Why NPs Need Full Practice and Prescriptive Authority


For Nurse Practitioner World News, May-June 2009
By Carla Mills, ARNP

I believe I should be in charge of my own practice. I’m a nurse practitioner and primary care provider with over 25 years of clinical experience. Yet every day I am forced to negotiate around practice restrictions that interfere with my ability to deliver optimal care to my patients. This is frustrating, both philosophically and practically. Valuable time and resources are wasted in the process.

What is most limiting to the effectiveness of nurse practitioners is the lack of full practice and prescriptive authority. According to the 2009 Pearson Report (see http://www.webnp.net), only 22 states and Washington, DC, have legislated NPs to have full practice authority. Only 12 states plus Washington, DC, have legislated full prescriptive authority. I practice in Florida, a state where we have neither full practice nor full prescriptive authority. We have been working hard in Florida for years to change that, but so far without success.

Doctors’ Arguments Against Independent NP Practice

Physician organizations oppose independent practice by NPs. They have long insisted that NPs practice only under a doctor’s supervision. They express concerns that unsupervised NPs will misdiagnose, miss less obvious and potentially life-threatening problems, and make prescribing errors. They state that NPs lack the skill to manage complex patients with multisystem diseases. They have presumed that NPs will order more tests than necessary and be quicker to send patients to the hospital, thus driving up health care costs.

For over 40 years now, NP practice has been studied extensively, and none of these concerns has been found to be valid. Many of them have been debunked entirely. Errors have not been found to occur more frequently in NP practice than in physician practice. NP case management has actually proven to dramatically reduce hospital visits, resulting in significant decreases in health care costs. As for chronic disease management, it is by its very nature a multisystem, complex problem that is rooted in lifestyle behaviors—an area of medicine that NPs are very well suited to manage, in both the short term and the
long term.

Regarding prescribing errors, Dr. Kenneth Brummel-Smith, chair of the department of geriatrics at Florida State University College of Medicine, wrote in a recent letter to the editor of the online newspaper, Tallahassee.com: “There simply is a ton of evidence that physicians often do not do a good job of prescribing [controlled drugs] and very little [evidence] that nurse practitioners do a bad job. Giving prescriptive authority to nurse practitioners will improve patients’ access to needed care and should be approved.”

Physician vs NP Care

Studies have shown that a nurse practitioner’s scope of practice is about 80% of that of a physician. For medical problems that fall within that 80% scope, NPs have proven to be as capable as physicians and sometimes even superior. For medical problems outside that 80%, the patient needs to see a physician. In these cases, the NP refers to a physician exactly the same way physician generalists refer to physician specialists. There is no evidence to date that NPs are reckless or unsafe in either their decision making or prescribing practices. Ultimately, it is a matter of putting trust in NPs’ judgment the same way we put trust in physicians’ judgment.

Doctors and NPs share a responsibility to see that every patient is treated with the highest quality of care possible. Like doctors, NPs have varying degrees of experience and education. The issue is not who is providing the care; the issue is whether the care provided is safe, appropriate, and of the highest professional caliber.

Independent Practice and NP–Physician Relationships

Full practice and prescriptive authority will make NPs more efficient and effective team players. It is unlikely that full practice and prescriptive authority for NPs will affect physician practices negatively. On the contrary, it will save doctors time and busy work. It will promote innovation in health care delivery. And it will enable a larger and more agile work force of qualified health professionals who can react quickly to emergencies. This was demonstrated after Hurricane Katrina, when NPs reached patients who otherwise would have been abandoned.

Nurse practitioners will never replace physicians and, speaking for myself, have no desire to. If I had wanted to become a doctor, I would have gone to medical school. I am proud to be a nurse practitioner. I deserve respect for what I am, not denigration for what I am not — a “nonphysician,” “physician extender,” or “midlevel provider.” In the best interests of patients, I want to be recognized as an NP, and I want control over my own practice.

NPs practice in many settings in every corner of the medical care system. The degree of autonomy each practitioner needs will depend upon the setting in which the NP works and the experience of the individual practitioner. Let’s look at just two examples.

I know a neurosurgical NP who manages the pre-op and post-op care and is the first surgical assistant for a brain surgeon. This NP will not be doing, nor does she aspire to do, brain surgery. But full practice and prescriptive authority will enable her to more efficiently manage pre-op and post-op pain, make home health referrals, and follow up independently. (She does this already, but with a great deal of hassle and red tape because of existing restrictions.)

In my own case, I share an internal medical practice with a DO. Ours is a high-acuity, medically complex practice with a lot of multisystem chronic disease. Because we are in south Florida, many of our patients are elderly—a significant number over age 80. Even when the doctor is in the office, my inability to write prescriptions for controlled drugs is a hassle for patients, the doctor, and me. When she is out of the office, my ability to manage pain and sleep and anxiety problems is hindered even more. Although I have years of home health experience and understand home care needs at least as well as the doctor with whom I work, as an NP I may not order or direct care for patients requiring home health services.

Having the practice and prescriptive authority I need to function to my fullest will not change my current practice arrangement at all. It will, however, make our practice and the care we offer our patients more efficient and more streamlined, and it will facilitate better use of the doctor’s time, my time, and our staff ’s time.

What I Believe

I believe that if patients are to receive the highest possible quality of care (and thus achieve the best health outcomes), every qualified medical professional should be able to work to the full extent of his or her education, experience, and expertise. I also believe that a more democratic process that promotes nonpartisan relationships among various provider groups will result in better communication and coordination of care and will add to a higher quality of care.

Experience shows that physicians and nurse practitioners are more effective as a team than either is alone. Patients should have the right to seek and receive care from their health professional of choice. Neither doctors nor NPs should be shackled with unnecessary supervisory responsibilities or practice restrictions that impede the delivery of high-quality care.

It doesn’t really matter whether the physician–NP collaboration happens in a single office or across town. When respect and collegiality promote interdisciplinary communication and mind-sharing, everyone will benefit—patients most of all.

Our country is facing severe shortages of primary care providers. Nurse practitioners, 147,000 strong, stand trained and ready to step in immediately to address many of the pressing health needs the nation faces. I believe empowering NPs is an urgent and critical step if health care reform is to have any chance at all for success.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

Permalink  ·  

#1 | On August 11, 2009, make more friends said:

This is exactly what I was looking for. Thanks for sharing this great article! That is very interesting smile I love reading and I am always searching for informative information like this! You are bookmarked!

#2 | On September 23, 2009, Tom said:

Bravo!!! Lets send you to DC to lobby for a Federal mandate to force States to get off their collective bums and help a health care system under strain.

#3 | On September 27, 2009, Carla Mills said:

Thank YOU, Tom! I am ready to go.

#4 | On October 02, 2009, Jill said:

Thank you for writing this! Everything you stated is so true; however we are only a voice now. We have to find a way to take serious action in the political arena. Many states have MD’s in the senate and house. I believe the problem starts in Washington not our own state. Until we demand UNITY like the American Medical Association, I don’t think we stand a chance. Nursing is so “scattered” with ANCC, AANP, etc. etc, then you have PNP, ANP, PMHNP, etc. etc. Power is in numbers and until we become ONE (like MD’s), it will continue to be an uphill climb.

Who is responsible for requiring NP’s to maintain their Registered Nurse License AFTER they have continued their graduate degrees?


#5 | On October 03, 2009, Carla said:

I agree with you, Jill. Unity and a single voice with a consistent message - both to leglslators and the public - will be key if we are to ever the have the influence we need to bring about beneficial change.

I am working on a column for NPWN to be published later this year about the disorganization of NP organizations. It’s a big problem.

As for RN licensure after NP licensure - continuing education by NPs covers both nursing and medical topics, therefore in my opinion NPs more than fulfill their RN licensure requirements by maintaing their NP license and board certification. Do you not agree?

Thanks for commenting.

Carla Mills

#6 | On February 23, 2011, Leah Greensmith said:

I would remind you that physicians do not have a copyright on “doctor.“  A doctor implies someone with a doctoral degree, and includes nurses, physical therapists, and even English majors.

By using specific language, physician or nurse practitioner, we can make clear who’s doing what to the public.

#7 | On February 23, 2011, Carla Mills said:

I am well aware of nurses’ and NPs’ desire to acquire and use the title “doctor”. This desire continues to gain popularity within the profession.

My question is - does calling NPs “doctor” enhance or hinder the care we are trying to deliver? Does it help distinguish NP care from physician care? Does it help create new role models of health care providers or just perpetuate an old model that isn’t working anymore?

That is what each of us must decide - NPs, physicians and health care consumers.

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