneficial in rural settings where physician access might be limited.
Regulation 2: Prescriptive Authority
West Texas: Texas regulations require APRNs to have a prescriptive authority agreement with a physician to prescribe medications, including controlled substances. This agreement mandated a specific number of face-to-face meetings between the APRN and the physician and required documented discussions about care decisions. For instance, an APRN in West Texas prescribing a controlled medication must adhere to the stipulations of their prescription with their collaborating physician, delaying the initiation of necessary medicines.
North Central New Mexico: In New Mexico, APRNs have independent prescriptive authority, including for controlled substances, if they have completed the required pharmacology education and meet state licensure standards. The only drugs to be included in the formulary are those relevant to the CNP’s specialty and practice setting (New Mexico Board of Nursing. 2022). This independence allows APRNs to respond immediately to patients’ needs without consulting a supervising physician, streamlining care processes and improving patient outcomes. For instance, an APRN can adjust a patient’s medication for chronic pain management without having to schedule a consultation with a physician.
Application of Regulations to APRNs’ Practice
Texas: The collaborative and prescriptive authority agreements in Texas restrict APRNs’ ability to exercise their education and expertise fully, often requiring time-consuming meetings and physician approvals. This dependency can limit an APRN’s capacity to provide timely and comprehensive care, particularly in regions where physician availability is inconsistent. It is the position of the American Academy of Nursing (Academy) that the FPA of APRNs is essential to achieving health equity (Bosse, J, 2017). For example, an APRN with extensive experience managing chronic conditions may find their clinical decision-making delayed or altered due to the need for physician sign-off on treatment changes.
New Mexico: The full practice authority in New Mexico empowers APRNs to utilize their skills and training completely, allowing them to manage patient care from diagnosis to treatment independently. This regulatory environment maximizes APRN efficiency, particularly in underserved areas where APRNs can fill critical gaps in care. For example, an APRN running a rural health clinic in North Central, New Mexico, can independently prescribe medications and adjust treatment plans without external approvals, providing patients with immediate and continuous care.
Examples of APRNs Adhering to Selected Regulations
West Texas Examples: An APRN working in a rural clinic in West Texas adheres to state regulations by maintaining a detailed collaborative agreement with a supervising physician. This agreement outlines specific treatments and medications the APRN can manage independently and those that require physician oversight. The APRN regularly meets with the physician to discuss complex cases and prescriptive decisions, documenting these interactions as required by Texas laws.
North Central New Mexico Example: An APRN in North Central New Mexico operates a primary care practice independently assessing, diagnosing, and treating patients. They adhere to state regulations by ensuring all prescriptive actions are within their licensure scope and training. For example, the APRN may adjust a diabetic patient’s insulin dosage based on clinical assessment during a visit without consulting or informing a supervising physician, adhering to New Mexico’s independent practice regulations.
Conclusion
This comparison highlights state regulations’ significant impact on APRNs’ autonomy and ability to practice to the full extent of their education. While Texas APRNs faces more restrictive practices requiring physician collaboration, New Mexico APRNs benefit from full practice authority, allowing them to provide comprehensive, independent care, especially crucial in rural and underserved areas. Understanding these regulatory differences is essential for APRNs to navigate their practice environments effectively and advocate for changes that promote greater autonomy in their professional roles.
References:
Texas Board of Nursing. (2022).
Advanced practice registered nurses: Rules and regulations.
Texas Board of Nursing. Retrieved from
https://www.bon.texas.govLinks to an external site.
Links to an external site.
New Mexico Board of Nursing. (2022).
Licensure and practice requirements for APRNs.
New Mexico Board of Nursing. Retrieved from
https://nmbon.sks.comLinks to an external site.
Links to an external site.
Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., VanHook, P., & Poghosyan, L. (2017). Position statement: Full Practice authority for advanced practice registered nurses is necessary to transform primary care.
Nursing
Outlook, 65(6), 761-765. doi: 10.1016/j.outlook.2017.10.004
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Tiffany Peron
Sep 24, 2024 9:19am
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Last reply Sep 25, 2024 7:11am
Reply from Tiffany Peron
Main Discussion
According to our reading this week experts think that we will see a huge shortage of primary care providers in the U.S. There is a chance that Nurse Practitioners could help with this shortage (Neff, D. F et al., 2018). When comparing APRNs in multiple states the biggest difference that I have found is that some of them can practice independently without a physician. In states where APRNs have full practice authority, research shows benefits like reduced emergency room visits, lower healthcare costs, and expansion of services. (Bosse et al., 2017). I chose to compare Ohio, Kentucky, and then California.
PLACE YOUR ORDER HERE
Comparison
In Ohio, Advanced Practice Registered Nurses (APRNs) can practice within the full scope of their education and training, provided that they hold a valid certificate as a Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), or Certified Nurse Midwife (CNM) (Ohio Board of Nursing). This allows them to assess, diagnose, and treat patients independently. However, when it comes to writing prescriptions Ohio APRNs must establish a collaborative agreement with a physician, which outlines the protocols for prescribing medications, as well as controlled substances. Kentucky also permits APRNs to practice to the full extent of their education but requires them to have a collaborative agreement with a physician to define their scope of practice and the procedures they can perform. Kentucky APRNs can prescribe medications, including controlled substances, but must adhere to a written collaborative agreement as well (Kentucky Board of Nursing).
Key differences
The key differences between Ohio and Kentucky in terms of APRN regulations primarily revolve around joint agreements and the level of independent practice. Both states require APRNs to collaborate with physicians. Kentucky’s regulations tend to be a little harder than Ohio’s. More documentation is often needed and continuation of care is required. Ohio allows for more autonomy within its collaborative agreements, allowing APRNs to practice more independently.
Adherence
In Ohio, an APRN may independently evaluate a patient with hypertension and decide to prescribe a new medication for management. Before doing so, they ensure that the prescription is within their scope of practice and aligns with their collaborative agreement if one exists with the physician. In Kentucky, an APRN would take a similar approach by assessing the patient and developing a treatment plan with the patient. Prior to prescribing any medication, they must review their agreement with the supervising physician to confirm that the prescription is authorized. This process highlights the importance of understanding and complying with state regulations to ensure safe and effective patient care.
I also wanted to compare somewhere completely different from Ohio and Kentucky. In California, Advanced Practice Registered Nurses (APRNs) Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives, and Nurse Anesthetists are allowed to practice independently, without supervisory or collaborative agreement with a physician. This independence extends to writing prescriptions, allowing APRNs to prescribe medications, including controlled substances, as long as they have completed all of the required educational prerequisites (California Board of Registered Nursing). The most notable difference in practice autonomy is that California APRNs can operate without direct oversight, whereas Ohio and Kentucky mandate collaboration with a physician which can delay patient care.
Conclusion
The differing regulations emphasize how state laws can influence the autonomy and practice of APRNs. In states like California, where full practice authority is granted, APRNs can provide care more effectively and timely. In states like Kentucky and Ohio, the collaborative agreements required can restrict APRNs’ abilities and pose obstacles to delivering care.
References
Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Poghosyan, L. (2017).
Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care
Links to an external site.
California Board of Registered Nursing. (n.d.).
California Board of Registered Nursing
. Retrieved September 23, 2024, from
https://www.rn.ca.gov/
Links to an external site.
Kentucky Board of Nursing. (n.d.).
Kentucky Board of Nursing
. Retrieved September 23, 2024, from
https://kbn.ky.gov/
Links to an external site.
Neff, D. F., Yoon, S. H., Steiner, R. L., Bumbach, M. D., Everhart, D., & Harman J. S. (2018).
The impact of nurse practitioner regulations on population access to care
Links to an external site.
Ohio Board of Nursing. (n.d.).
Ohio Board of Nursing
. Retrieved September 23, 2024, from https://nursing.ohio.gov/
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Elizabeth Rachel Fofanah
Sep 24, 2024 8:12am
Reply from Elizabeth Rachel Fofanah
Main Discussion Post:
Rules for advanced practice registered nurses (APRN) vary by state, although all aim to safeguard public health by governing the actions of healthcare workers. The Nurse Practice Act empowers state boards of nursing to formulate and oversee requirements for safe nursing operations within their jurisdiction for qualified nurses throughout various levels of nursing practice, including advanced practice. State boards of nursing regulate license requirements in accordance with the Nurse Practice Act, develop processes for licensure renewal, and impose disciplinary proceedings where warranted (Milstead & Short, 2019).
APRNs are integral to the US healthcare system. APRNs are registered nurses with education at the master’s or post-master’s level, specializing in a particular job and patient demographic. APRNs are trained and qualified to evaluate, diagnose, and address patient issues, in addition to ordering tests and prescribing medications (National Council of State Boards of Nursing [NCSBN], 2022). There are several contrasts and similarities in the full practice authorization and licensure regulations between Minnesota and California.
In contrast to California, Minnesota’s nursing board grants full practice authority (FPA) to APRNs. The Minnesota Board of Nursing permits nurse practitioners to practice autonomously, indicating that they are not required to be overseen by or work alongside physicians. Minnesota’s regulations on nurse practitioner supervision stipulate that nurse practitioners can prescribe medications independently, without the need for physician consultation or oversight. Nurse practitioners are authorized to prescribe, dispense, and deliver medications, including prohibited medicines (Schedule II to V), as well as therapeutic devices (mn.gov). In California, APRNs possess restricted practice privileges, sometimes referred to as limited practice. Restrictive practice, as defined by Peterson (2017), constrains APRNs’ capacity for independent practice by necessitating that they execute one or more facets of their duties under the guidance of a physician. Under FPA, APRNs in Minnesota possess the autonomy to independently diagnose and assess patients, initiate and manage treatment protocols, and order and interpret diagnostic tests, with the exception of interpreting computed tomography scans, magnetic resonance imaging scans, positron emission tomography scans, nuclear scans, and mammography. The California Board of Nursing mandates that APRNs be overseen by physicians. In contrast to their counterparts in Minnesota, who practice without adhering to standardized protocols, APRNs in California are permitted to practice solely in accordance with established procedures (Bosse et al., 2017).
The Nursing Practice Act (NPA) 2725 and the California Code of Regulations (CCR) 1480 permit the implementation of standardized processes. Standardized procedures are legal frameworks that permit registered nurses and nurse practitioners to perform duties often classified as medical practice. In a structured healthcare system, the establishment of standardized procedures requires cooperation among nursing, medicine, and administration. APRNs are authorized to execute various functions pertinent to their specialized training, experience, and credentials, including the assessment, management, and treatment of episodic and chronic illnesses, contraception, and standard nursing duties related to health promotion and general health evaluation. This encompasses, but is not limited to, ordering laboratory tests, x-rays, and physical therapy, recommending dietary plans, and making referrals to specialty clinics as required (California Board of Registered Nursing [CABRN], 1998). Nurse practitioners are permitted to execute standardized procedure functions alone in compliance with a health care system’s established protocol; they must furnish adequate proof of their requisite experience, training, and/or education.
Licensure is similarly governed by the nursing boards of California and Minnesota. Advanced Practice Registered Nurses (APRNs) are required to obtain graduate education in their specific field of specialization prior to undertaking national certification examinations. Milstead and Short (2019) assert that APRNs are required to get state-specific licenses to practice following the successful completion of the certification examination. APRNs seeking licensure in Minnesota and California must first be licensed as registered nurses in the respective state prior to acquiring APRN licensing. Although both jurisdictions employ comparable regulatory frameworks for licensure, the California Board of Nursing imposes restrictions on APRN practice, whereas the Minnesota Board of Nursing ensures Full Practice Authority (FPA). Upon completing graduate study, passing the national examination, and acquiring their APRN license, APRNs are required to operate within the defined area of their profession, as previously outlined.
Numerous governments have progressed to a level of full practice and exhibit greater autonomy than others.
Reference:
Advanced Practice Registered Nurse (APRN) License General Information / Minnesota Board of Nursing (mn.gov)
Links to an external site.
California Board of Registered Nursing. (1998, December). An explanation of standardized procedure requirements for nurse practitioner practice. State of California Department of Consumer Affairs.
https://www.rn.ca.gov/pdfs/regulations/npr-b-20.pdf
Links to an external site.
Full Practice Authority States for Nurse Practitioners | 2024
Links to an external site.
Milstead, J. A., & Short, N. M. (2019). Health policy and politics: A nurse’s guide (6th ed.). Jones & Bartlett Learning.
National Council of State Boards of Nursing. (n.d.). APRNs in the U.S. https://ncsbn.org/nursingregulation/practice/aprn.page
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Elizabeth Rachel Fofanah
Sep 24, 2024 8:08am
Reply from Elizabeth Rachel Fofanah
Rules for advanced practice registered nurses (APRN) vary by state, although all aim to safeguard public health by governing the actions of healthcare workers. The Nurse Practice Act empowers state boards of nursing to formulate and oversee requirements for safe nursing operations within their jurisdiction for qualified nurses throughout various levels of nursing practice, including advanced practice. State boards of nursing regulate license requirements in accordance with the Nurse Practice Act, develop processes for licensure renewal, and impose disciplinary proceedings where warranted (Milstead & Short, 2019).
APRNs are integral to the US healthcare system. APRNs are registered nurses with education at the master’s or post-master’s level, specializing in a particular job and patient demographic. APRNs are trained and qualified to evaluate, diagnose, and address patient issues, in addition to ordering tests and prescribing medications (National Council of State Boards of Nursing [NCSBN], 2022). There are several contrasts and similarities in the full practice authorization and licensure regulations between Minnesota and California.
In contrast to California, Minnesota’s nursing board grants full practice authority (FPA) to APRNs. The Minnesota Board of Nursing permits nurse practitioners to practice autonomously, indicating that they are not required to be overseen by or work alongside physicians. Minnesota’s regulations on nurse practitioner supervision stipulate that nurse practitioners can prescribe medications independently, without the need for physician consultation or oversight. Nurse practitioners are authorized to prescribe, dispense, and deliver medications, including prohibited medicines (Schedule II to V), as well as therapeutic devices (mn.gov). In California, APRNs possess restricted practice privileges, sometimes referred to as limited practice. Restrictive practice, as defined by Peterson (2017), constrains APRNs’ capacity for independent practice by necessitating that they execute one or more facets of their duties under the guidance of a physician. Under FPA, APRNs in Minnesota possess the autonomy to independently diagnose and assess patients, initiate and manage treatment protocols, and order and interpret diagnostic tests, with the exception of interpreting computed tomography scans, magnetic resonance imaging scans, positron emission tomography scans, nuclear scans, and mammography. The California Board of Nursing mandates that APRNs be overseen by physicians. In contrast to their counterparts in Minnesota, who practice without adhering to standardized protocols, APRNs in California are permitted to practice solely in accordance with established procedures (Bosse et al., 2017).
The
Nursing Practice Act (NPA)
2725 and the California Code of Regulations (CCR) 1480 permit the implementation of standardized processes. Standardized procedures are legal frameworks that permit registered nurses and nurse practitioners to perform duties often classified as medical practice. In a structured healthcare system, the establishment of standardized procedures requires cooperation among nursing, medicine, and administration. APRNs are authorized to execute various functions pertinent to their specialized training, experience, and credentials, including the assessment, management, and treatment of episodic and chronic illnesses, contraception, and standard nursing duties related to health promotion and general health evaluation. This encompasses, but is not limited to, ordering laboratory tests, x-rays, and physical therapy, recommending dietary plans, and making referrals to specialty clinics as required (California Board of Registered Nursing [CABRN], 1998). Nurse practitioners are permitted to execute standardized procedure functions alone in compliance with a health care system’s established protocol; they must furnish adequate proof of their requisite experience, training, and/or education.
Licensure is similarly governed by the nursing boards of California and Minnesota. Advanced Practice Registered Nurses (APRNs) are required to obtain graduate education in their specific field of specialization prior to undertaking national certification examinations. Milstead and Short (2019) assert that APRNs are required to get state-specific licenses to practice following the successful completion of the certification examination. APRNs seeking licensure in Minnesota and California must first be licensed as registered nurses in the respective state prior to acquiring APRN licensing. Although both jurisdictions employ comparable regulatory frameworks for licensure, the California Board of Nursing imposes restrictions on APRN practice, whereas the Minnesota Board of Nursing ensures Full Practice Authority (FPA). Upon completing graduate study, passing the national examination, and acquiring their APRN license, APRNs are required to operate within the defined area of their profession, as previously outlined.
Numerous governments have progressed to a level of full practice and exhibit greater autonomy than others.
Reference
Advanced Practice Registered Nurse (APRN) License General Information / Minnesota Board of Nursing (mn.gov)
Links to an external site.
California Board of Registered Nursing. (1998, December). An explanation of standardized procedure requirements for nurse practitioner practice. State of California Department of Consumer Affairs.
https://www.rn.ca.gov/pdfs/regulations/npr-b-20.pdf
Links to an external site.
Full Practice Authority States for Nurse Practitioners | 2024
Links to an external site.
Milstead, J. A., & Short, N. M. (2019). Health policy and politics: A nurse’s guide (6th ed.). Jones & Bartlett Learning.
National Council of State Boards of Nursing. (n.d.). APRNs in the U.S. https://ncsbn.org/nursingregulation/practice/aprn.page Professional Nursing and State-Level Regulations