THE OFFICIAL JOURNAL FOR NURSE PRACTITIONERS A Peer-Reviewed Journal VOL. 11 NO. 2 WWW.WEBNP.NET FEBRUARY 2007 The American Journal for Nurse Practitioners THE PEARSON REPORT The 2007 state-by-state national overview of nurse practitioner legislation and healthcare issues, brought to you by Linda J. Pearson Log on to www.webnp.net after March 1 for the full version of The Pearson Report.
THE OFFICIAL JOURNAL FOR NURSE PRACTITIONERS A Peer-Reviewed Journal The American Journal for Nurse Practitioners VOL. 11 NO. 2 FEBRUARY 2007 Page 10 Page 98 THE PEARSON REPORT Introduction... 10 NP Numbers, 1999-2006... 14 State-by-State Presentation... 17 US Maps Overview of Diagnosing and Treating Aspects of NP Practice... 24 Overview of Prescribing Aspect of NP Practice... 25 State-by-State Presentation (Continued)... 30 2007 Pearson Report Summary... 46 State-by-State Presentation (Continued)... 48 State-by-State Presentation (Continued)... 99 Other Features Meetings & Events... 98 The American Journal for Nurse Practitioners www.webnp.net Editorial Co-Directors Executive Editor Policy Editor Art Director Advertising Sales Editorial Assistant Publisher CEO Columnists Charlene M. Hanson EdD, RN,CS, FNP, FAAN Donna R. Hodnicki PhD, APRN,BC, FNP, FAAN Dory Greene Eileen T. O Grady, PhD, RN, NP Victoria Baum Dorothy Howard Dawn Citron Louise K. Young George R. Young Tom Bartol, NP, CDE Carolyn Buppert, JD, NP Loretta C. Ford, RN, PNP, EdD Susan Kellogg-Spadt, PhD, CRNP Donna G. Nativio, PhD, PNP, FAAN Linda J. Pearson, MSN, DNSc, APRN,BC, FAANP Nancy Rudner Lugo, DrPH, NP The American Journal for Nurse Practitioners is published by NP Communications, LLC. It is indexed in CINAHL. Contents of the articles are determined by the authors and do not reflect the views or opinions of the publisher or advertisers. 2007 NP Communications, LLC The American Journal for Nurse Practitioners is offered free of charge to all licensed nurse practitioners. Annual paid subscriptions to The American Journal for Nurse Practitioners are also available at $59 (US) per year. To receive a paid subscription, send name, address, and speciality, along with a check for $59, to NP Communications, LLC, 109 South Main Street, Cranbury, NJ 08512. NP Communications, LLC 109 South Main Street Cranbury, NJ 08512 Postmaster: Address Correction Requested Phone: 609-371-5085 Fax: 609-371-5086 Website: www.webnp.net ADDRESS CHANGE: Please send your new information and address label to: The American Journal for Nurse Practitioners (AJNP) 650 Dresher Road, Horsham, PA 19044 or email information and label code # to Christine.Perretti@verispan.com (ph) 215-674-2700 6 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
LETTER FROM THE EDITORIAL CO-DIRECTORS Dear Colleagues, Changes in the legal and practice environment for nurse practitioners (NPs) are important to the profession as a whole. Without an open practice environment, our scope of practice is limited and our services are not available to all patients who may need them. As healthcare professionals, we are frustrated about these unnecessary barriers to practice. Please Write The American Journal for Nurse Practitioners welcomes your letters. Please send us your comments, ideas, and suggestions by letter, fax, or email to Dory Greene, Executive Editor, phone (908) 903-0230, fax (908) 903-0231, email: dorygreene@hotmail. com; or to NP Communications, LLC, 109 South Main Street, Cranbury, NJ 08512; phone (609) 371-5085, fax (609) 371-5086. As we all know, rules and regulations (R&R) for NP practice vary from state to state. In light of this variation, we all look forward to The Pearson Report every year to see how the practice environment for NPs has changed in the past year. However, we must point out that not all change is good. As an example, in 2006, we NPs in Georgia gained prescriptive authority for legend drugs and controlled substances III-V, but the Board of Medical Examiners (BoME) was given the right to develop R&R for establishing the Nurse Protocol Agreement covering prescriptive authority for Georgia NPs. The net result is that the BoME s R&R are more restrictive than those of the law, so we will continue our legislative efforts this year in Georgia. With regard to The Pearson Report 2007, we are once again pleased to provide you with a state-by-state summary of the practice environment for NPs in the United States and the District of Columbia (DC). A chart shows the year-by-year increase in the number of NPs in each state and DC; two US maps provide an overview of physician involvement in terms of diagnosing/treating and prescribing, and a table provides a bird s-eye view of NP titles, physician involvement, NP role expansion, and other data. More detailed data on each state and DC can be found at the NP Communications website (www.webnp.net); when this information becomes available online, just click on AJNP and look for The Pearson Report. Surveys indicate that The American Journal for Nurse Practitioners is the most widely read NP journal in the country, with more than 100,000 NPs perusing each issue. We appreciate your sustained interest in our journal as a respected, peer-reviewed resource. As editorial co-directors, we look forward to reviewing every manuscript that is submitted for consideration for publication in AJNP. We will both be attending the National Organization of Nurse Practitioner Faculties (NONPF) meeting in Denver, Colorado, on April 12-15, and look forward to seeing many of our past, current, and aspiring authors. Come talk to us! Charlene M. Hanson EdD, RN,CS, FNP, FAAN Donna R. Hodnicki PhD, APRN,BC, FNP, FAAN EDITORIAL ADVISORY BOARD Ivy M. Alexander, PhD, ANP Associate Professor Yale University School of Nursing Primary Care Clinician Yale University Health Sciences, Internal Medicine New Haven, Connecticut Carolyn Buppert, JD, NP Law Office of Carolyn Buppert, P.C. Annapolis, Maryland Patricia A. Burns, PhD, RN, FAAN Professor, Dean University of South Florida College of Nursing, Tampa, Florida Winifred Carson-Smith, Esq. Humphries and Brooks Washington, District of Columbia Katherine Crabtree, DNSc, ANP, RN, CS Associate Professor Oregon Health Sciences University Portland, Oregon Linda Dominguez, CNP, BSN, WHNP Assistant Medical Director Planned Parenthood of New Mexico Albuquerque, New Mexico Edward P. Gruber, PhD, RN, ARNP Assistant Dean and Clinical Professor Graduate Nursing Program Intercollegiate College of Nursing Washington State University College of Nursing Spokane, Washington Thomasine D. Guberski, PhD, CRNP Associate Professor University of Maryland School of Nursing Baltimore, Maryland Doreen C. Harper, PhD, RN, FAAN Dean and Professor University of Alabama at Birmingham Birmingham, Alabama Jean Johnson, PhD, RN, FAAN Senior Associate Dean, Health Sciences Program The George Washington University Washington, District of Columbia Mary Knudtson, DNSc, NP Professor, Department of Family Medicine University of California at Irvine Irvine, California Nancy Rudner Lugo, DrPH, NP School of Nursing, University of Central Florida President, NR Consulting, Inc. Orlando, Florida Carolyn Montoya, MSN, CPNP Coordinator FNP Concentration University of New Mexico, Albuquerque, New Mexico Beth Moran, RN, CNP Private Practice, Women s Health Sag Harbor, New York Donna G. Nativio, PhD, CRNP, FAAN Associate Professor Director of Adult, Family, and Pediatric Nurse Practitioner Programs University of Pittsburgh School of Nursing Pittsburgh, Pennsylvania Eileen T. O Grady, PhD, RN, NP Policy Liaison, American College of Nurse Practitioners Policy Editor, NP Communications McLean, Virginia Susan Wysocki, RNC, NP, FAANP President & CEO National Association of Nurse Practitioners in Women s Health (NPWH) Washington, District of Columbia Phyllis Arn Zimmer, MN, ARNP, FNP, FAAN Faculty, FNP Program University of Washington School of Nursing Seattle, Washington Partner, FnP Associates, LLP Seattle, Washington VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 9
The PEARSON REPORT A National Overview of Nurse Practitioner Legislation and Healthcare Issues By Linda J. Pearson, DNSc, MSN, APRN,BC, FAANP Family Psychiatric Mental Health NP F or the past 19 years, I have summarized nurse practitioner (NP) legislation, recapping the latest information from each state s Nurse Practice Act (NPA) and rules and regulations (R&R), along with presenting pertinent government, policy, and reimbursement information. This year, the complete version of The Pearson Report is available free of charge at www.webnp.net. Highlights of each state report, as well as many other features, are presented in this issue of The American Journal for Nurse Practitioners. Perusing this report, whether online or in this hard-copy version, enables NPs, policymakers, and other healthcare professionals to understand NPs impressive impact on our nation s health care. In addition, the report allows NPs to compare and contrast their own state s legislative statutes with those of other states, and to help determine how each state ranks regarding NP autonomy and allowing unfettered patient access to the top-notch health care that NPs provide. Each state report includes five sections: (1) a general NP practice overview, (2) the legal realities of NP scope of practice related to diagnosing and treating, (3) NP prescriptive authority, (4) NP reimbursement specifics, and (5) other factors that may affect NP practice. The Pearson Report also provides an 10 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
NP Numbers Table displaying the growth of the number of NPs within each state over the past 8 years (page 14), two maps summarizing any requirement for physician involvement in diagnosing/treating and in prescribing (pages 24 and 25), and a Summary Table listing pertinent characteristics and 2006 legislative NP role expansions (pages 46 and 47). In the online version of The Pearson Report, within the revised Other Factors That May Affect NP Practice section for every state, source citations are as follows: 1. Number and listing of NP schools in state: This box lists NP schools in each state, as provided by NP contacts and schools of nursing within each state. This year, the report includes 7 updates/ corrections (net change, 1 additional NP school). Please email me at lindapearson@comcast.net if the specifics of NP education in your state require updating. 2. Statewide NP association(s): This box lists the most active NP groups in each state, as provided to me by NPs within each state. I wish to provide accurate information for our readers, so, if I have omitted an active NP organization in your state, please email me at lindapearson@comcast.net for inclusion in next year s report. 3. Organized opposition to NP legislative or regulatory changes? It is important to provide an accurate description of the political landscape and of any restrictions limiting full patient access to NP care. In addition, NPs must be aware not only of any opposition to their practice within their own state, but also of the national opposition of the American Medical Association (AMA) and other physician groups in terms of limiting their ability and/or license to practice. For example, one national AMA-sponsored thrust is to get doctor title protection within each state. The newly formed Coalition for Patients Rights (www.patientsrightscoali tion.org) provides an excellent summary of national AMA opposition. Please contact me at linda pearson@comcast.net to provide me with any updates regarding the political climate in your state. 4. Percentage of medical residents/fellows who are international medical school graduates (2005 data): This brand-new feature of The Pearson Report indicates the percentage of current physicians-in-training (residents) who were not trained in US medical schools in each state. Readers may be surprised to learn that one quarter to one half of all resident positions are filled by international medical school graduates. Several questions emerge from this observation: Could NP programs be adequately supported and encouraged to provide the required number of healthcare providers in training? Would a changeover to NPs instead of medical residents encourage an expansion of the number of primary care providers (rather than developing more specialists)? Are NPs being utilized to their maximum potential by medical centers and within our healthcare system? If not, what pressures compel healthcare policymakers to support foreign-trained residents over encouraging the expansion of NP programs to supply qualified healthcare providers? Does a high number of foreign-trained residents (who become fully licensed physicians) increase a state medical association s attitude of turf protection? In this cell, the percentages of international medical school graduates reported for each state were obtained from Key Physician Data by State from the Association of American Medical Colleges Center for Workforce Studies (http://www.aamc.org/ workforce/ [Version Updated 1/17/06]). 5. Relevant Medical Malpractice Law applicable to NPs? This data box provides a state-bystate summary of the highlights of medical malpractice law most relevant to NP practice. Sources include input from nurse colleagues and the Summary of Medical Malpractice Law by McCullough, Campbell & Lane, Attorneys at Law, 205 North Michigan Ave., Suite 4100, Chicago, Illinois (http://www.mcandl.com/ states.html). 6. Recent state malpractice liability tort reform? This data box summarizes each state s civil justice reforms that are most applicable to NP practice. Permission to data mine from ATRA Tort Reform Record (July 2006) is granted with full credit to American Tort Reform Association, 1101 Connecticut Avenue, NW, Suite 400, Washington, DC 20036 (http:// www.atra.org). 7. Medical Malpractice Claims 2005: This box provides data on the average amount of medical malpractice payments on 2005 claims for each state, along with the relative ranking of the payment amount among the 50 states. These data have been compiled by the Henry J. Kaiser Family Foundation, a non-profit, privately operating foundation focusing on the major healthcare issues facing the nation. The Kaiser Foundation (http:// www.kff.org/insurance/7328.cfm) VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 11
THE PEARSON REPORT Perusing The Pearson Report enables NPs, policymakers, and other healthcare professionals to understand NPs impressive impact on our nation s health care. provides an independent source of facts and analysis for policymakers, the media, the healthcare community, and the general public. 8. Cumulative Number of National Practitioner Data Bank (NPDB) filings (9/90-9/06): This box compares the total accumulated malpractice and adverse actions of NPs with those of DOs/ Interns/Residents and MDs /Interns/ Residents. National legislation related to the Health Care Quality Improvement Act (1986) created the NPDB to help improve the quality of medical care. The NPDB s goal is to encourage state licensing boards, hospitals, and other healthcare entities and professional societies to identify and discipline providers who engage in unprofessional behavior, and to restrict the ability of healthcare providers to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history. Adverse actions may involve licensure, clinical privileges, professional society membership, and exclusions from Medicare and Medicaid. Note: There are more than 8 times as many MDs as NPs in the United States, and yet the accumulated number of reported incidents for MDs is far higher than 8 times that for NPs. Source: http://www. npdb-hipdb.com/annualrpt.html 9. Cumulative Number of Healthcare Integrity and Protection Data Bank (HIPDB) filings (1/99-9/06): This box summarizes the total number of accumulated adverse action reports (including licensure actions and any other negative actions, findings, or adjudicated actions) and civil judgments or criminal conviction reports submitted for NPs relative to those of DOs/Interns/ Residents and MDs/Interns/ Residents. The Health Insurance Portability and Accountability Act of 1996 created the HIPDB to combat fraud and abuse in health insurance and healthcare delivery. Annual losses due to healthcare fraud range from 3% to 10% of all healthcare costs. HIPDB is primarily a flagging system whose goal is to alert users that a comprehensive review of the past actions of a practitioner, provider, or supplier may be prudent. Again worthy of note is the ratio disparity between the accumulated number of reported incidents for NPs relative to those for DOs and MDs. Source: http:// www.npdb-hipdb.com/annualrpt. html 10. State pharmaceutical assistance program available to needy: The material in this box highlights each state s subsidy programs providing assistance to persons who do not qualify for Medicaid or to seniors, disabled persons, uninsured persons, or others. The National Conference of State Legislatures (NCSL), founded in 1975, is a bipartisan organization providing legislators and their staff with research and technical assistance. The NCSL website (http://www.ncsl.org/programs/ health/drugaid.htm) provides information about state pharmaceutical assistance programs. 11. 2005 & 2006 prescription drug legislation: State legislatures have increasingly attended to health policy related to prescription drugs. Most states have introduced several bills before their legislature related to this topic. Pertinent 2005 bills that passed were summarized in this section last year. The 2006 laws and actions related to prescription drug access were retrieved from the NCSL website (http://www.ncsl.org/pro grams/health/drugbill06.htm). 12. 2002-2004 US Census Bureau survey % in state without health insurance: The figure in this box represents the 3-year average (2002-2004) of the proportion of persons in the state without health insurance coverage. This information was obtained from a publication of the US Census Bureau entitled Income, Poverty, and Health Care Coverage 12 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
in the United States: 2004 (http:// www.census.gov/prod/2005pubs/ p60-229.pdf). 13. State Children s Health Insurance Program (SCHIP): This box presents information about the SCHIP, a national/state program enacted in 1997 to help cover close to 11 million US children who lack health insurance coverage. SCHIP, which operates with both state and federal funds, allows states flexibility in how they structure their Medicaid and children s health programs. Sources for these data include the State Children s Health Insurance Program (http://www.ncsl.org/pro grams/health/update.htm) and the National Academy for State Health Policy (http://www.nashp.org/_ docdisp_page.cfm?lid=2856c20a -3476-4B98-A372E42092 02F68A). 14. Telemedicine legislation applicable to NPs: The material in this box gives a legislative summary of telemedicine laws most pertinent to NPs. This information was supplied by sources within each state. Additional information about telemedicine legislation can be found at http://www.ncsl.org/ programs/health/teleleg.htm Conclusion The Pearson Report provides a comprehensive summary of each state s practice realities and healthcare practice specifics, including the NPA, R&R, other statutes, environmental characteristics, and practice Linda J. Pearson is a columnist/ consultant for The American Journal for Nurse Practitioners and NP World News. One of her main contributions, The Pearson Report, a comprehensive nationwide legislative and healthcare issue summary for NPs, is published in AJNP on an annual basis. She received BSN and MSN degrees at the University of Washington, and began her professional career as a family nurse practitioner (FNP). While participating in the master s degree FNP program at the U of W, she became involved with the inaugural issue of The Nurse Practitioner journal, and went on to serve as editor-in-chief of that publication for more than 20 years. As her children entered college, she returned to school to earn her doctorate degree in nursing as a family psychiatric mental health nurse practitioner (PMHNP). In addition to writing The Pearson Report, she also works as a PMHNP, gives speeches around the country, and has written a book with L.A. Stamford entitled The Discipline Miracle: The Clinically Proven System for Raising Happy, Healthy, and Well-Behaved Kids. She is a treasured member of the NPC team. specifics related to NP practice. This year s two Maps (summarizing any requirement for physician involvement in diagnosing/treating and in prescribing) and Summary Table (including 2006 legislative changes) enable readers to see at a glance the status of NPs within each state. In addition, the new NP Numbers Table displays the growth of NPs within each state over the past 8 years, providing an overview of the expansion of the NP profession. The huge amount of data contained in The Pearson Report is a treasure trove for future analyses. As this issue goes to press, Eileen O Grady and her committee (Nancy Rudner Lugo, Chuckie Hanson, and Donna Hodnicki) are reviewing certain aspects of these data to develop a succinct policyrelevant analysis for AJNP readers in 2007. Across the nation, legislators, policy experts, NP leaders, and readers will benefit from their upcoming ground-breaking policy analysis. More to come soon Acknowledgments Thank you to George and Louise Young on behalf of NPs nationwide without you, The Pearson Report would not exist. I would also like to thank the hundreds of colleagues who answered my survey questions to help clarify their state s statutes, R&R, and/or practice reality. I am deeply grateful for your time and hope that the website availability of this report will partially repay you. I welcome corrections/additions/updates for next year s report please contact me at lindapearson@comcast.net 2007 Linda J. Pearson All rights reserved VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 13
THE PEARSON REPORT NP NUMBERS, 1999 2006 1999 2000 2001 2002 2003 2004 2005 2006 % Change ALABAMA 973 1100 1096 1027 939 1000 1200 1600 + 64.44 ALASKA 363 422 455 455 504 850 554 592 + 63.09 ARIZONA 2061 1893 1979 2148 2068 2627 2600 2644 + 28.29 ARKANSAS 323 415 500 1582 546 1442 1442 1471 + 355.42 CALIFORNIA 9564 10,126 11,028 11,320 12,064 12,543 13,350 13,649 + 42.71 COLORADO 1626 1938 2130 2323 2523 2319 2814 3019 + 85.67 CONNECTICUT 872 872 2047 2257 2474 2585 2585 2613 + 199.66 DELAWARE 440 679 648 644 803 789 812 501 + 13.86 DISTRICT OF COLUMBIA 294 315 324 388 399 810 824 908 + 208.84 FLORIDA 5102 5525 6114 9190 10,100 10,100 12,000 15,500 + 203.80 GEORGIA 1934 2315 2437 2437 2884 3163 3313 3484 + 80.14 HAWAII 360 400 420 337 342 400 415 446 + 23.89 IDAHO 240 298 349 358 389 747 415 444 + 85.00 ILLINOIS 1000 1000 1870 2191 2419 2521 2789 2849 + 184.90 INDIANA 630 630 1151 1396 1493 1500 1500 1774 + 181.59 IOWA 635 707 750 813 856 1461 1538 1684 + 165.20 KANSAS 755 961 918 1258 1080 1251 1304 1491 + 97.48 KENTUCKY 861 989 1126 1250 1374 1543 1626 1739 + 101.97 LOUISIANA 714 686 795 958 1055 1159 1159 1048 + 46.78 MAINE 581 1189 737 784 872 904 985 793 + 36.49 MARYLAND 2082 1472 2298 2404 2547 2550 2350 2238 + 7.49 MASSACHUSETTS 3835 4165 5141 5501 5768 5770 5770 5600 + 46.02 MICHIGAN 1729 1974 2297 2297 2612 2600 2600 3118 + 80.34 MINNESOTA 1000 658 1485 1490 1532 1662 1780 2081 + 108.10 MISSISSIPPI 721 823 906 960 1000 1680 1700 1867 + 158.95 MISSOURI 1753 2053 2142 2415 2568 2759 2955 2824 + 61.10 MONTANA 275 323 313 344 342 369 371 412 + 49.82 NEBRASKA 350 342 398 442 460 547 547 659 + 88.29 NEVADA 299 400 339 343 397 435 472 483 + 61.54 NEW HAMPSHIRE 586 514 883 936 911 1295 1321 1335 + 127.82 NEW JERSEY 1600 1600 1945 3238 3238 3400 3603 3734 + 133.38 NEW MEXICO 492 522 567 567 600 650 638 672 + 36.59 NEW YORK 8186 8948 9789 10,196 11,195 11,700 12,402 12,902 + 57.61 NORTH CAROLINA 1545 1665 1802 1979 2112 2300 2300 2582 + 67.12 NORTH DAKOTA 192 188 200 232 270 270 270 308 + 60.42 OHIO 1875 2020 2148 2399 2574 2851 3062 2984 + 59.15 OKLAHOMA 456 462 492 510 615 648 687 693 + 51.97 OREGON 1500 1500 1700 1787 1863 1969 2056 2145 + 43.00 PENNSYLVANIA 4603 4858 5230 5513 5719 5969 6017 6269 + 36.19 RHODE ISLAND 325 386 438 461 468 494 519 673 + 107.08 SOUTH CAROLINA 1047 603 1250 1288 1462 1200 2500 3000 + 186.53 SOUTH DAKOTA 196 240 231 251 301 329 308 320 + 63.27 TENNESSEE 1331 2102 2086 1992 2290 2300 2300 3466 + 160.41 TEXAS 3666 3666 4488 4875 5160 5532 5988 6372 + 73.81 UTAH 800 792 888 903 970 970 970 1077 + 34.63 VERMONT 267 254 295 364 449 488 479 519 + 94.38 VIRGINIA 2426 2676 2742 2983 3024 4838 4573 5167 + 112.98 WASHINGTON 2564 2254 2451 3335 3460 3590 3720 3822 + 49.06 WEST VIRGINIA 472 439 515 577 585 635 1215 1075 + 127.75 WISCONSIN 689 689 1826 1973 1501 2000 2300 2533 + 267.63 WYOMING 116 55 124 146 160 285 286 341 + 193.97 Totals 76,306 81,103 94,283 105,817 111,337 121,799 129,284 139,520 + 82.84% 14 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
ALABAMA NP title(s) used in this state: CRNP (certified registered nurse practitioner) Number of NPs in state? 1600. Only RNs who have been issued a certificate of qualification by the BoN and have current approval for collaborative practice from the BoN and the Board of Medical Examiners (BME) may use title CRNP.. CRNP applicants must have current certification granted by a national certifying agency recognized by the BoN in the clinical specialty consistent with educational preparation and appropriate to the area of practice. BoN sole state authority over NPs? BoN is sole authority to recognize CRNP qualifications. MSN required for at least a master s degree or higher in advanced practice nursing from an accredited program recognized by the BoN is required.. The Joint Committee (of BoN and BME members) has the authority to recommend to the BoN and BME R&R governing the collaborative relationship between physicians and CRNPs, model practice protocols to be used by CRNPs, and a formulary of legend drugs that CRNPs may prescribe. Requirement for collaborative practice agreement (CPA) and written protocol (WP) with Alabama physician (see more below). Recent legislative changes affecting NP Legislative/administrative plans for state? Proposed BoN/BME rule filed July 2006, defining remote practice site and collaboration requirements. treating? Yes, as per the WP. authorization)? CRNPs are subject to CPAs with an Alabama physician. The collaborating physician provides professional medical oversight and direction to the CRNP; is available for direct communication or by radio, telephone, or telecommunications; and is available for consultation or referral of patients. If the CRNP performs duties at a site away from the collaborating physician, the WP must specify the circumstances and provide written verification of physician availability for consultation, referral, and direct medical intervention in emergencies and after hours, if indicated. The collaborating physician must be present in a practice site with the CRNP a minimum of 10% of the CRNP s collaboration time as specified in the protocol application (exceptions in licensed acute care hospitals, licensed skilled nursing facilities, and the Department of Public Health). The physician shall not collaborate with or supervise any combination of CRNPs, certified nurse midwives, and/or assistants to physicians exceeding three full-time equivalent positions unless the CRNP is an employee of the Department of Public Health or an exemption is granted by the BoN/BME. Required physician record/chart review? Ten percent (10%) of medical records plus all adverse outcomes. Required NP/physician practice agreement? Yes, as detailed in the BoN protocol application. authority? No BOM/physician involvement in NP prescribing? Yes? The WP must include a formulary of drugs, devices, medical treatments, tests, and procedures that may be prescribed, ordered, and implemented by the CRNP and that are appropriate for the collaborative practice setting. NP authorized to Rx controlled substances? No If so, which Schedules? NA changes? Yes. Medical association has informed NPs that its members will staunchly oppose any legislation that would expand NP scope of practice. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 17
THE PEARSON REPORT ALASKA NP title(s) used in this state: ANP (advanced nurse practitioner) Number of NPs in state? 592 (includes CNMs). The ANP must conspicuously display a name plate with ANP and display evidence at work setting of authorization to practice with a specified sign defining an ANP. BoN sole state authority over NPs? Yes MSN required for, as applies to requirements for national specialty certification. NA Recent legislative changes affecting NP Legislative/administrative plans for state? Yes. Specific plans are still in development stages. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? No BoM/physician involvement in NP prescribing? No? NA NP authorized to Rx controlled substances? Yes, the BoN may grant controlled substances (CS) prescriptive and dispensing authority in addition to the authorization of legend drug prescribing. The ANP must have experience prescribing for 1 year before being able to apply for CS prescribing authority. If so, which Schedules? Schedules II-V changes? No ARIZONA NP title(s) used in this state: RNP (registered nurse practitioner) Number of NPs in state? 2644 NP title protection? BoN rules specify title protection for any words or letters to indicate RNP, NP, CNM, NM, or CNS unless certified. BoN sole state authority over NPs? Yes MSN required for practice? A graduate degree in nursing is required. No collaborative agreements are required; NPs work independently and refer when appropriate without required physician collaboration.. Medical board statutes allow use of designation of doctor by other branches of healing arts as long as the other branch of the healing arts is also designated. Recent legislative changes affecting NP Legislative/administrative plans for state? Yes. Meetings are scheduled with Arizona Health Care Cost Containment System (ie, Arizona Medicaid) to discuss empanelment requirements for contracting agencies. Collective effort to support federal 18 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
legislation requiring Medicaid to empanel NPs. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? No? NA NP authorized to Rx controlled substances? Yes If so, which schedules? Schedules II-V changes? Yes, the Arizona Medical Association. ARKANSAS NP title(s) used in this state: ARNP (advanced registered nurse practitioner), RNP (registered nurse practitioner), ANP (advanced nurse practitioner), NP (nurse practitioner) Number of NPs in state? 1471, for practice as an ANP (but not required to practice as an RNP). The RNP license, which does not require a master s degree or national board certification, has not been issued since November 2000 but is still recognized. BoN sole state authority over NPs? Yes MSN required for, for ANP practice., but an NPA-specified Prescriptive Authority Advisory Committee (3 APNs, 1 MD in collaborative practice, and 1 pharmacist) advises the BoN regarding implementing prescriptive authority.. Collaborative practice agreement (CPA) required for prescribing ANPs and for all aspects of RNP practice. Applicable to the RNP for all aspects of practice: in collaboration with and under the direction of a licensed physician or under the direction of protocols developed with a physician. An ANP with prescriptive authority must have a CPA with a physician. No. Legislative sessions held during odd-numbered years only. Legislative plans for state? No treating? Yes, for RNP; no, for ANP. authorization)? The RNP s scope of practice (SoP) is defined by protocols (developed in collaboration with and signed by physician) and in accordance with BoN R&R; thus, for RNP, the degree of supervision is determined by the protocols. Required physician record/chart review? Yes. The ANP must have a provision for quality assurance in the CPA. There is no requirement that a certain percentage of records be reviewed; orders need to be cosigned as specified in the protocol or in facility requirements. Required NP/physician practice agreement? No authority? Yes, for ANPs; RNPs do not prescribe. BoM/physician involvement in NP prescribing? Yes? An ANP with prescriptive authority must have a CPA with a physician. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules III-V changes? Opposition to NP legislative or regulatory change is based on the subject matter; in general, increases in NP SoP are opposed by the state medical society. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 21
THE PEARSON REPORT CALIFORNIA NP title(s) used in this state: APRN (advanced practice registered nurse), NP (nurse practitioner) Number of NPs in state? 13,649. BoN requires (1) successful completion of a program of study that conforms to board standards and (2) certification by a national or state organization whose standards are acceptable to BoN. BoN sole state authority over NPs? Yes MSN required for, but master s degree required for new applicants after January 2008. Standardized procedures (SPs) must be developed collaboratively by Nursing, Medicine, and administration in the organized healthcare system where they will be used. Once an SP has been signed by the physician, nurse, and facility (if applicable), the practice is considered independent. The SP is agency specific and must meet certain requirements, including collaborative development by Nursing, Medicine, and administration within the agency. Yes. Legislation in 2006 allows NPs to provide a disability sticker and expands the categories of NPs who can be primary care providers. Legislative/administrative plans for state? Yes. Working on authorization to perform Department of Motor Vehicles physical exams on bus drivers/paratransit drivers/farm-labor vehicle drivers; Medi-Cal reimbursement for all specialties; durable medical equipment prescribing. treating? Yes, until the SP is drafted. Once the SP is signed by the physician, nurse, and facility (if applicable), the practice is considered independent. authorization)? Required SPs specify the scope of supervision for the NP authorized to perform the procedure functions. Required physician record/chart review? No Required NP/physician practice agreement? Yes. An SP is the legal mechanism for APRNs and NPs to perform functions that would otherwise be considered the practice of Medicine. SPs must be developed collaboratively by Nursing, Medicine, and administration in the organized healthcare system where they will be utilized. The procedure functions are basically the diagnosing, prescribing, and severing or penetrating of tissue functions under the MPA. The SP outlines when the nurse is to refer or seek a second opinion, limitations, required education, settings, how the practice will be evaluated, and so forth. authority? Yes BoM/physician involvement in NP prescribing? Yes? In addition to involvement in the prescriptive agreement, physician involvement is also required when Schedule II-III controlled substances (CS) are furnished or ordered by an NP. In particular, the CS shall be furnished or ordered in accordance with a patient-specific protocol approved by the treating or supervising physician. A copy of the section of the NP s SP relating to CS shall be provided, upon request, to any licensed pharmacist who dispenses drugs or devices when there is uncertainty about the NP furnishing the order. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? California Medical Association and California Association for Nurse Practitioners work closely together to avoid regulatory and legislative battles. 22 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
COLORADO NP title(s) used in this state: APN (advanced practice nurse), NP (nurse practitioner) Number of NPs in state? 3019 BoN sole state authority over NPs? Yes MSN required for, but after July 1, 2008, inclusion in the Advanced Practice Registry requires graduate or postgraduate degree in the practice area. Prescribing NPs must have a written collaborative agreement (CA) with a Colorado-licensed physician in same field of practice. No Legislative plans for state? None currently. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes. An APN may be granted authority to prescribe prescription drugs and controlled substances to provide treatment for persons requiring (1) care for an acute self-limiting condition, (2) care for a chronic condition that has stabilized, or (3) terminal comfort care. BoM/physician involvement in NP prescribing? Yes. CA for consultation and referral.? Prescribing NPs with a CA shall provide to the BoN the name and appropriate identifier of the collaborating physician and shall keep such information current with the BoN. This information shall also be available to the BoM, the BoP, and the general public. The nurse and collaborating physician shall advise each other of CAs signed with other parties. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Issue specific and not currently active. CONNECTICUT NP title(s) used in this state: APRN (advanced practice registered nurse), NP (nurse practitioner) Number of NPs in state? 2613 APRNs (this number includes CRNAs and CNSs) BoN sole state authority over NPs? Yes MSN required for The APRN performs acts of diagnosis and treatment of alterations in health status and shall collaborate with a physician. Yes, effective October 1, 2006: (1) expanded health insurance coverage for breast cancer screening VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 23
THE PEARSON REPORT Map 1. OVERVIEW OF DIAGNOSING AND TREATING ASPECTS OF NP PRACTICE NO REQUIREMENT FOR ANY PHYSICIAN INVOLVEMENT (N = 23) Alaska Arizona Colorado District of Columbia Hawaii Idaho Iowa Kentucky Maine Michigan Montana New Hampshire New Jersey New Mexico North Dakota Oklahoma Oregon Rhode Island Tennessee Utah Washington West Virginia Wyoming REQUIREMENT FOR PHYSICIAN INVOLVEMENT,* BUT NO REQUIREMENT FOR WRITTEN DOCUMENTATION OF RELATIONSHIP (N = 4) Connecticut Indiana Pennsylvania Minnesota * The requirement for a physician s relationship with an NP may vary from collaboration, supervision, authorization, and/or delegation to direction of activities. After the first 2 years of practice. REQUIREMENT FOR PHYSICIAN INVOLVEMENT,* DOCUMENTED IN WRITING (N = 24) Alabama Arkansas California Delaware Florida Georgia Illinois Kansas Louisiana Maryland Massachusetts Mississippi Missouri Nebraska Nevada New York North Carolina Ohio South Carolina South Dakota Texas Vermont Virginia Wisconsin 24 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
Map 2. OVERVIEW OF PRESCRIBING ASPECT OF NP PRACTICE ABSOLUTELY NO REQUIREMENT FOR ANY PHYSICIAN INVOLVEMENT (N = 12) Alaska Arizona District of Columbia Idaho Iowa Maine Montana New Hampshire New Mexico Oregon Washington Wyoming REQUIREMENT FOR PHYSICIAN INVOLVEMENT,* DOCUMENTED IN WRITING (N = 39) Alabama Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Illinois Indiana Kansas Kentucky Louisiana Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Jersey New York North Carolina North Dakota Ohio Oklahoma Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia West Virginia Wisconsin * The requirement for a physician s relationship with an NP may vary from collaboration, supervision, authorization, and/or delegation to direction of activities. After the first 2 years of practice. Collaboration required only for prescribing Schedule II-III drugs. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 25
THE PEARSON REPORT includes APRNs; (2) APRNs may request, receive, and dispense sample medication in all healthcare settings (prior law restricted this to non-institutional settings); (3) a graduate APRN working in a hospital or other organization under the supervision of a physician or APRN can practice up to 120 days after the date of graduation while awaiting the national certification exam (no authorization to prescribe or dispense drugs during this time). Legislative plans for state? Yes removing all barriers to practice, including ability to sign for worker s compensation and exploring a professional assistance program for healthcare professionals to include the term advanced practice registered nurse. treating? Yes authorization)? The APRN performs acts of diagnosis and treatment of alterations in health status and shall collaborate with a physician. Required physician record/chart review? No Required NP/physician practice agreement? The required collaboration means a mutually agreed upon relationship (between APRN and physician in relevant field) that shall address a reasonable and appropriate level of consultation and referral, coverage for the patient in the absence of the APRN, a method to review patient outcomes, and a method of disclosure of the relationship to the patient. authority? No BoM/physician involvement in NP prescribing? Yes? Collaboration NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Yes, by the state medical society. DELAWARE NP title(s) used in this state: APN (advanced practice nurse), NP (nurse practitioner) Number of NPs in state? 501 practice? In general, yes, although exceptions to the requirement may be made on a case-by-case basis. BoN sole state authority over NPs? Yes, for APNs who do not perform independent acts of diagnosis or prescription, and no, for NPs who are performing independently. These NPs are regulated by a Joint Practice Committee (JPC), which consists of 9 members: 1 public member and 5 APNs appointed by the BoN, 1 pharmacist appointed by the BoP, and 2 physicians appointed by the Board of Medical Practice (BoM). MSN required for, APNs may have either a master s degree or a post-basic program certification in a clinical nursing specialty with national certification. NPs who are working independently practice and prescribe without written guidelines or protocols but with a collaborative agreement (CA) with a licensed physician, dentist, podiatrist, or licensed Delaware healthcare delivery system and with the approval of the JPC. Recent legislative changes affecting NP Legislative plans for state? Yes. There are plans to introduce legislation in 2007 that will eliminate the need for a CA for APNs who do not have prescriptive authority and who would have the BoN rather than the BoM give final approval to decisions of the JPC that is charged with reviewing and approving APNs for prescriptive authority. treating? Yes authorization)? Authorized NPs perform independent acts of diagnosis and prescription and are granted 30 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
THE PEARSON REPORT authority by the BoN. APNs perform independent acts of diagnosis and prescription with the collaboration of a licensed physician, dentist, or podiatrist, or licensed Delaware healthcare delivery system without written guidelines or protocols and within their SoP, as defined in the R&R promulgated by the JPC and approved by the BoM. Required physician record/chart review? No Required NP/physician practice agreement? Yes. Depending on the type of practice, the CA may be written verification of a healthcare facility-approved job description and/or clinical privileges; and/or a written document outlining the consultation, referral, and/or hospitalization plan between an APN and a licensed physician, dentist, or podiatrist, or licensed Delaware healthcare delivery system. authority? Yes BoM/physician involvement in NP prescribing? Yes. The names and credentials of qualified APN applicants will be forwarded to the JPC for approval and then forwarded to the BoM for review and final approval.? R&R regarding the independent practice and prescriptive authority of APNs are the responsibility of the JPC, subject to the approval of the BoM. NP authorized to Rx controlled substances? Yes (those with Rx authority) If so, which Schedules? Schedules II-V changes? No DISTRICT OF COLUMBIA NP title(s) used in district: APRN (advanced practice registered nurse), NP (nurse practitioner), (CNP) certified nurse practitioner, CRNP (certified registered nurse practitioner) Number of NPs in district? 908 BoN sole authority over NPs in district? Yes MSN required for NA Recent legislative changes affecting NP Legislative plans for district? Maintain APRN on BoN. treating? No authorization)? 2005 wording: APRNs, when functioning within the authorized scope of practice, are qualified to assume primary responsibility for the care of their patients. This practice incorporates the use of independent judgment, as well as collaborative interaction with physicians, dentists, or osteopaths. Required physician record/chart review? No Required NP/physician practice agreement? No authority? No BoM/physician involvement in NP prescribing? No? NA NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Remains to be seen. 32 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
THE PEARSON REPORT FLORIDA NP title(s) used in this state: ARNP (advanced registered nurse practitioner), NP (nurse practitioner) Number of NPs in state? 15,500, with pending legislation to add CNS to the ARNP language. practice? As of July 2006, all new applicants for ARNP need national certification. BoN sole state authority over NPs? No. The Florida Department of Health requires that all practitioners, including ARNPs, file information in a Mandatory Practitioner Profile Questionnaire for both initial certification and renewal. It is each practitioner s responsibility to keep the Practitioner Profile (made public after practitioner verification) current. There is joint BoN/BoM control over advance practice protocols (as of July 2006, available on the Internet). MSN required for, except for those grandmothered or grandfathered in., for medical acts. Supervision by a Florida-licensed physician or dentist is required for the ARNP protocol., but this issue is being hotly debated and contested. Yes. A new law specifies that (1) an MD may supervise ARNPs offering primary care services at no more than 4 satellite offices in addition to the primary place of practice, (2) an MD may supervise ARNPs offering specialty services at no more than 2 satellite offices in addition to the primary place of practice, and (3) a board-certified/eligible MD in plastic surgery or dermatology must supervise ARNPs offering primarily dermatologic or skin care at no more than 1 satellite office in addition to the primary place of practice. In addition, there are mile specifications for the satellite clinics and rules regarding posting the physician s schedule. The bill affects ARNP protocols. Another new law specifies that all healthcare licensees must provide notice to patients of what type of license they have, with name tag and advertising requirements. Legislative/administrative plans for state? Yes. Plans include the following: (1) forthcoming BoN rule change to require national certification for all NPs, including CNSs, (2) legislative plans to defend NP scope of practice issues and to increase NP autonomy and expand Rx authority to prescribe controlled substances, (3) plans to continue to kill Florida Medical Association s legislative proposals requiring MD supervision 30% of the time, and require limit on the number of NPs whom MDs can supervise, (4) plans to change physical therapy practice act that would allow physical therapists to accept referrals from NPs, and (5) work on medical malpractice issues currently, Florida has an insurance crisis wherein only two carriers (CM&F and NSO) cover only claims made (not occurrence policies) with a 250K/750K limit. treating? Yes authorization)? The degree and method of supervision, determined by the ARNP and the physician or dentist, must be specifically identified in the written protocol and shall be appropriate for prudent healthcare providers under similar circumstances. Required physician record/chart review? No Required NP/physician practice agreement? Yes. A practice protocol is required. It must be filed annually with review/oversight by the BoN. 34 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
authority? No. The written approval in the protocols by the supervising practitioner gives the ARNP prescriptive privileges. The protocol states which medications can be prescribed (ie, generic and broad drug categories that the supervising physician has agreed that the ARNP may prescribe). BoM/physician involvement in NP prescribing? Yes? The ARNP protocol contains a description of the duties of the physician or dentist, which shall include consultant and supervisory arrangements in case the physician or dentist is unavailable. NP authorized to Rx controlled substances? No If so, which Schedules? NA changes? Yes. There is tremendous opposition from the state medical associations. Dermatologists and family practice physicians are seeking more supervision of NPs. GEORGIA NP title(s) used in this state: NP (nurse practitioner), APRN (advanced practice registered nurse) Number of NPs in state? 3484. Certification is required initially, as well as for continued practice. BoN sole state authority over NPs? No MSN required for, in the respective NP specialty and evidence of advanced pharmacology within the curriculum or a separate course (for all initial applicants after January 1999).. Under the terms of a nurse protocol agreement, which is a written document mutually agreed upon and signed by an RN and a licensed physician, the physician delegates to that nurse the authority to perform certain medical acts, which shall include, without being limited to, ordering dangerous drugs, medical treatments, or diagnostic studies. The protocol also provides for immediate consultation with the delegating physician. The Board of Medical Examiners (BoME) promulgates the R&R for the nurse protocol agreement. Delegation, as per the nurse protocol agreement described above. In addition, a physician may delegate to a nurse recognized as an APRN, in accordance with the nurse protocol agreement, the authority to write for legend drugs and controlled substances (CS except for CI and CII). being addressed as Dr? Yes. A person cannot present himself or herself to the public as a doctor in a medical environment where the public would have a reasonable expectation that the term meant that the person was a physician rather than a PhD, DNS, and so forth (OCGA 43-34-28). Yes, legislation for prescriptive authority passed and became effective on July 1, 2006, for legend drugs and CS (except for CI and CII) under nurse protocol agreement only. Legislative/administrative plans for state? 2006: BoME R&R are much more restrictive than legislation, so this will be addressed in 2007. treating? Yes authorization)? An APRN is authorized to perform advanced nursing functions and certain medical acts that include, but are not limited to, ordering drugs, treatments, and diagnostic studies as delegated by the physician via nurse protocol agreement. Required physician record/chart review? Yes. The nurse protocol agreement must include a schedule for periodic review of patient records by the delegating physician and must be reviewed, revised, or updated annually. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 35
THE PEARSON REPORT Required NP/physician practice agreement? Yes, a written protocol is required. authority? Yes BOM/physician involvement in NP prescribing? See above.? 100% chart review on all patients who receive Rx. Onsite 4 hours per month at each practice location. APRN may perform medical acts that include, but are not limited to, the ordering of drugs, medical devices, medical treatments, diagnostic studies, and, in certain life-threatening situations, radiographic imaging tests (CT, MRI, PET, nuclear). NP authorized to Rx controlled substances? Yes If so, which Schedules? All Schedules except CI and CII. changes? Definitely. The Medical Association of Georgia is strongly in opposition to NP autonomy. HAWAII NP title(s) used in this state: APRN (advanced practice registered nurse) Number of NPs in state? 446. Applicants may have official transcript from accredited or approved master s program in nursing sent to BoN or official proof of national certification sent to BoN. BoN sole state authority over NPs? Yes, for practice; no, for prescribing. MSN required for, for practice may have verification of current national certification in specialty sent to BoN. Requirements for an APRN with prescriptive authority include both a master s degree in nursing and current national certification., for prescriptive practice. A collegial working relationship agreement (WRA) is required between a currently licensed physician and a recognized APRN to be granted prescriptive authority. No Legislative/administrative plans for state? No treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes. APRNs must file a separate application for prescriptive authority. A pocket identification card with the designation APRN-Rx and a number, assigned by the Department of Commerce and Consumer Affairs, are issued to the recognized APRN granted authority to prescribe. BoM/physician involvement in NP prescribing? Yes? The BoM shall submit an annual report of all amendments made to the formularies. NP authorized to Rx controlled substances? Yes. A new 2005 statute replaces the term collegial agreement as it relates to APRN prescriptive authority with the term appropriate agreement. This change is due to BoM agreement to allow APRN with Rx authority to Rx controlled substances (CS) provided there is a supervisory WRA. The rules to implement are being drafted. The collegial (non-supervisory) WRA to prescribe non-cs remains intact. If so, which Schedules? Rules not yet drafted. changes? The Hawaii Medical Association has been a consistent opponent, but in recent years there has been more cooperation between the medical and nursing communities. 36 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
IDAHO NP title(s) used in this state: NP (nurse practitioner), APPN (advanced practice professional nurse) Number of NPs in state? 444 BoN sole state authority over NPs? Yes MSN required for NA July 2004 legislation passed removing the requirement for physician consultation, collaboration, supervision, and referral from the statute; replaced wording requires collaboration with other healthcare professionals. In addition, the legislation requires that NPs participate in a peer review process in order to renew their license. In 2006, the BoN implemented rule revisions to increase licensure fees for APPNs. Legislative/administrative plans for state? No legislation is anticipated in 2007. treating? No. The Advisory Committee is not involved in NP diagnosing or treating; the committee advises the BoN on issues related to licensure, discipline, defining scope of practice (SoP), and other issues directed by the BoN. authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes. Prescriptive authority is a process separate from licensure to practice; however, once granted, prescriptive authority renews automatically with NP licensure renewal. BoM/physician involvement in NP prescribing? Yes minimal? The Advisory Committee to the BoN addresses issues related to the advanced practice of nursing of NPs and other APPNs. This committee consists of 2 APPNs appointed by the BoN, 2 physicians nominated by the BoM and appointed by the BoN, and 1 pharmacist nominated by the BoP. The committee responds to BoN questions regarding advanced practice nursing; considers non-routine applications for Rx authority; and makes recommendations to the BoN, including those regarding the SoP of APNs, using national standards as a guideline. The BoN cannot expand the SoP or prescriptive authority of an APN beyond that recommended by the committee. Routine applications for Rx authority are managed by the BoN staff following directives by the BoN. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V if appropriate to APPN s defined SoP. changes? Yes, traditionally from the state s medical association. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 41
THE PEARSON REPORT ILLINOIS NP title(s) used in this state: APN (advanced practice nurse), CNP (certified nurse practitioner) Number of NPs in state? 2849 BoN sole state authority over NPs? No MSN required for practice? The Illinois Department of Financial and Professional Regulation (IDFPR) has numerous voluntary advisory boards overseeing nursing and medicine and other professions. The head of IDFPR can and does overrule decisions by these boards. The BoN handles RN and LPN issues and an APN Board controls APN practice. The APN Board consists of 9 members appointed by the governor, of whom 4 are APNs, 3 are licensed physicians, and 2 are members of the public. A written collaborative agreement (CA), which shall be available to the APN Board upon request, shall describe the working relationship of the APN with the collaborating physician. The agreement authorizes the categories of care, treatment, or procedures to be performed by the APN and documents the medical direction to be given. being addressed as Dr? Yes No legislative changes in 2006. However, the Illinois Society for Advanced Practice Nursing (ISAPN) negotiated with the state Medicaid office the Illinois Department of Healthcare and Family Services (IDHFS) to revise the rule regarding Medicaid reimbursement. As a result, as of January 2006, APNs are eligible for reimbursement at the same rate as physicians and for an enhanced rate available to certain physicians who provide maternal-child services; and all types and categories of APNs (NPs, CNMs, CRNAs, and CNSs) are eligible for Medicaid reimbursement, with one exception there will be certain specific psychiatric codes for which only psychiatrists can bill. This exclusion applies to psychologists and social workers as well as APNs. Since July 1, 2006, a new Medicaid managed care system, Primary Care Case Management (PCCM), has been launched. APNs will be allowed to serve as primary care case managers, and IDHFS has sought ISAPN s assistance in appointing an APN to serve on the PCCM steering committee. Legislative/administrative plans for state? Plans are under way to prepare for the Nursing Act Sunset of 2007. For the first time ever, this initiative has been launched by the Nursing Act Coordinator of the IDFPR, who has called together a large planning group of nursing leaders across the state representing LPNs, RNs, APNs, and CNPs. treating? Yes authorization)? The CNP must have a written CA with a licensed physician in the diagnosis of illness and management of wellness and other conditions. Required physician record/chart review? The physician must be on site at least once a month to provide medical direction and consultation. On site is defined in the CA. Chart review is not specifically mentioned as a requirement. Required NP/physician practice agreement? Yes authority? Yes BoM/physician involvement in NP prescribing? Yes? A collaborating physician who delegates limited prescriptive authority to a CNP shall include that delegation in the CA. Delegated authority may include prescription and dispensing of legend drugs and legend controlled substances (CS). The delegation of authority form shall be submitted to the department prior to the issuance of a CS license. The CNP may prescribe and dispense only within the scope of practice of the collaborating physician. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules III-V Organized opposition to NP legislative or regula- 42 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
THE PEARSON REPORT tory changes? During the 2006 legislative session, the ISAPN retested the waters to try to change the practice act so as to provide all APNs with Schedule II Rx authority. The bill did not get out of the Rules Committee, which was not unexpected in light of it being an election year with legislators striving for a short session. 2007 is the year that the nursing act will sunset, and many nursing organizations are working to revamp the entire act. INDIANA NP title(s) used in this state: APN (advanced practice nurse), NP (nurse practitioner) Number of NPs in state? 1774, but practitioners who have completed a certificate program rather than an accredited graduate program must be certified and maintain certification as an NP by a national organization that requires a national certifying examination. BoN sole state authority over NPs? Yes. BoM approves rules for prescribing but has no further involvement. MSN required for, involvement by a physician or other recognized licensed practitioner (dentist, podiatrist, or optometrist) is needed for prescriptive authority. Under statute, APNs must operate in collaboration with a licensed practitioner. Under R&R, NP standards of practice include consultation and collaboration with other members of the healthcare team as appropriate to provide reasonable patient care and collaboration with or referral to a practitioner in managing the plan of care. Recent legislative changes affecting NP Legislative plans for state? To maintain the present status of Rx authority, scope of practice, and title protection; and to be identified as designated primary care providers within the state-managed Medicaid programs. treating? Yes authorization)? Under statute, all APNs are required to collaborate with a licensed practitioner as evidenced by a written practice agreement (WPA), or by privileges granted by the governing board of a hospital with the advice of the medical staff of the hospital, which defines the manner in which the APN and the licensed practitioner (physician, dentist, podiatrist, optometrist) will cooperate, coordinate, and consult with each other in the provision of health care to their patients. Under R&R, NP standards of practice include consultation and collaboration with other members of the healthcare team as appropriate to provide reasonable care, and collaboration with or referral to a practitioner in managing the plan of care. Required physician record/chart review? No. The standards for NPs include a requirement to participate in periodic or joint evaluations of service rendered including chart reviews, patient evaluations, and outcome statistics, but there is no requirement for this to be done with a physician. Required NP/physician practice agreement? Yes, but this does not need to be written unless prescriptive authority is sought. authority? Yes BoM/physician involvement in NP prescribing? Yes? Decisions made by the BoN regarding requirements for initial and renewed prescriptive authority must meet the approval of the BoM. WPAs for APNs applying for Rx authority are not valid until Rx authority is granted by the BoN. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V if permitted on the WPA. changes? No 44 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
THE PEARSON REPORT 2007 PEARSON REPORT SUMMARY State NP title(s) used: Physician involvement in Physician involvement in 2006 NP # of NPs # of NP NP diagnosing & treating? NP prescribing? role expansion? schools ALABAMA CRNP WP oversight & direction WP drugs in formulary No 1600 7 ALASKA ANP NONE NONE No 592 1 ARIZONA RNP NONE NONE No 2644 5 ARKANSAS ANP, RNP, ANPs: none ANPs & RNPs: CPA No 1471 3 ARNP, NP RNPs: protocols, supervision CALIFORNIA APRN SP developed collaboratively SP + protocol for CS II-III SoP expansion 13,649 23 & signed COLORADO APN, NP NONE Written CA No 3019 5 CONNECTICUT APRN, NP Required collaboration Required written collaboration SoP expansion 2613 8 DELAWARE APN, NP Written CA Approval by BoM No 501 2 DISTRICT OF COLUMBIA APRN, CNP, NONE NONE No 908 4 CRNP, NP FLORIDA ARNP, NP WP supervision WP supervision No; added work-site 15,500 13 restrictions GEORGIA APRN, NP Delegation via protocol Under delegated medical authority No 3484 11 HAWAII APRN NONE Approved supervisory WRA No 446 2 IDAHO APPN, NP NONE NONE No 444 1 ILLINOIS APN, CNP Written CA Delegation CA Expanded reimbursement 2849 10 INDIANA APN, NP Required collaboration in WPA Required collaboration in WPA No 1774 10 IOWA ARNP, CNP, NP ARNP: NONE required ARNP: NONE required No 1684 5 KANSAS ARNP Required protocols or guidelines WP No 1491 5 KENTUCKY ARNP, NP NONE Written CPA Prescribing now includes 1739 8 CS II-V LOUISIANA APRN, NP Written CPG within CPA CPA: direction in CPG SoP expansion 1048 8 MAINE APRN, CNP NONE after initial 2 years NONE after initial 2 years No 793 3 MARYLAND CRNP, NP WA WA No 2238 6 MASSACHUSETTS NP Direction within WG Direction & supervision within WG SoP expansion 5600 11 MICHIGAN NP NONE Delegation & supervision; CS - DPAA No 3118 10 MINNESOTA APRN, NP, CNP Collaborative Management Delegated via WA APRN SoP expansion 2081 10 MISSISSIPPI APRN, CNP, NP CCR CCR No 1867 5 MISSOURI APRN, APN, NP Delegation or WCPA Delegation through WCPA No 2824 11 MONTANA APRN, NP NONE NONE No 412 1 NEBRASKA APRN Collaboration, supervision per IPA Collaboration, supervision per IPA Removed CS II restrictions 659 3 46 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
2007 PEARSON REPORT SUMMARY State NP title(s) used: Physician involvement in Physician involvement in 2006 NP # of NPs # of NP NP diagnosing & treating? NP prescribing? role expansion? schools NEVADA APN Collaboration with protocols Collaboration with protocols SoP & Rx authority expansion 483 2 NEW HAMPSHIRE ARNP NONE Minor involvement ARNP defined in statute 1335 2 NEW JERSEY APN NONE Collaboration via JP SoP expansion 3734 10 NEW MEXICO CNP, NP NONE NONE No 672 3 NEW YORK NP Collaboration with WPA & WPP Collaboration with WPA & WPP SoP expansion 12,902 29 NORTH CAROLINA NP Supervision & collaboration: CPA Supervision & collaboration: CPA No 2582 7 NORTH DAKOTA APRN, NP NONE Collaboration via CPAPA-PA No 308 3 OHIO CNP, CRNP Collaboration via SCA Collaboration via SCA No 2984 12 OKLAHOMA ARNP, APN NONE Supervision via EF BoN-added NP specialty: 693 1 ACPNP OREGON NP NONE NONE No 2145 2 PENNSYLVANIA CRNP Collaboration Collaboration via written CA No 6269 23 RHODE ISLAND RNP NONE Collaboration via WP SoP expansion 673 1 SOUTH CAROLINA APRN, NP Supervision via AWP Supervision & delegation via AWP SoP expansion 3000 3 SOUTH DAKOTA CNP Collaboration via approved CA Collaboration via approved CA May Rx CS II for 30 days 320 1 TENNESSEE APN, NP NONE Supervision via protocol, formulary No 3466 9 TEXAS NP (+ specialty) Delegation & written authorization Delegation & written authorization Medicaid reimbursement 6372 16 increased UTAH APRN, RNP, NP NONE Consultation for CS II-III No 1077 3 VERMONT APRN Collaboration via WPG Collaboration via WPG No 519 1 VIRGINIA LNP, APN Collaboration & direction via WP Supervision via WPA Expansion of Rx authority 5167 10 to CS II WASHINGTON ARNP NONE NONE No 3822 6 WEST VIRGINIA ANP NONE Collaboration: CA with WP or WG No 1075 6 WISCONSIN APN, APNP, NP Supervision & delegation Collaboration & delegation SoP expansion for APNP 2533 8 WYOMING APRN NONE NONE No 341 1 TOTALS 139,520 350 NP = nurse practitioner; CRNP = certified registered nurse practitioner; WP = written protocol; ANP = advanced nurse practitioner; RNP = registered nurse practitioner; CPA = collaborative practice agreement; APRN = advanced practice registered nurse; SP = standardized procedure; CS = controlled substances; SoP = scope of practice; APN = advanced practice nurse; CA = collaborative agreement; BoM = board of medicine; ARNP = advanced registered nurse practitioner; WRA = working relationship agreement; APPN = advanced practice professional nurse; CNP = certified nurse practitioner; WPA = written practice agreement; CPG = clinical practice guideline; WA = written agreement; WG = written guideline; DPAA = delegation of prescriptive authority agreement; CCR = collaborative/consultative relationship; WCPA = written collaborative practice arrangement; IPA = integrated practice agreement; JP = joint protocol; WPP = written practice protocol; CPAPA-PA = collaborative practice affidavit physician agreement-prescribing authority; SCA = standard care arrangement; EF = exclusionary formulary; BoN = board of nursing; ACPNP = acute care pediatric nurse practitioner; AWP = approved written protocols; WPG = written practice guideline; LNP = licensed nurse practitioner; APNP = advanced practice nurse prescriber. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 47
THE PEARSON REPORT IOWA NP title(s) used in this state: ARNP (advanced registered nurse practitioner), CNP (certified nurse practitioner), NP (nurse practitioner). The term ARNP encompasses certified clinical nurse specialist, certified nurse midwife, and certified registered nurse anesthetist. Number of NPs in state? 1684 NP title protection? The ARNP title is restricted to those who are board-certified in their specialty and recognized through registration with the BoN. The NP title is not protected RNs may practice at the advanced level without registration as an ARNP. Registration with the BoN at the advanced level permits the nurse to use the title ARNP and authorizes the nurse to prescribe substances or devices within the nurse s recognized nursing specialty. practice? ARNPs must be board-certified in their specialty. National certification is not required for practice under the NP title. BoN sole state authority over NPs? Yes, for the ARNP. MSN required for practice? ARNP applicants must have graduated from a BoN-approved master s degree program or completed a formal advanced practice educational program with study in a nursing specialty area.. ARNPs may prescribe, dispense, admit, and treat independently; the ARNP does not need to have a collaborative practice agreement (CPA). As applicable to any RN working independently, ARNPs must practice within their educationally prepared scope of practice (SoP). A CPA is completely up to the physician and the ARNP, but it is not necessary. ARNPs must practice within their educationally prepared SoP area, and they cannot practice Medicine. An NP is someone who has graduated from a NP master s degree program and who may not prescribe independently; the other aspects of the NP s SoP are limited to the healthcare facility s rules and by federal regulations for nursing homes. If operating with a CPA, the NP may practice without being certified or having registered with the BoN, but he or she may not have prescriptive authority nor call himself or herself an ARNP. The ARNP may perform selected medically designated functions when a CPA exists; the CPA is not required, and medically delegated functions are not defined. Yes, legislative approval to be part of the ARNP compact. Legislative/administrative plans for state? Not at this time. treating? No. ARNPs may practice independently within their recognized nursing specialties; they are not required to have physician supervision. An ARNP may have a CPA with a physician if the practice so warrants, but there is no BoN requirement to do so. There is a provision for entering into a CPA if an ARNP accepts medical delegation. authorization)? CPA agreement is a voluntary agreement wherein an ARNP and physician practice together within the framework of their respective professional SoP. This CPA reflects both independent and cooperative decision making and is based on the preparation and ability of each practitioner. Required physician record/chart review? No Required NP/physician practice agreement? No authority? No. ARNPs are granted prescriptive authority within their specialty area. BoM/physician involvement in NP prescribing? No? The ARNP who qualifies for and is registered in a recognized nursing specialty may prescribe substances or devices, including controlled substances (CS) or controlled devices, if engaged in the practice of a nursing specialty regulated under rules adopted by the BoN in consultation with the BoM and the BoP 48 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
(http://www.state.ia.us/ibpe), but the BoN makes the final decision. NP authorized to Rx controlled substances? Registration with the Federal Drug Enforcement Administration and the Iowa Board of Pharmacy Examiner extends the authority for the ARNP to prescribe CS. ARNPs practicing in a non-institutional setting as sole practitioners, or in small clinical practice groups, shall regularly consult with a licensed physician or pharmacist regarding the distribution, storage, and appropriate use of CS. If so, which Schedules? Schedules II-V changes? In general, physician groups are opposed, although sometimes when mutually advantageous, they cooperate with NP groups. KANSAS NP title(s) used in this state: ARNP (advanced registered nurse practitioner) Number of NPs in state? 1491, but ARNPs must have graduated from a BoN-approved educational and training program. BoN sole state authority over NPs? Yes MSN required for ARNPs are expected to maintain collegial relationships with physicians and other healthcare professionals in delivering healthcare services. ARNPs make independent decisions about the nursing needs of patients and interdependent decisions with physicians for healthcare regimens. Recent legislative changes affecting NP Legislative/administrative plans for state? The goal is to increase ARNPs independent prescribing authority by eliminating any physician oversight or supervision for NPs. The following two bills died in the 2006 legislative session and will be reintroduced in 2007: HB 2256, which would have amended the ARNP statutes to allow ARNPs to prescribe without written protocols (WPs); and HB 2342, which would have allowed the pronouncement of death by ARNPs in licensed adult care homes and hospices. treating? Yes authorization)? ARNPs function in collegial relationships with physicians and other healthcare professionals in delivering healthcare services. ARNPs make independent decisions about the nursing needs of patients and interdependent decisions with physicians for healthcare regimens. ARNPs manage the medical plan of care prescribed for the patient based on protocols or guidelines adopted jointly by the NP and the attending physician. Required physician record/chart review? No Required NP/physician practice agreement? Yes. See below. authority? No. Authority to prescribe is subsumed under the practice certificate, but prescriptive parameters must be spelled out in WPs. Each WP shall contain a precise and detailed medical plan of care for each classification of disease or injury for which the ARNP is authorized to prescribe and shall specify all drugs that may be prescribed by the ARNP. BoM/physician involvement in NP prescribing? Yes? Each WP that an ARNP is to follow when prescribing, administering, or supplying a prescription drug shall meet the following requirements: It must specify for each classification of disease or injury the corresponding class of drugs that the ARNP is permitted to prescribe. It must be maintained in a loose-leaf notebook or a book of published protocols. The WP shall include a cover page containing the following data: names, telephone numbers, and signatures of the ARNP and a responsible physician who has VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 49
authorized the protocol, and the date on which the protocol was adopted or last reviewed. The notebook must be kept at the ARNP s principal place of practice. NP authorized to Rx controlled substances? Yes. In prescribing controlled substances, the scope of authority of the ARNP must not exceed the normal and customary practice of the responsible physician. If so, which Schedules? Schedules II-V, as long as the Rx is from a class of drugs prescribed pursuant to protocol. changes? No KENTUCKY NP title(s) used in this state: ARNP (advanced registered nurse practitioner), NP (nurse practitioner) Number of NPs in state? 1739, the title ARNP is protected. BoN sole state authority over NPs? Yes MSN required for, it is required for new graduates after January 2005.. The NPA statute creates an Advanced Registered Nurse Practice Advisory Council composed of 9 members (1 from the BoN, 1 from the BoM, 1 from the BoP, and 6 ARNPs) who meet annually or more often. However, this council has no regulatory or statutory oversight. prescribing only. A written collaborative practice agreement (CPA) for ARNP prescriptive authority with a physician is required before prescribing or dispensing drugs. Two separate collaborative agreements for prescriptive authority are required: one for nonscheduled drugs (CAPA-NS) and one for controlled substances (CAPA-CS). Yes. A bill to grant ARNPs authority to prescribe scheduled drugs II-V was passed in 2006. Schedule II is limited to a 72-hour supply, except for ARNPs certified in psych/mental health who may prescribe a 30- day supply of psychostimulants, Schedule III drugs (a 30-day supply with no refills), and Schedule IV-V drugs (up to a 6-month supply of medication). Legislative plans for state? Monitor and respond in a proactive manner to AMA and Kentucky Medical Association (KMA) activities related to restricting the scope of practice (SoP) of ARNPs and other healthcare professionals who are not physicians. Participate in activities of the Coalition for Patient Rights, an organization formed in response to the divisive activities of the AMA. Continue legislative activities related to ARNP prescribing and practice. treating? No. Consultation and collaboration required for situations outside the ARNP s SoP. authorization)? ARNP practice means the performance of additional acts by RNs who have gained added knowledge and shall include prescribing treatments, drugs, and devices and ordering diagnostic tests that are consistent with the SoP of the ARNP. When performing in those situations outside his or her SoP, the ARNP shall practice in accordance with the CPA and shall seek consultation or referral in those situations. Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? Yes? Before the ARNP can Rx or dispense non-scheduled legend drugs, the ARNP must enter into a written CPA for prescriptive authority with a physician that defines the scope of the prescriptive authority (ie, a CAPA-NS). If the ARNP has been registered to practice for at least 1 year, he or she may also enter into a CAPA-CS with a physician, which defines the scope of the prescriptive authority for CS. The CAPA-CS must be in writing, signed by ARNP and physician, and available at each practice site; the BoN must be officially notified. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 53
THE PEARSON REPORT NP authorized to Rx controlled substances? Yes, if the ARNP has a CAPA-CS and DEA #. If so, which Schedules? CS II-V may be defined within the ARNP s CAPA-CS, with the following limitations: Schedule II drugs: a 72-hour supply (except for ARNPs certified in psych/mental health, who may prescribe a 30-day supply of psychostimulants); Schedule III drugs: a 30-day supply, with no refills; Schedule IV and V drugs: a 6-month supply of medication. changes? Yes, by the KMA. LOUISIANA NP title(s) used in this state: APRN (advanced practice registered nurse), NP (nurse practitioner) Number of NPs in state? 1048 (833 with prescriptive authority) BoN sole state authority over NPs? Yes MSN required for An APRN shall make decisions to solve patient care problems and select medical treatment regimens in collaboration with a licensed physician or dentist. Psychiatric mental health nurse practitioners have authority to perform psychiatric emergency commitments. Legislative plans for state? Not at this time. treating? Yes (eg, APRNs who engage in medical diagnosis and management shall have a collaborative practice agreement (CPA) that includes the availability of the physician or dentist and the methods of management, including clinical practice guidelines (ie, written documents jointly agreed upon by the collaborating professionals that describe a specific plan, arrangement, or sequence of orders, steps, or procedures to be followed or carried out in providing patient care in various clinical situations), and coverage of the healthcare needs of the patient during any absence of any of the providers. APRNs practicing solely in their nursing SoP are not required to have a CPA. Required physician record/chart review? No Required NP/physician practice agreement? Yes, a CPA. authority? Yes. An application requesting that an APRN be granted Rx authority to prescribe assessment studies, drugs, and therapeutic devices and to distribute free drug samples and other gratuitous medications uses a separate application from that for APRN licensure. BoM/physician involvement in NP prescribing? Yes, collaboration.? APRNs apply to the BoN for Rx authority which, once granted, must be specified in the CPA clarifying that the APRN prescribing is in collaboration. NP authorized to Rx controlled substances? Yes. APRNs granted Rx authority by the BoN are allowed to Rx or distribute controlled substances (CS). The BoN may authorize an APRN with limited Rx authority to Rx or distribute CS on an individual practice basis. Such an applicant must have practiced with limited Rx and distributing authority with the same collaborative physician for 500 hours immediately preceding the request. If so, which Schedules? Schedules II-IV (Schedule II under certain circumstances; no CS for treating chronic and intractable pain and/or obesity). changes? Yes. The state medical society lobbied against the collaboration issue; negotiation is continuous. 54 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
MAINE NP title(s) used in this state: APRN (advanced practice registered nurse), CNP (certified nurse practitioner) Number of NPs in state? 793 BoN sole state authority over NPs? Yes MSN required for practice? As of January 1, 2006, an applicant for initial approval must hold a master s degree with preparation in the specialty area for which application is made.. Recent graduates of NP programs must practice under physician supervision for the first 2 years, after which independent practice is authorized. The first 2 years of practice must be either under supervision of a licensed physician practicing in the same practice category who will provide oversight for the NP or as an employee of a clinic or hospital that has a medical director who is a licensed physician. The CNP applicant must submit written evidence to the BoN upon completion of the required clinical experience. being addressed as Dr? Yes. The restriction contains an exception allowing the use of Dr if the person is a chiropractor, naturopathic doctor, optometrist, or podiatrist. Statute describes a Class E crime if others use the term Dr and are engaged in the treatment of a disease or human ailment. No Legislative plans for state? Not yet formalized. treating? Only within the first 2 years of practice for recent graduates of NP programs. authorization)? Supervision and oversight Required physician record/chart review? No Required NP/physician practice agreement? Only for the initial supervised 2-year period. authority? No BoM/physician involvement in NP prescribing? Only for the initial supervised 2-year period.? Delegation NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? On occasion, the state medical association or the insurance industry has opposed NPs, but NPs have always prevailed. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 55
THE PEARSON REPORT MARYLAND NP title(s) used in this state: NP (nurse practitioner), CRNP (certified registered nurse practitioner) Number of NPs in state? 2238 BoN sole state authority over NPs? No MSN required for practice? The BoN and the Board of Physician Quality Assurance (BPQA) under the Department of Health and Mental Hygiene jointly control NP practice. A Joint Committee on Nurse Practitioners is composed of an equal number of members appointed by the BPQA and BoN. This joint committee makes recommendations to the BoN regarding approval of a written agreement (WA) submitted for review. Once the BoN approves the WA, it is sent to the BPQA, which approves the physician s role, as described in the WA, before the letter of agreement is approved. The term mutual collaboration is used on the state s WA form. Not in 2006. Legislative/administrative plans for state? Plans to cooperate with physicians to address medical tort reform; also plan to tie up loose legislative ends to have NPs accurately and properly recognized in the insurance code. treating? Yes, indirectly. authorization)? NPs function under a WA between an NP and a licensed physician concerning the performance by the NP of the functions authorized by these regulations. Required physician record/chart review? Before an NP may practice, he or she shall enter into a WA with a physician whereby the physician, on a regularly scheduled basis, shall establish and review drug and other medical guidelines with the NP, participate with the NP in periodically reviewing and discussing medical diagnoses and the therapeutic or corrective measures used in the practice setting, and jointly sign records if needed to document accountability of both the physician and NP. Required NP/physician practice agreement? Yes authority? No, with the exception of new NP graduates, who may be authorized to practice pending national board certification but may not prescribe until successful examination results are reported to the BoN. BoM/physician involvement in NP prescribing? Yes? Wording as specified on the WA between the NP and the physician. NP authorized to Rx controlled substances? NPs must provide the patient with a written prescription and stamp all Schedule III, IV, and V prescriptions with the letter C in red ink, not less than 1 inch high in the lower-right-hand corner. If so, which Schedules? Schedules II-V changes? Not currently, but in the past, there has been substantial opposition from organized medical groups. 56 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
MASSACHUSETTS NP title(s) used in this state: NP (nurse practitioner) Number of NPs in state? 5600 BoN sole state authority over NPs? No. An advisory committee composed of 5 practicing nurses in the expanded role shall be appointed by the Board of Registration in Nursing (BoRN) for each category of nurses practicing in the expanded role. The BoRN must consult with the appropriate advisory committee on matters relating to the practice of the nurse in the expanded role and on matters relating to practice guidelines of the nurse in that specific expanded role. A nurse practicing in an institution may not practice in an expanded role until he or she is credentialed using guidelines that are formally reviewed and approved by the professional medical and nursing staff. If there is no professional staff of nurses and physicians, the guidelines must be reviewed by the BoRN. MSN required for ; MS required. practice? Yes. The BoRN adopted 244 CMR (Regulations Governing the Practice of Nursing in the Expanded Role), which it and the BoM approved (4/94) under statute authority. Supervision, direction, collaboration: All nurses practicing in an expanded role (in a physician s office, institution, or private practice) shall practice in accordance with written guidelines (WG) developed in collaboration with and mutually acceptable to the nurse and to either a physician (physician office or nurse in private practice) with same practice area as the nurse or the appropriate medical staff and nursing administration staff of the institution employing the nurse. Early in the December 2005 legislative session, a bill entitled An Act to Ensure Consumer Choice of NP Services was introduced and is currently being reviewed by the House Ways and Means Committee. This bill would grant primary care provider (PCP) status to NPs, prohibit discrimination against NPs as a class of PCPs by third-party payors, and give consumers the opportunity to choose NPs as their PCP. Legislative plans for state? (1) To ensure PCP status for NPs; (2) to become proactive for NP inclusion in healthcare reform; and (3) to focus on fundraising to support NPs by funding a political action committee for NPs. treating? Yes authorization)? Nurses in the expanded role must work under WG (ie, written instructions and procedures describing methods to follow in managing a healthcare situation or resolving a healthcare problem, which specify those instances in which referral to or consultation with a physician is required). The WG shall designate a physician who shall provide medical direction. The guidelines must describe the NP s scope of practice, describe the circumstances in which physician consultation or referral is required, describe the use of established procedures for the treatment of common medical conditions, and include provisions for managing emergencies. Required physician record/chart review? Yes, for prescriptive practice. Required NP/physician practice agreement? Yes, if the NP prescribes. authority? Yes. NPs applying for prescriptive authority must document minimum of 24 contact hours in pharmacotherapeutics (beyond those acquired through a generic nursing education program) and a valid registration(s) to issue written or oral prescriptions or medication orders for controlled substances from the state and the DEA. BoM/physician involvement in NP prescribing? Yes? The guidelines pertaining to prescriptive practice must include a defined mechanism to monitor VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 61
THE PEARSON REPORT prescribing practices, including documentation of review with a supervising physician at least every 3 months. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Yes, intense and severe opposition from state medical society. MICHIGAN NP title(s) used in this state: NP (nurse practitioner) Number of NPs in state? 3118, as part of specialty certification., for initial specialty certification; for renewal, NP must submit proof of current national certification/recertification or 40 hours of CE earned in the 2-year period preceding the date of application. BoN sole state authority over NPs? Yes MSN required for, because currently, initial specialty certification requires certification by an approved national certification board., for Rx authority and for insurance reimbursement. According to a 1980 attorney general opinion, a physician may delegate prescribing to a registered professional nurse. Rules passed in 1999 authorize physicians to delegate prescribing of controlled substances (CS) to an NP, with certain restrictions and with a signed collaborative agreement. Recent legislative changes affecting NP Legislative plans for state? Yes. Senate Bill S1245 was introduced but failed to pass before the Senate health policy committee for a hearing. The bill would have authorized prescriptive authority for Registered Professional Nurses with Specialty Certification ; the bill may be reintroduced in the 2007 legislature. State NPs also plan to continue to ensure that state regulations are updated to reflect current practice, including use of the term health provider instead of physician in legislation; long-term goals to promote legislation that will remove barriers to NP practice and improve access to care for patients. treating? No authorization)? The Michigan Public Health code defines nursing, and this serves as the legal scope of practice statement. RNs are licensed to practice independently within this scope. For medically delegated functions such as prescribing, supervision by the delegating physician is required. Diagnosis is not addressed. Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes, as a delegated act. BoM/physician involvement in NP prescribing? Yes? A prescriber is defined as a licensed health professional acting under the delegation and supervision of and using, recording, or otherwise indicating the name of the delegating physician. NPs prescribe CS under a Delegation of Prescriptive Authority Agreement (DPAA) signed by their supervising physician, which, according to the BoM administrative rules and Public Health Code, must be reviewed annually. NP authorized to Rx controlled substances? Yes If so, which Schedules? NPs who practice in the hospital setting or free-standing surgical suites or who practice in oncology/hospice/palliative care may apply for Schedules II-V if in accordance with the DPAA. All other NPs are eligible for Schedules III-V. A delegating physician may not delegate the Rx of Schedule II CS on the day of hospital discharge for more than a 7-day period. Schedules III-V may be prescribed as long as in accordance with the delegation protocol. changes? Yes, the state medical and osteopathic societies usually oppose. 62 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
HELP US CELEBRATE! NPWH Silver Anniversary CONTRIBUTE TO THE CAPITAL BUILDING CAMPAIGN to support the purchase of NPWH s New Headquarters in the heart of Capitol Hill Levels of Giving: $ 25 Your name will be published in NPWH s Annual Meeting Syllabus. $ 50 $ 100 Your name will appear in the Annual Meeting Syllabus and on the donors list displayed at NPWH s new headquarters. $ 100 or more Your name will be included in the Annual Meeting Syllabus and on the donors list display and published in Women s Health Care: A Practical Journal for Nurse Practitioners. NPWH National Association of Nurse Practitioners in Women s Health PLATINUM CM & F Group, Inc. Linda Dominguez, RNC, BSN, WHNP NP Communications, LLC RSG Consulting, Inc., in Memory of Sasha GOLD Kathy Coleman, MSN, ANP Sarah Freeman, PhD, ARNP, FAANP Dr. Robert A. Hatcher Mary Ann Nihart, MA, APRN, CS, BC PROmedica Communications, Inc. Suzy Reiter, RNC, WHNP, MM, MSN, SANE-A Sandra Worthington, in Memory of William R. & Ann I. Worthington SILVER Linda C. Andrist, PhD, RNC, WHNP Cookie Bible, ANP Linda Byers, RNC, CNS Lynne Calkins, CRNP, Ob/Gyn, NP Dory Greene LeAnne Gundy, MS, NP Versie Johnson-Mallard, PhDc, MSN, ARNP Beth M. Kelsey, EdD, RNC, NP Susan Kendig, RNC, MSN, WHCNP Linda S. Kohn, CRNP Deborah Kowal Diana E. Lopez, CNP Claire Mills, FNP-C Delia I. O Hara, FNP BRONZE Suzanne Ollivier Bailey, NP Wanda S. Bauer, WHNP Diane L. Batz, MA, RNC, ARNP Leslie A. Christopher Erin Hebert Dunn, RNP, CNM, MSN FemCap, Incorporated Joy F. Harvey Heidi Hurliman BRONZE:...... $100 - $200 Barbara L. Jameson, RNC, WHNP SILVER:....... $200 - $500 Mary Ellen Kenworthey, RNP Barbara J. Koons, CRNP GOLD:........ $500 - $1000 Christine Kuhni, WHNP Carolyn Lane, WHNP PLATINUM:... $1000 and above Beverly D. Lavenson, MSN, CNP Claire (Kearney) Lewis, NP Francie Likis, MSN, FNP, CNM, WHCNP Julianne McGandy, RN, BSN, WHNP Patricia Lynn Money Pubcomm Group, NYC Karen Rasmusson, WHNP Joy Rothschild, WHNP Lori Settersten, PhD, RN, WHNP, C, FNP, BC Mitzi M. Siebert, NP Angela F. Sims, RNC, MSN, CWHNP Lisa A. Steffenhagen, CRNP, OGNP Nancy L. Whitehead, MS, FNP Women s Care of Southern Illinois PC JoAnn Woodward, RN, CNP Yama, Inc. This message provided VOL. by 11 NP NO. Communications, 2 FEBRUARY 2007 LLCTHE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 63 Please make checks payable to: NPWH Capital Campaign Mail contributions to: 505 C Street, NE, Washington, DC 20002 We also accept credit cards. Please contact us for more information. Tel: 202-543-9693 or Email: info@npwh.org Capital Campaign Donor List (as of 11/28/06)
THE PEARSON REPORT MINNESOTA NP title(s) used in this state: APRN (advanced practice registered nurse), NP (nurse practitioner), CNP (certified nurse practitioner) Number of NPs in state? 2081 BoN sole state authority over NPs? No. For prescribing scope of practice, CNPs must maintain a written agreement (WA) with a physician based on standards established by the Minnesota Nurses Association (MNA) and the Minnesota Medical Association (MMA). MSN required for Regarding diagnosing and nonpharmacologic treatment, collaborative management, consultation, and referral, as indicated; regarding prescribing pharmacologic agents, delegation. An APRN certified in mental health may act as an examiner to place a patient on emergency hold for care and treatment and to petition the court for retention for treatment. He or she may act as a health officer for purposes of taking an individual into custody for transport to a treatment facility. Legislative/administrative plans for state? No plans are being made public at this time. treating? Yes, within the context of collaborative management: (1) diagnosing, directly managing, and preventing acute and chronic illness and disease; and (2) promoting wellness, including providing nonpharmacologic treatment. authorization)? Collaborative management is a mutually agreed upon plan between an APRN and physician(s) that designates the scope of collaboration necessary to manage the care of patients. Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? Yes? NPs prescribe by a WA with a physician based on standards jointly established by the MNA and MMA. NP Rx authority is physician delegated via a WA that defines the delegated responsibilities related to the prescription of drugs and therapeutic devices. The WA must be maintained at the primary practice site of the APRN and collaborating physician. NP authorized to Rx controlled substances? Yes, as authorized in the WA. If so, which Schedules? Schedules II-V changes? NA at this time. 64 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
MISSISSIPPI NP title(s) used in this state: NP (nurse practitioner), CNP (certified nurse practitioner), APRN (advanced practice registered nurse) Number of NPs in state? 1867 BoN sole state authority over NPs? No. R&R for NPs are jointly promulgated by the BoN and BoM and implemented by the BoN. MSN required for, since January 1999. Physician involvement required for any aspect of NPs must practice in a collaborative/consultative relationship (CCR) with a physician whose practice is compatible with that of the NP. The NP s BoN-approved protocol must be agreed upon by the NP and a state-licensed physician. being addressed as Dr? Yes. All healthcare providers are required to clearly identify themselves to the public; they may use credentials after their name but may not place Dr before their name. None Legislative plans for state? Legislation to allow NPs in rural underserved areas who are unable to find a collaborating physician to ask for a 1-year waiver to practice without a collaborating physician. treating? Yes authorization)? Prior to practice as an NP, the applicant must submit protocol/practice guidelines (developed by NP and collaborating physician) for BoN approval. The protocol must outline diagnostic and therapeutic procedures and categories of pharmacologic agents that may be ordered, administered, dispensed, and/or prescribed for patients with diagnoses identified by the NP and physician as within the NP s scope of practice. Required physician record/chart review? A quality assurance program is required by the BoN; the physician is required to periodically review the charts. Required NP/physician practice agreement? Yes, as previously described in protocol. authority? Yes, related to controlled substances (CS) prescribing. BoM/physician involvement in NP prescribing? Yes? Each physician acting in a CCR with an NP must submit a signed protocol certifying that the BoN Protocol for Controlled Substance Prescriptive Authority has been reviewed and mutually agreed upon. In addition, the NP and collaborative/consultative physician must have an active quality assurance/continued quality improvement plan in place specific to the prescribing of CS. At all times, this plan must be kept current and on file and available for review by BoN/BoM representatives. NP authorized to Rx controlled substances? Yes. The BoN may grant CS authority, or the authority to Rx any combination of Schedules (eg, V only, IV-V; III-V; II, IV, and V). A letter justifying the requested Rx authority must be signed by the NP and NP s collaborative/consultative physician outlining the NP s practice and the necessity for the requested CS protocol approval (including an explanation of the practice, the population served, and the types of diseases treated). If so, which Schedules? Schedules II-V, depending on BoN authorization. There are two separate forms (one labeled Protocol for Schedules II and III and another for Protocol for Schedules IV and V ). A detailed protocol covering CSIII-V anorectics is included in R&R. changes? Yes, the state medical association. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 65
THE PEARSON REPORT MISSOURI NP title(s) used in this state: APN (advanced practice nurse), NP (nurse practitioner), APRN (advanced practice registered nurse) Number of NPs in state? 2824, unless certification in NP s specialty is not available, in which case BoN may recognize those who submit documentation evidencing a minimum of 1500 hours of clinical practice in the APN clinical specialty area within the past 2 years. BoN sole state authority over NPs? No MSN required for Delegation, as detailed in a written collaborative practice arrangement (WCPA). Effective August 28, 2006: SB 756 modifies requirements for licensing and registration of certain professionals. Within the section that potentially affects APRN practice (titled Collaborative Practice Agreements ), the BoM requires physicians to identify whether they are engaged or have any WCPA, and to report the name of the licensed professional. The BoM may provide this information to the public and shall track and review the agreements for compliance. New in 2005: Establishes that all products containing pseudoephedrine or ephedrine in solid forms are now Schedule V controlled substances (CS). Because APNs in this state do not have independent CS prescribing authority, they may no longer Rx these products in solid dosage forms. Legislative plans for state? Goals to obtain CS prescriptive privileges, to change NP recognition to license, and to establish a broad category of APRN. treating? Yes authorization)? The WCPA contains jointly agreedupon protocols or standing orders for the delivery of healthcare services. A WCPA is not necessary unless the APN is functioning under delegated medical acts, including making medical diagnoses, prescribing medical treatments, and prescribing drug therapies. Required physician record/chart review? Yes. The WCPA must specify a 2-week physician review with a practice-setting, site-specific process. There must be evidence of physician patient contact for new or significantly changed conditions within 2 weeks after contact with the APN when conditions are other than acute self-limited or well-defined problems. RNs involved in advanced practice whose practice includes these three components (ie, hospital employee, inpatient care, within the hospital) need not adhere to the statutorily defined WCPA. Required NP/physician practice agreement? Yes authority? No BoM/physician involvement in NP prescribing? Yes? Delegation the collaborating physician retains responsibility for the NP s prescriptive decisions. NP authorized to Rx controlled substances? No If so, which Schedules? NA changes? Yes, from state medical association. 66 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
MONTANA NP title(s) used in this state: APRN (advanced practice registered nurse), NP (nurse practitioner) Number of NPs in state? 412 BoN sole state authority over NPs? Yes MSN required for NA No Legislative plans for state? Not at this time. treating? No authorization)? NA Required physician record/chart review? No. The NP must have a Method of Quality Assurance (MQA) whereby a physician and/or an APRN peer of the same specialty (with Rx authority) is identified as part of the plan. The MQA must include 15 charts or 5% of all charts handled by the NP, which must be peer reviewed quarterly using pre-established patient outcome criteria specific to the NP s patient population with written evaluation of review with steps for corrective action if indicated. NPs must file with the BoN any proposed change in the MQA, and any change is subject to BoN approval. Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? No? NA NP authorized to Rx controlled substances? Yes, although Rx for Schedules III-V shall not exceed the quantity necessary for a 3-month period. If so, which Schedules? Schedules II-V changes? One local physician and hospital have taken an aggressive stance against NPs. NEBRASKA NP title(s) used in this state: APRN (advanced practice registered nurse) Number of NPs in state? 659 BoN sole state authority over NPs? No. APRNs are licensed and regulated by the Department of Health and Human Services (DHHS) Regulation and Licensure, which is advised by the APRN Board (separate from the BoN) on all issues related to the regulation of APRNs. Under the department, the APRN Board is charged with establishing standards for integrated practice agreements (IPAs) between APRNs and collaborating physicians, monitoring APRN scope of practice (SoP), advising the BoN regarding matters pertaining to APRN SoP, and approving R&R with BoN to implement the APRN Act for adoption and promulgation by the department. MSN required for Collaboration, supervision, and direction of NP activities, as outlined in the IPA. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 69
THE PEARSON REPORT New bill to take effect July 1, 2007, creates an umbrella board for all APRNs, which includes CNSs, CRNAs and CNMs within APRN category. Removed restrictions for Schedule II drugs; if collaborating physician wants the NP to be restricted, the APRN board must be notified. Otherwise, the APRN is assumed to be able to prescribe Schedule II drugs. Legislative plans for state? The long-term goal is to remove the requirement for the IPA. treating? Yes, the physician, not the BoM. authorization)? Collaboration, supervision, and direction of NP activities as per IPA, under which the NP and physician have both individual and joint responsibility for management of patient health care. The collaborating physician is responsible for supervision through readily available consultation and direction of the activities of the APRN within the APRN s defined SoP to ensure the quality of health care provided to patients. APRNs must also maintain liability insurance ($200,000 per incident and $600,000 aggregate per year). Required physician record/chart review? No Required NP/physician practice agreement? Yes, but if, after diligent effort, an APRN is unable to obtain an IPA with a physician, the APRN Board may waive the requirement (if the APRN has demonstrated proper course work, has a master s degree or higher in nursing, has completed 2000 hours under the supervision of a physician, and will practice in a geographic area where there is a shortage of healthcare services). authority? No BoM/physician involvement in NP prescribing? Yes physician, not BoM.? Collaboration, supervision, and direction of NP activities as per IPA. The APRN provides health services within specialty areas and functions by established collaborate networks and prescribes therapeutic measures and medications, including Schedule II-V drugs (if the collaborating physician wants the NP to be restricted from prescribing Schedule II drugs, the physician must notify the APRN board; otherwise the APRN is assumed to be able to prescribe Schedule II drugs). NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Not currently, although the physician groups are strongly in favor of IPAs and many NPs want to have this requirement removed. NEVADA NP title(s) used in this state: APN (advanced practitioner of nursing) Number of NPs in state? 483, but only for APNs without a BSN or MSN who completed their program between 1992 and June 1, 2005. BoN sole state authority over NPs? No MSN required for, for APNs who graduated after June 2005. APNs must have a protocol that reflects current practice that the APN and collaborating physician have agreed upon as a basis for their practice. Regulations adopted by the BoN in 2006 include revisions that (1) allow APNs to perform practices that are taught to them by physicians or other APNs and that are identified as being within their scope of practice in the latest BoN-approved Cumulative Index to Nursing and Allied Health Literature (CINAHL), (2) clarify that an APN s protocol must reflect the ongoing collaborative relationship 70 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
THE PEARSON REPORT between the APN and the physician, rather than one that is documented at the time of renewal, (3) replace the physician review of a representative sample of an APN s records with a more comprehensive review of the APN s records based on a system of quality assurance, (4) remove barriers and streamline the collaborative relationship between the physician and APN by deleting the requirement for a drug list and, instead, allowing for reference to drugs in terms of drug classes, and (5) make an APN s practice requirement the same as that for RNs if an APN has not practiced in the previous 5 years (ie, the APN must first practice 800 hours under the supervision of a physician or an APN). Legislative plans for state? Not currently treating? Yes authorization)? All APNs must maintain current protocols that they and their collaborating physician have agreed upon as a basis for their practice. Required physician record/chart review? Yes Required NP/physician practice agreement? Yes authority? Yes. An applicant for a certificate of recognition as an APN to issue written prescriptions for controlled substances (CS), poisons, or dangerous drugs or devices must submit a Statement of Competency (ie, a signed statement from the collaborating physician indicating to the board that the applicant is competent to prescribe those drugs listed in the protocols). BoM/physician involvement in NP prescribing? Yes? An APN may prescribe only CS, poisons, or dangerous drugs or devices that are within the standard of medical practice in his or her identified medical specialty. These classes of drugs must be listed in the protocols that the collaborating physician has approved in writing. NP authorized to Rx controlled substances? Yes, per protocol. If so, which Schedules? Schedules II-V changes? Depends on the change being proposed yes, when NPs want to increase autonomy. NEW HAMPSHIRE NP title(s) used in this state: ARNP (advanced registered nurse practitioner) Number of NPs in state? 1335 BoN sole state authority over NPs? Yes MSN required for, unless the individual graduated before July 1, 2004, from an ARNP education program accredited by a national accrediting body.. ARNPs use an official formulary established by the Joint Health Council (JHC). NA Effective January 2006, ARNP scope of practice (SoP) is defined in statute, and requires that all ARNPs practice within the guidelines of their specialty. Also, New Hampshire joined multi-state nurse licensure compact. Legislative plans for state? The most immediate goal is to remove specific license categories from rules and license as ARNP without mention of license categories. Another goal is to retain plenary authority and repeal old statutes and administrative rules that prohibit ARNPs from authorizing handicapped plates and certifying death certificates. treating? No authorization)? NA 72 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
Required physician record/chart review? No, although there are some federal requirements in critical access hospitals. Required NP/physician practice agreement? No authority? No. ARNPs have plenary authority to possess, compound, prescribe, administer, dispense, or distribute controlled and non-controlled drugs to patients from the official formulary established by the JHC and within the ARNP s SoP as defined by the BoN. Controlled and non-controlled substances shall be prescribed from the formulary according to protocol guidelines approved by the JHC. BoM/physician involvement in NP prescribing? Yes, minor.? Only as related to the JHC (which consists of 3 ARNPs appointed by the BoN; 3 physicians who work with ARNPs, appointed by the BoM; and 3 licensed clinical pharmacists appointed by the BoP, who are practicing clinical pharmacists). JHC members are not members of their respective boards. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Yes. New Hampshire Medical Society opposes any proposals it views as expanding ARNP authority. NEW JERSEY NP title(s) used in this state: APN (advanced practice nurse) Number of NPs in state? 3734 BoN sole state authority over NPs? Yes, for practice; no, for prescribing. MSN required for, except for OB/GYN NPs and WHNPs practice? The joint protocol (JP) required for prescribing must conform to the standards established by the Director of the Division of Consumer Affairs, and is developed by the BoN with the BoM. For prescribing purposes only, an APN and physician must engage in collaboration, which means an ongoing process consistent with agreedupon parameters of their respective practice using a JP (ie, an agreement or contract between an APN and a collaborating physician). A 2006 law authorizes RNs, including APNs, to pronounce death in all clinical settings, including acute and long-term care facilities (although the law does not authorize the pronouncement of brain death or to certify the cause of death). In January 2006, Assisted Living Standards added APNs to those providers whom patients have a right to choose. Legislative plans for state? Not at present treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 73
authority? Yes BoM/physician involvement in NP prescribing? Yes? APNs (who seek to Rx or order medications or devices) and the collaborating physician must develop a written JP signed by both, maintained on the premises of every office in which the APN practices, and updated at least annually to reflect changes in the practice, skills, and reference materials containing practice guidelines or accepted standards of practice. The JP must contain the nature of the practice, the patient population and settings, the recordkeeping methodology, a list of categories of medications prescribed, specific requirements for recording information and refills, and rules for direct consultation. NP authorized to Rx controlled substances? Yes. The new law authorizes APNs to initiate controlled substances (CS) according to the JP as long as the APN and physician revise their JP to explicitly address whether or not the APN must consult with the collaborating physician prior to prescribing or ordering CS. If so, which Schedules? Schedules II-V changes? Yes. The Medical Society of New Jersey has a stated philosophy of rigorously opposing any regulatory and legislative changes that may expand the practice of those providers who are not physicians. Because the Medical Board licenses and regulates PAs and nurse midwives, physicians are generally supportive of PAs and nurse midwives laws, as long as the laws do not increase these providers autonomy. NEW MEXICO NP title(s) used in this state: CNP (certified nurse practitioner), NP (nurse practitioner) Number of NPs in state? 672 BoN sole state authority over NPs? Yes MSN required for NA No Legislative plans for state? The NP Council has its own lobbyist to monitor legislation. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? No? NA NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Because the state has few physicians in rural and frontier areas, legislators and state medical society are supportive of NP practice. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 75
THE PEARSON REPORT NEW YORK NP title(s) used in this state: NP (nurse practitioner) Number of NPs in state? 12,902 BoN sole state authority over NPs? Yes, within umbrella context of Board of Regents jurisdiction. MSN required for Certified NPs may diagnose illness and physical conditions and perform therapeutic and corrective measures within their specialty area, as long as a collaborative agreement with a physician qualified to collaborate in the same specialty is in place., but in General Business Law statute, if you use the term Doctor when offering to perform health services, you must indicate the profession in which you hold a doctorate. The governor vetoed a bill that would have allowed NPs to sign death certificates but signed a measure allowing all NPs to declare an emergency in relation to ordering utilities turned back on after shutoff action. Legislative plans for state? Legislation is planned to reform worker s compensation system that would include NPs within the omnibus reform legislation. Also, New York State Education Department Board of Regents may seek to eliminate the alternative criteria for obtaining certification in a second specialty. In addition, there are several areas in the law in which NPs status has not caught up with physicians status; every year, new legislative measures are introduced to correct this problem. treating? Yes (sometimes, but not always). authorization)? NPs must function with physician collaboration, which must be performed with a written practice agreement (WPA) and written practice protocols (WPPs). The WPA must include explicit provisions for resolving disagreements between the collaborating physician and the NP, with the physician s diagnosis and treatment taking final priority in a dispute. Required physician record/chart review? Yes. Each WPA shall provide for a review of a sample of patient records by the collaborating physician at least every 3 months. The names of the NP and the collaborating physician shall be clearly posted in the practice setting of the NP. Required NP/physician practice agreement? Yes. WPAs shall include provisions for referral and consultation, coverage for emergency absence of either the NP or collaborating physician, and resolution of disagreements between the NP and collaborating physician regarding matters of diagnosis and treatment. authority? Yes. NPs who have satisfied all requirements for certification as an NP may be authorized to issue prescriptions after completing instruction, satisfactory to the department relating to prescriptions and recordkeeping. Prior to prescribing, NPs must obtain a certificate from the department. The certificate states whether the NP has successfully completed an appropriate pharmacology component or equivalent necessary to be authorized to prescribe. NPs may Rx drugs, devices, and immunizing agents in accordance with the WPA and WPPS. However, if an NP comes from another state, he or she must take the pharmacy law course (online). BoM/physician involvement in NP prescribing? Yes, but only related to the collaborative WPA.? Collaboration within the WPA and WPPs. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-IV changes? Tends to depend on issue strong resistance to increasing NP reimbursement autonomy. The governor just vetoed a measure that would have granted NP authority to sign a death certificate based on Department of Health recommendation that sounded suspiciously as if it had been written by the medical society. 76 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
NORTH CAROLINA NP title(s) used in this state: NP (nurse practitioner) Number of NPs in state? 2582 BoN sole state authority over NPs? No. NPs are governed by a Joint Subcommittee (JSC) of the BoN and BoM. MSN required for practice? Registration means authorization by the BoM and the BoN for an RN to use the title NP. The BoM appoints and maintains a subcommittee to work jointly with a subcommittee of the BoN to develop rules to govern the performance of medical acts. The BoM/BoN has the responsibility for securing compliance with these rules. Approval to Practice means authorization by the BoM and the BoN for an NP to perform medical acts within his or her area of educational preparation and certification under a collaborative practice agreement (CPA) with a licensed physician. NP means an RN approved to perform medical acts consistent with the nurse s area of NP academic educational preparation and national certification under an agreement with a licensed physician for ongoing supervision, consultation, collaboration, and evaluation of the medical acts performed. New rules that went into effect in August 2004 were tweaked in 2006 by the JSC to remove references to temporary approval and to move a few phrases to improve clarity. Legislative plans for state? Long-range plans are to move from the current joint regulatory model to BoN-only regulation. treating? Yes authorization)? Primary Supervising Physician means the licensed physician who, by signing the NP application, shall provide ongoing supervision, collaboration, consultation, and evaluation of the medical acts performed by the NP as defined in the CPA. The primary supervising physician shall assure both boards that the NP is qualified to perform those medical acts described in the CPA. treating? Yes authorization)? Primary Supervising Physician means the licensed physician who, by signing the NP application, shall provide ongoing supervision, collaboration, consultation, and evaluation of the medical acts performed by the NP as defined in the CPA. The primary supervising physician shall assure both boards that the NP is qualified to perform those medical acts described in the CPA. Required physician record/chart review? The primary supervising physician and the NP shall develop a process for the ongoing review of the care provided in each practice site, including a written plan for evaluating the quality of care provided for frequently encountered clinical problems. The plan must include a description of the clinical problem(s), an evaluation of the current treatment interventions, and if needed, a plan for improving outcomes within an identified time frame. The quality improvement process shall include scheduled meetings between the primary supervising physician and the nurse practitioner at least every 6 months; documentation of such meetings shall be available for review by BoN and BoM and be kept for 5 years by both the NP and physician. Required NP/physician practice agreement? Yes authority? No BoM/physician involvement in NP prescribing? Yes? Prescribing and dispensing are allowed as long as the drug or device is included in the CPA. NP authorized to Rx controlled substances? Yes, VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 79
THE PEARSON REPORT controlled substances (Schedules II, IIN, III, IIIN, IV, and V) may be procured, prescribed, or ordered as established in the CPA. Providing dosage units for Schedules II, IIN, III, and IIIN are limited to a 30-day supply, and the prescription or order for Schedules II, IIN, III, and IIIN may not be refilled. If so, which Schedules? Schedules II-V changes? Yes. The North Carolina medical board, state medical society, and other medical specialty groups and some insurers are opposed to increased NP autonomy and reimbursement. A 2006 legislative bill pushed by the medical board (to win authority to require additional scrutiny and training for any physician, physician assistant, or NP returning to active practice) was approved out of committee with modified language that did not include NPs. NORTH DAKOTA NP title(s) used in this state: APRN (advanced practice registered nurse), NP (nurse practitioner) Number of NPs in state? 308 BoN sole state authority over NPs? Yes MSN required for The APRN who wants to Rx must submit to the BoN a Collaborative Practice Affidavit Physician Agreement Prescribing Authority that requires a specified licensed physician to sign that he or she will be participating in the collaborative prescriptive agreement (CPA). The physician must acknowledge the manner of review and approval of the planned Rx practices; info in the affidavit must also indicate that the APRN s scope of practice (SoP) is appropriately related to the collaborating physician s area of expertise. No Legislative plans for state? No treating? No authorization)? NA Required physician record/chart review? No, but a BoN-provided sample SoP without Rx Authority form that must be filed with the BoN indicates that recognition of consultative and referral plan for patients is required. Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? Yes? The Prescriptive Authority Committee is composed of 4 members: 1 from the BoM, 1 from the BoP, and 2 from the BoN. The committee meets at least once each year to review rules for prescriptive authority, oversee the process of granting prescriptive authority, and recommend changes to the BoN. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V, as long as specified in the CPA. changes? Nothing major 80 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
THE PEARSON REPORT OHIO NP title(s) used in this state: CNP (certified nurse practitioner), CRNP (certified registered nurse practitioner) Number of NPs in state? 2984 BoN sole state authority over NPs? Yes MSN required for CNPs may practice only when granted a Certificate of Authority and when a standard care arrangement (SCA) with one or more collaborating physicians or podiatrists is filed at each practice site and kept current. A CNP in collaboration with one or more physicians or podiatrists may provide care consistent with his or her education and certification and BoN rules. A CNP who holds a certificate to prescribe may (in collaboration with one or more physicians or podiatrists) prescribe drugs and therapeutic devices. For a CNP working with a podiatrist, his or her SoP is limited to the procedures that the podiatrist has authority to perform. being addressed as Dr? Yes. According to medical statute ORC 4731.34 (A) (1), a person shall be regarded as practicing unauthorized medicine and surgery who uses the words or letters Dr or doctor in any way that represents the person as engaged in the practice of medicine and surgery. Recent legislative changes affecting NP Legislative plans for state? For 2007: Plan to introduce a bill to permit CNPs to admit to hospitals and a bill to eliminate certain restrictions on the types of drugs and therapeutic devices that CNPs may provide. treating? Yes authorization)? Collaboration a CNP may practice only in accordance with an SCA entered into with a physician or a podiatrist. Required physician record/chart review? As specified on the SCA, but at least annually. Required NP/physician practice agreement? Yes authority? Yes. A Certificate to Prescribe issued by the BoN authorizes the CNP to Rx drugs and therapeutic devices in collaboration with one or more physicians or podiatrists. BoM/physician involvement in NP prescribing? Yes? The CNP needs to consult the physician to initiate a medication when the formulary indicates that this is necessary for a particular drug or category of drug. The formulary contains many drugs and drug categories that require no physician consultation prior to the CNP initiating the drug. When applicable, the CNP documents the consultation in the patient s record, noting the consulting physician s name and date that the consultation took place. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V. The CNP may Rx Schedule II drugs only for a patient with a terminal condition if the CNP s collaborating physician initially prescribed it for the patient and only in an amount necessary for a 24-hour period. changes? Minimal. CNPs work collaboratively with organized Medicine in common areas of interest such as tort and malpractice reform. 82 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
OKLAHOMA NP title(s) used in this state: ARNP (advanced registered nurse practitioners), APN (advanced practice nurse) Number of NPs in state? 693 BoN sole state authority over NPs? Yes MSN required for, only for initial application for Rx authority., but minor role: BoM appoints physicians to the Formulary Advisory Council with power to select appropriate drugs for the formulary. The BoN may accept or reject the council s recommendations, but the BoN may not amend the formulary without the approval of the council. Physician involvement required for any aspect of, for Rx authority. A physician must supervise the ARNP with prescriptive authority by overseeing and accepting responsibility for the ordering and transmission of written telephonic electronic or oral prescriptions for drugs and other medical supplies subject to a defined formulary. being addressed as Dr? Yes. The Oklahoma Allopathic Medical & Surgical Licensure Act includes in the definition of the practice of Medicine that a person must not represent himself or herself as a Doctor of Medicine, Physician, Surgeon, Dr, MD, or any combination thereof. Exclusion in Medical Practice Act: optometrists, chiropractors, and podiatrists may all be addressed as doctor. In 2006, the BoN made several rule changes regarding APNs: (1) clarified national certification status, (2) addressed requirements for APNs who want to change their national certification, (3) clarified that the BoN reviews and approves certifying bodies and certifications, (4) added a new specialty (acute care pediatric ARNP) to the types of ARNP specialties, (5) clarified language regarding CE categories, (6) clarified requirements for Rx authority for APNs and added a definition for CE credit, (7) clarified the required time period allowed for APNs to notify the BoN of DEA number, and (8) added a rule clarifying that the APN must have a supervising physician on file with the BoN prior to prescribing drugs or medical supplies. Legislative plans/administrative for state? Goals: to develop NP/legislator relationships; to seek removal of 7-day limit on controlled substance prescriptions; to delete school nurse ARNP from the Rules because the certification exam is no longer available; to clarify requirements for reinstatement/ return to active Rx authority. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? Yes? An ARNP is eligible to obtain recognition by the BoN to prescribe if he or she is subject to the medical direction of a supervising physician. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules III-V. The ARNP may not Rx more than a 7-day supply for these drugs and must Rx in accordance with the Exclusionary Formulary. changes? State DOs fought the proposed BoN regulatory ruling regarding performing digital blocks, but NPs prevailed. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 83
THE PEARSON REPORT OREGON NP title(s) used in this state: NP (nurse practitioner) Number of NPs in state? 2145 BoN sole state authority over NPs? Yes MSN required for, with some exceptions available for persons educated before 1986. NA being addressed as Dr? Yes. Two mentions in Medical Practice Act: (1) Medicine Act 677.060 states: Nothing (in statute) prevents the use of the words Doctor or Specialist, or any abbreviation or combination thereof, or any letters or words of similar import by any person duly licensed to practice optometry within Oregon ; and (2) Statute ORS 677.085 states: A person is practicing Medicine if the person does one or more of the following use the words Doctor, Physician, Surgeon, or any abbreviations or combination thereof, or any letters or words of similar import in connection with the name of the person, or any trade name in which the person is interested, in the conduct of any occupation or profession pertaining to the diagnosis or treatment of human diseases or conditions The BoN considers it improper if a person uses the term Doctor and does not use his or her legal title of licensure in connection with it (eg, FNP, WHCNP, ANP). In 2005, SB 880 added NP to statutes that had been MD-specific; accomplished by a team of 38 NPs who reviewed more than 750 Oregon statutes looking for places in which NPs were appropriate but excluded as providers. CNS prescriptive authority passed with rules being written for mid-2006. Legislative plans for state? Yes next legislative session in 2007. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes. BoN-authorized NPs with Rx Authority are authorized to Rx all over-the-counter drugs and appliances and devices (ie, an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component part or accessory, that is required under federal or state law to be prescribed by a practitioner and dispensed by a pharmacist) in addition to Rx drugs. BoM/physician involvement in NP prescribing? No? NA NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? In general, the state medical society is supportive of NPs; for the latest dispensing expansion, the medical society remained neutral and the BoP was in opposition. 84 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
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THE PEARSON REPORT PENNSYLVANIA NP title(s) used in this state: CRNP (certified registered nurse practitioner) Number of NPs in state? 6269, for new licensees after February 2005. BoN sole state authority over NPs? Yes MSN required for, for new applicants as of February 2005. The CRNP performs acts of medical diagnosis or Rx of medical therapeutic or corrective measures in collaboration with and under the direction of a state-licensed physician. The direction includes the establishing and updating of standing orders, drug orders, and other medical protocols within the practice setting, and co-signing records when necessary to document accountability by both the CRNP and supervising physician. SB 1208 (2002) removed the under the direction of language and made it collaboration, but the BoN regulations have not been finalized., but as specified in the NPA, a CRNP who holds a doctorate should take appropriate steps to inform patients that the CRNP is not a Doctor of Medicine or a Doctor of Osteopathic Medicine. All CRNPs, regardless of specialty, can now receive a provider number from Medicare. Legislative plans for state? Seeking revisions of CRNP regulations so as to remove the need for name tags, remove the requirement for ratios of supervising MDs to CRNPs, remove the requirement for collaborative agreements to be filed with the BoN, and require doctoral preparation for NP program directors. Anticipated revision of regulations: change welfare code to allow NPs to perform physicals for TANF (Temporary Assistance to Needy Families) disability and change school code to allow teacher physicals. Also working on regulation change to allow NPs to do psychiatric evaluations for Medicaid patients. treating? Yes authorization)? Collaboration, defined by statute as a process in which a CRNP works with one or more physicians to deliver health care within the scope of the CRNP s expertise. Required physician record/chart review? Collaborating physician must be willing to be available for chart review on a regular basis. Required NP/physician practice agreement? Yes. NP/physician agreement to practice collaboratively must be a signed written agreement kept at the practice site. The regulations require a written practice agreement only for prescriptive authority. authority? Yes BoM/physician involvement in NP prescribing? Yes? Collaborative per written signed agreement. In addition, a Drug Review Committee composed of APNs, physicians, and pharmacists is charged with approving or disapproving any changes proposed by the BoN to the categories from which NPs may prescribe. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-IV, but Schedule II is limited to 72-hour supply and Schedule III-IV is limited to 30-day supply. changes? No 86 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
NP title(s) used in this state: RNP (certified registered nurse practitioner) Number of NPs in state? 673 RHODE ISLAND BoN sole state authority over NPs? Yes. Prescriptive privileges for the RNP are granted from the Department of Health and Office of Health Services Regulation, Board of Nurse Registration and Nursing Education (BoN). MSN required for Physician involvement required for any aspect of Individual NP/physician collaboration in writing is for prescriptions only. In addition, an Advanced Nurse Practice Council composed of 2 RNPs, 2 CRNAs, 2 psychiatric and mental health CNSs and 1 physician has been created to improve patient care, review complaints regarding APNs, and to report periodically to the BoN regarding advanced practice. Yes. A new law allows for the global signature authority of the RNP (ie, whenever any provision of the general or public law or regulation requires a signature, certification, stamp, verification, affidavit, or endorsement by a physician, it shall be deemed to include a signature, certification, stamp, verification, affidavit, or endorsement by an RNP, provided that nothing shall be construed to expand the scope of practice of the RNP). Legislative plans for state? No treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? No BoM/physician involvement in NP prescribing? Yes? An RNP must Rx in accordance with annually updated guidelines written in collaboration with the medical director or physician consultant of his or her medical establishment. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? No VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 87
THE PEARSON REPORT SOUTH CAROLINA NP title(s) used in this state: APRN (advanced practice registered nurse), NP (nurse practitioner) Number of NPs in state? 3000 BoN sole state authority over NPs? No MSN required for. Additional acts that constitute delegated medical acts must be agreed to jointly by the BoN and the Board of Medical Examiners (BoM) and must be promulgated by the BoN in regulation. Physician involvement required for any aspect of Supervision by physician who delegates medical acts as outlined in collaboratively developed approved written protocols (AWPs) that are subject to joint BoN/BoM approval. 2006: New law allows APRNs (in addition to physicians) to perform physical examinations on school bus drivers. 2004: (1) APRN licensure, definitions, and title protection; (2) expanded Rx authority to include Schedules III-V; (3) licensure based upon credentials; and (4) ability to collaborate with an electronically available supervising physician. Legislative plans for state? Yes. Although vetoed in 2006, an amendment will be sought to repeal recent requirement that every prescribing NP must register with the state controlled substances (CS) division and the federal FDA, regardless of whether or not the NP intends to prescribe CS. If the amendment passes, then NPs will have the same requirement for state and federal registration as all other prescribers in the state. treating? Yes authorization)? Supervision by physician who delegates medical acts as outlined in collaboratively developed AWPs that are subject to joint BoN/BoM approval. NPs who perform delegated medical acts must have a supervising physician or dentist who is readily available for consultation. When an application is made for more than 3 NPs to practice with 1 physician or when an NP is performing delegated medical acts in a practice site greater than 45 miles from the supervising physician, the BoN and BoM shall each review the application to determine if adequate supervision exists. Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? Yes? Authority to prescribe is delegated by supervising physician as outlined in collaboratively developed AWPs that are subject to joint BoN/BoM approval. Authorized prescriptions are limited to drugs and devices used to treat common, well-defined medical problems within the NP s specialty. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules III-V changes? Yes, there is always concern when APRNs expand their practice. 88 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
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THE PEARSON REPORT SOUTH DAKOTA NP title(s) used in this state: CNP (certified nurse practitioner) Number of NPs in state? 320 BoN sole state authority over NPs? No MSN required for. Practice as an NP is subject to the joint control and regulation of the BoN and the South Dakota Board of Medical and Osteopathic Examiners (BoM). The joint boards may license, supervise the practice, and revoke or suspend licenses or otherwise discipline any person applying for or practicing as an NP. The BoN shall appoint an APN advisory committee composed of 2 CNMs and four CNPs. Committee members shall meet annually and assist the boards in evaluating standards of APN care and the R&R for CNPs and CNMs. Physician involvement required for any aspect of An NP may perform the overlapping scope of APN and medical functions only under the terms of a required collaborative agreement (CA) with a physician. Collaboration may be by direct personal contact, or by a combination of direct personal contact and indirect contact via telecommunication, as may be required by the BoN and BoM., but there is some concern that the BoM could cite SDCL 36-4-9 Use of title and other acts constituting the practice of Medicine section of the statute to hassle CNPs with doctorate from using their earned and justified appropriate title of Dr. 2006: NPs and CNMs may prescribe Schedule II drugs for up to 30 days (previous legislation restricted Rx to 48 hours). Legislative plans for state? Not at this point. treating? Yes authorization)? A CNP may perform overlapping scope of practice of APN and medical functions, including initial medical diagnosis and institution of plan of therapy or referral as delineated in the CA with licensed South Dakota physician. Required physician record/chart review? Collaboration between CNP and physician must occur no less than one-half day a week or a minimum of 1 hour per 10 hours of practice by direct personal contact. Direct personal contact means that both the collaborating physician and the CNP are physically present onsite and available for purposes of collaboration. Required NP/physician practice agreement? Yes. A CA defines or describes the agreed-upon overlapping scope of APN and medical functions that may be performed and contains other information as required by the BoN and BoM. authority? No BoM/physician involvement in NP prescribing? Yes? A CNP may prescribe medications as a function of overlapping scope of medical functions only with an approved CA on file with the BoN and BoM. A CNP may prescribe medications and provide drug samples or a limited supply of labeled medications, including controlled drugs or substances listed on Schedule II for one period of not more than 30 days, for treatment of causative factors and symptoms. NP authorized to Rx controlled substances? Yes, as described above. If so, which Schedules? Schedules II-V, but Schedule II substances must not be prescribed for a period longer than 30 days. changes? Yes, historically from both the state medical society and the state pharmaceutical association when NP legislation seeks expansion of autonomy. 90 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
TENNESSEE NP title(s) used in this state: APN (advanced practice nurse), NP (nurse practitioner) Number of NPs in state? 3466 (of these, 3408 have authority to prescribe) NP title protection? The umbrella APN credential issued upon BoN certification is expressly protected, but that protection may be inferred to extend to the specific titles covered by the APN designation (ie, NP, CNM, CRNA, and CNS). BoN sole state authority over NPs? Yes. However, prescribing NPs are under rules that were jointly adopted by the BoN and the Board of Medical Examiners (BME). Under these rules, physicians supervising NP prescriptive practice are regulated by the BME whereas NPs are regulated by the BoN. MSN required for, beginning July 2006.. Rules governing the practice of NP prescribing are jointly adopted by the BME and the BoN. Physician involvement required for any aspect of, for prescribing NPs. The supervising physician in a collaborative NP/physician practice shall be responsible for ensuring compliance with the applicable standard of care outlined in jointly developed and approved protocols. In addition, the supervising physician shall develop clinical guidelines in collaboration with the NP to include a method for documenting consultation and referral, and shall supervise, control, and be responsible for the prescriptive services rendered by the NP. None Legislative plans for state? Goal to increase prescriptive autonomy. treating? No. NPs meeting requirements to practice but who do not include prescribing documentation with their application to practice and who do not request prescriptive authority are issued APN certificate without prescriptive writing privileges. authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes. Qualified applicants who submit prescribing documentation with their application to practice are issued an APN certificate with prescription writing privileges (COF). Qualifications to prescribe include current registered nurse licensure, a master s degree in a nursing clinical specialty area, three (3) quarter hours of pharmacology, national certification, and evidence of specialized practitioner skills. Once an NP has a COF and establishes joint protocols and files a notice of formulary and name of a supervisory physician with the BoN, he or she is authorized to prescribe and/or issue legend drugs. BoM/physician involvement in NP prescribing? Yes? Supervision, control, and responsibility. Under BoM rules, the supervising physician must sign (minimum of 20% of charts) the NP s chart documentation within 30 days for any patient for whom the NP prescribes a controlled drug. NP authorized to Rx controlled substances? Yes If so, which Schedules? An NP who holds a COF is authorized to prescribe and/or issue controlled substances (CS) listed in Schedules II-V upon joint adoption of physician supervisory rules concerning CS. changes? General opposition by organized Medicine. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 91
THE PEARSON REPORT TEXAS NP title(s) used in this state: NP (nurse practitioner; must indicate BoN-approved specialty) Number of NPs in state? 6372 BoN sole state authority over NPs? Yes MSN required for practice? No. The BoM regulates physician delegation. Delegation and supervision of medical aspects of patient care, including diagnosis and prescriptions. Protocols or other written authorization are required to provide medical aspects of patient care that are agreed upon and signed by the NP and the physician., as long as the NP clarifies the basis of the title that he or she is not a physician (per Section 104.004 of Texas Occupations Code related to Other Persons Using Title Doctor ). The state Regular Legislative Session meets once every other year a session is due to have begun in January 2007. By rule, the Medicaid reimbursement increased to 92%. Legislative plans for state? An agreement between NPs and medical organizations prohibits NPs from supporting any legislative initiatives that would change the way NPs and physicians practice. The BoN is undergoing Sunset Review prior to the 2007 session, and the NPA will be revised in accordance with recommendation of the Sunset Review Commission. treating? Yes authorization)? Delegation and supervision of medical aspects of care. NPs use mechanisms (ie, protocols/policies/practice guidelines/clinical practice privileges) that provide authority from the physician for that care. Such protocols or other written authorization need not describe the exact steps that NPs must take with respect to each specific condition, disease, or symptom. The degree of detail within the protocols or other written authorization may vary in relation to the complexity of the situations covered, the advanced specialty area of practice, the advanced educational preparation of the individual NP, and the experience level of the individual NP. Required physician record/chart review? Yes, but only in relation to prescriptive authority. A review of 10% of charts is required in medically underserved and alternate practice sites. Required NP/physician practice agreement? Yes. Protocols or other written authorization is reviewed and signed at least annually and maintained in the NP s practice setting. authority? Yes. The APN with a valid Rx authorization number shall (1) carry out or sign Rx drug orders for only those drugs that are authorized by protocols or other written authorization for medical aspects of patient care, (2) prescribe for patient populations within the accepted scope of professional practice for the NP s specialty area, and (3) comply with the requirements for adequate physician supervision published in the rules of the BoM relating to Delegation of the Carrying Out or Signing of Prescription Drug Orders to Advanced Practice Nurses. BoM/physician involvement in NP prescribing? Yes? In order to Rx, the NP must work at a site where physicians are permitted to delegate Rx authority within protocols or other written authorization. The Medical Practice Act and BoM require that a physician meet certain supervisory requirements that vary 92 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
Legal Products for NPs from the Law Office of Carolyn Buppert Quantity Item Price Total Avoiding Malpractice: 10 Rules, 5 Systems, 20 Cases (79-page booklet, published 2006) The Green Sheet: The latest on compensation and reimbursement for NPs (monthly newsletter) The Gold Sheet: The latest on quality for NPs (monthly newsletter) $35/ea $45/yr $45/yr Safe, Smart Billing and Coding for Evaluation and $99 per individual Management (2006) A training package on compact disk: licensee, 6 modules, including billing, coding background, coding history, $600 for licensed coding exam, coding medical decision-making, pearls use by an (290 Power Point slides, Power Point viewer included), educational track simplified documentation guidelines, coding exercises, coding text Template Employment Contract for an NP $250 (13 pages, with 12 pages of instructions) in Word 6.0 for Windows in Word Perfect 6.0 Billing physician services provided by NPs in specialists $89 offices, hospitals, nursing homes, homes and hospice (175-page book, 2006) Negotiating Employment $35 (64-page booklet with self-assessment tools, published 2006) NP Data Tracker, Version 2 $199 Access-based software for tracking billings and clinical outcomes Prescribing: Preventing Legal Pitfalls for Nurse Practitioners $49 (120-page book, published 2006) Productivity Incentive Plans for Nurse Practitioners $89 (154-page book, published 2006) Subtotal Maryland residents must by law include 5% sales tax Total enclosed Handling/mailing is included in the prices listed above. Purchaser/licensee Name Address Credit card # Exp. date C.V.V.2 code Telephone # Email address Or, send a check payable to Law Office of Carolyn Buppert and mail to: 7972 Old Georgetown Road, Bethesda, MD 20814 For additional information, visit www.buppert.com TO ORDER The Nurse Practitioner s Business Practice and Legal Guide (Jones & Bartlett, 2004) The Primary Care Provider s Guide to Compensation and Quality (Jones & Bartlett, 2005). Visit jbpub.com VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 93
THE PEARSON REPORT based on the practice site. When working at a practice site serving a medically underserved population, the APN must have access to the delegating physician, provide a daily status report to the physician on any problems or complications, and be available during onsite visits by the physician with the APN at least once every 10 business days. When working at an alternate site, the APN shall be onsite with the physician at least 20% of the time and have access to the physician through direct telecommunication. When working at a facility-based practice site, the APN shall sign or co-sign Rx drug orders for the care or treatment of only those patients for whom physicians have given prior consent. The BoM may waive certain site/supervisory requirements. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules III, IV, or V limited to 30 days refillable only upon consultation with delegating physician. Any controlled substance (CS) Rx for patient <2 years old requires delegating physician consultation. All CS prescriptions must show not only NP s DEA # but also physician s DEA #. changes? Any changes are opposed by the Texas Medical Association (TMA), with 40,000 members, and by a coalition of TMA and specialty medical societies calling itself PatientsFIRST. An agreement between NPs and medical organizations prohibits NPs from supporting any legislative initiatives that would change the way NPs and physicians practice in 2007. UTAH NP title(s) used in this state: APRN (advanced practice registered nurse), RNP (registered nurse practitioner), NP (nurse practitioner) Number of NPs in state? 1077 BoN sole state authority over NPs? Yes. However, the BoN is advisory to the Utah Division of Occupational and Professional Licensing, the agency that oversees licensure of approximately 60 different occupations and professions. MSN required for An APRN who chooses to prescribe Schedule II-III controlled substances (CS) must have a completed Consultation and Referral Plan on file at the practice site. The written plan must describe the process of consultation, including how it will be documented and a description of how referrals will be made. The plan must be signed by the consulting physician. No Legislative plans for state? Yes. NPs plan to work on legislation that will allow them to sign death certificates and handicap permits and to eliminate the requirement for a consultation or referral plan with a physician for the prescription of Schedule II CS; they will also seek to include CRNAs and CNMs in the APRN compact. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? No (for new applicants). BoM/physician involvement in NP prescribing? Yes? The APRN must have a consultation and referral plan on file if prescribing Schedule II-III CS. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? No; tends to be issue specific. 94 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
VERMONT NP title(s) used in this state: APRN (advanced practice registered nurse) Number of NPs in state? 519 BoN sole state authority over NPs? Yes MSN required for The collaborating physician is a qualified statelicensed physician who has formally agreed to be available for consultation, collaboration, and referral. None Legislative plans for state? Goal is for healthcare reform, including possible universal healthcare with increased public oversight or mandated budgets for hospitals. Also will strive for a rule change eliminating the collaborative agreement requirement for endorsement as an NP. treating? Yes authorization)? The APRN acts independently, consistent with written practice guidelines (WPGs), with a collaborating physician in the appropriate specialty area for all related medical functions or by clinical privileges approved by the facility or facilities at which the APRN practices. WPGs must be mutually agreed upon between the APRN and collaborating physician and must reflect current standards of medical and nursing practice. Required physician record/chart review? Yes, as per the required submission of quality assurance, which is described by the BoN as a letter written by the APRN and signed by the APRN and collaborating physician describing the method the APRN will use concerning chart/care review and collaboration and conferencing. Required NP/physician practice agreement? Yes. WPGs, mutually agreed upon by the APRN and collaborating physician and jointly acceptable to the medical and nursing professions, are reviewed and approved by the BoN. WPGs must include (1) a description of the clinical practice, including practice site, focus of care, and general category of patients; (2) an indexed copy of standards for clinical practice, including method of data collection, assessment, plan of care, and criteria for collaboration, consultation, and referral and the name of at least 1 physician who will be routinely contacted for collaboration, consultation, and referral; and (3) methods of quality assurance. authority? No BoM/physician involvement in NP prescribing? Yes? A collaborating physician agrees to the WPGs (which specify which medications are to be prescribed by the APRN) and must be routinely contacted for collaboration, consultation, and referral, and the APRN s methods of quality assurance. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? No active opposition, although anesthesiologists and some obstetricians are vocal about their competition. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 95
THE PEARSON REPORT VIRGINIA NP title(s) used in this state: LNP (licensed nurse practitioner), APN (advanced practice nurse), NP (nurse practitioner) Number of NPs in state? 5167 practice? Initial licensure requires evidence of professional certification that is consistent with the specialty area of the LNP s educational preparation. License by endorsement also requires evidence of national certification consistent with the specialty area of the LNP s educational preparation. To renew a license, an LNP licensed on or after May 8, 2002, shall hold current professional certification in an area of specialty practice from one of the national certifying agencies designated by the boards. LNPs licensed prior to May 8, 2002, must hold current professional certification in an area of specialty practice from one of the national certifying agencies designated by the boards or complete at least 40 hours of CE in the area of specialty practice approved by one of the national certifying agencies designated by the boards. BoN sole state authority over NPs? No MSN required for. BoN and BoM appoint 3 members each to the Committee of the Joint Boards of Nursing and Medicine, which administers the R&R for LNPs. An LNP is authorized to engage in practices constituting the practice of Medicine in collaboration with and under the medical direction and supervision of a licensed physician. Medical direction means participation in the development of a written protocol (WP) including (1) delineation of periodic review and revision, (2) development of guidelines for ongoing communications defining consultation between the LNP and physician, (3) periodic joint evaluation (eg, chart review, case review, review of patient care outcomes), and (4) guidelines addressing the minimum availability of the collaborating physician related to the practice site, geography, and acuity. CNMs are authorized to engage in practices constituting the practice of Medicine in collaboration and consultation with a duly licensed physician when such services are authorized by regulations promulgated by the joint boards of medicine and nursing. Emergency regulations defining collaboration and consultation are in the process of being developed and will go into effect no later than May 2007., but there is a requirement that any person who uses the Dr title and is not a physician must also use the appropriate designation following his or her name to be clear that he or she is not a physician. 2006 legislation: Senate Bill 456 (effective July 2006) expanded the prescriptive authority of Virginia s NPs to include Schedule II drugs. Legislative plans for state? (1) Review the outcome of the 2004 legislation Signature and Certification law to determine whether additional changes are needed, (2) monitor implementation of Medicaid s decision to reimburse NPs directly, (3) evaluate end-of-life issues, including the physician only signature requirement on Do-Not- Resuscitate Orders, and (4) review the possibility of NP liability in relation to a physician s immunity for failing to review or act in regard to laboratory tests or examinations that the physician did not order. treating? Yes authorization)? Collaboration means the process whereby an LNP delivers health care with medical direction and supervision from a physician. Medical direction means participation in the development of a WP including (1) delineation of periodic review and revision, (2) development of guidelines for ongoing communications defining consultation between the LNP and physician, (3) periodic joint evaluation (eg, chart review, case review, review of patient care outcomes), and (4) guidelines addressing the minimum availability of the collaborating physician related to the practice 96 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
This message provided by NP Communications, LLC Coming Up in Future Issues of The American Journal for Nurse Practitioners Clinical Rationale for Continuous Oral Contraception, by Susan Wysocki, RNC, NP, FAANP Quick Guide to Rule Out Chest Pain Emergencies, by Shannon E. Runion, RN, BS and Elizabeth M. Lamb, RN, BS Inverse Psoriasis: A Case Report, by Nancy M. George, PhD, APRN,BC and Karen Nichols, MS, APRN,BC Stop, Assess, and Motivate: The SAM Approach to Autism, by Rebecca A. Belschner, CRNP Centering Pregnancy: A Paradigm Shift for Adolescent Prenatal Care, by Amber H. Moeller, BSN, RN; Toni M. Vezeau, PhD, RNC; and Katherine Camacho Carr, PhD, ARNP, CNM Optimizing Clinical Use of Handheld Technology: PDAs for APRNs, by Rebecca Koeniger-Donohue, PhD, APRN, RNC and Shannon L. Bisbee, RN, MSN(c) Continued on page 102 VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 97
MEETINGS & EVENTS MARCH 11-14, 2007: The Northwest Chicago Area Chapter of the American Association of Critical-Care Nurses (NWCAC- AACN) will hold its 33rd Annual Midwest Conference at the Sheraton Chicago Northwest Hotel in Arlington Heights, Illinois. Costs vary for the conference based on the number of days attended, with the opportunity to obtain more than 90 CEUs. For more information, please contact Jodi Gunther at (847) 526-5865 or at jlg0618@aol.com. Copies of the brochure may be downloaded from the NWCAC-AACN website at www.aacn.org/nwcac MARCH 21-24, 2007: The National Association of Pediatric Nurse Practitioners (NAPNAP) will hold its 28th Annual Conference on Pediatric Healthcare: Rediscovering the Magic, at Disney s Coronado Springs Resort in Lake Buena Vista, Florida. For more information, visit the NAPNAP website at www.napnap.org MARCH 22-24, 2007: The Texas Association of Neonatal Nurse Practitioners (TxANNP) will hold its 3rd Annual Conference at the Moody Gardens Hotel, Spa, & Resort in Galveston, Texas. For information and registration, visit the TxANNP website at www.txannp.org MARCH 26-29, 2007: Carol Molfetta Health Education is offering a Diabetes Core Curriculum Workshop at the Sheraton LaGuardia East Hotel in Queens, New York. This comprehensive diabetes update will help nurses and APNs study for the Certified Diabetes Educator (CDE) exam. For more information, please contact Carol Molfetta, RD, CDE, by phone at (631)754-3663 or by email at carol@healthbyte.org or log on to http://www.healthbyte.org MARCH 28-APRIL 1, 2007: The California Association for Nurse Practitioners (CANP) will be holding its 2007 Annual Conference at the Sheraton Grand Hotel in Sacramento. For more information, log on to the CANP website at www.canpweb.org APRIL 10-14, 2007: The National Kidney Foundation will hold its 2007 Clinical Meetings at the Walt Disney World Swan and Dolphin Hotel in Orlando, Florida. Prospective attendees can register online at www.nkfclini calmeetings.org APRIL 12-15, 2007: The National Organization of Nurse Practitioner Faculties (NONPF) will hold its 33rd Annual Meeting at the Grand Hyatt Downtown in Denver, Colorado. For more information, check the NONPF website at www.nonpf.org/ MAY 18-19, 2007: Utah Nurse Practitioners will hold its 14th Annual Pharmacology Conference at the Thanksgiving Point Convention Center in Lehi, Utah. For more information, please send an email to unppharm2007@hotmail.com MAY 19-24, 2007: The American Association of Critical-Care Nurses (AACN) will hold its National Teaching Institute (NTI) & Critical Care Exposition at the Georgia World Congress Center in Atlanta, Georgia. For more information, call AACN at (800) 899-2226, send a fax to (949) 362-2020, send an email to ntimail@aacn.org, or log on to the AACN website at www. aacn.org/nti JUNE 7-10, 2007: The American Holistic Nurses Association (AHNA) will hold its 27th Annual Conference, Wheels of Life: Celebrating Transitions, in Lake Tahoe, California. For more information, log on to the AHNA website at http://www.ahna.org/events/ 2007.html or contact Angela Krupica at education@ahna.org or at (928) 526-2752, ext 11. JULY 12-15, 2007: The 32nd National Primary Care Nurse Practitioner Symposium, also known as the Keystone Conference, will take place at the Keystone Resort in Keystone, Colorado. The conference is sponsored by the University of Colorado at Denver and Health Sciences Center School of Nursing. For more information, log on to www.uchsc.edu/nursing/nps.htm AUGUST 27-29, 2007: The American Association of Spinal Cord Injury Nurses (AASCIN) cordially invites nurses and nurse researchers specializing in spinal cord injuries and disorders to attend the 2007 North American Spinal Cord Injury Conference & Disability Expo, which will be held at the Gaylord Palms Resort & Convention Center, in Orlando, Florida. The deadline for registration is July 1, 2007. For more information, visit www.aascin.org OCTOBER 10-13, 2007: The National Association of Nurse Practitioners in Women s Health (NPWH) will hold its 10th Annual Conference at the Sheraton Philadelphia in Philadelphia, Pennsylvania. For more information about the conference, please log on to www.npwh.org 98 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
site, geography, and acuity. Required physician record/chart review? Yes, per WP between the physician and LNP. Required NP/physician practice agreement? No. R&R require an LNP without Rx authority to develop a practice agreement. authority? Yes BoM/physician involvement in NP prescribing? Yes? An LNP with Rx authority may prescribe only within the scope of a written practice agreement (WPA) with a supervising physician. A physician who enters into a WPA with an LNP for prescriptive authority shall (1) supervise and direct, at any one time no more than 4 LNPs with prescriptive authority, (2) regularly practice in any location in which the LNP exercises prescriptive authority (if a supervising physician does not regularly practice at the same location as the LNP, the physician shall make regular site visits for consultation and direction for appropriate patient management), and (3) conduct a monthly random review of patient charts on which the LNP has a prescription for an approved drug or device. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Yes WASHINGTON NP title(s) used in this state: ARNP (advanced registered nurse practitioner) Number of NPs in state? 3822 BoN sole state authority over NPs? Yes MSN required for. However, a graduate degree with a concentration in advanced practice nursing is required if the program was completed after January 1, 1995. NA Legislation in 2006 amends the pharmacy act by requiring that all prescriptions from all prescribing providers be hand-printed, typewritten, or electronically generated. All cursive writing will be considered illegible and will no longer meet the definition of a legible prescription. Legislative plans for state? Yes still in planning phase. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes. An ARNP applies for authorization to prescribe after completion of pharmacologic education requirement. The ARNP is then authorized to prescribe drugs within his or her scope of practice; this authorization is valid only with a current RN license. BoM/physician involvement in NP prescribing? No? NA NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Yes. The state medical association has a history of trying to control or limit APRN practice whenever its interest is served by doing so. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 99
THE PEARSON REPORT WEST VIRGINIA NP title(s) used in this state: ANP (advanced nurse practitioner) Number of NPs in state? 1075 NP title protection? No BoN sole state authority over NPs? Yes MSN required for The ANP applying for Limited Prescriptive Authority must provide written verification of an agreement to a collaborative relationship with a licensed physician for Rx practice. No. Legislative plans for state? None planned by BoN. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? Yes BoM/physician involvement in NP prescribing? Yes? The ANP applying for Limited Prescriptive Authority must submit to the BoN a voided sample of his or her prescription form and written verification of an agreement to a collaborative relationship with a licensed physician. The ANP must certify that his or her collaborative agreement (CA) includes (1) agreed-upon written guidelines (WGs) or written protocols (WPs), (2) statements describing the individual and shared responsibilities of the ANP and the physician, (3) provision for the periodic and joint evaluation of the prescriptive practice, and (4) provision for the periodic and joint review and updating of the WGs or WPs. The BoN shall forward a copy of the verification to the BoM or to the Board of Osteopathy. NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules III-V. The ANP must file with the BoN any restrictions on Rx authority that are agreed to within the written CA and the collaborating physician(s). changes? Not currently. WISCONSIN NP title(s) used in this state: APN (advanced practice nurse), APNP (advanced practice nurse prescriber), NP (nurse practitioner) Number of NPs in state? 2533 APNPs BoN sole state authority over NPs? Yes MSN required for, a master s degree in nursing or a related health field. collaboration, supervision, direction, delegation, authorization)? For APNPs, collaborative practice under a written practice agreement with independent prescribing authority. NP is a non-protected title that means an RN whose practice of professional nursing includes the performance of delegated medical services under 100 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2
the supervision of a physician, dentist, or podiatrist. A 2006 legislative act amended about 30 selected statutes allowing APNPs to order or authorize release of information to a variety of organizations and provides civil liability protection. Legislative plans for state? A pending bill (Assembly Bill 683) specifies that APNPs may perform various medically related acts that are currently allowed for physicians and other healthcare professionals. treating? Yes (eg, Collaboration for qualified APNs and APNPs; supervision for RNs functioning as NPs in the performance of delegated medical services at the discretion of a physician, dentist, optometrist, or podiatrist. Required physician record/chart review? No Required NP/physician practice agreement? Yes. The APNP and the physician must document their collaborative relationship; the RN following physician-delegated medical acts must follow protocols or written or verbal orders. authority? Yes. An APNP is an APN who has been granted a certificate to independently issue prescription orders. An APN may not independently prescribe unless he or she holds a current APNP certificate granted by the BoN. BoM/physician involvement in NP prescribing? Yes? RNs may prescribe (including controlled substances) as a delegated medical act under the NPA. APN prescribers shall facilitate collaboration with other healthcare professionals, at least one of whom must be a physician, through use of modern communication techniques. NP authorized to Rx controlled substances? Yes, APNPs independently, and APNs and RNs under supervision. If so, which Schedules? Schedule II-V, with certain limitations on CSII prescribing. changes? Not currently. WYOMING NP title(s) used in this state: APRN (advanced practice registered nurse) Number of NPs in state: 341 BoN sole state authority over NPs? Yes MSN required for NA Not in 2006 Legislative plans for state? Primary efforts relate to revising all chapters of the R&R as a result of the 2005 NPA revisions. treating? No authorization)? NA Required physician record/chart review? No Required NP/physician practice agreement? No authority? No BoM/physician involvement in NP prescribing? No? NA NP authorized to Rx controlled substances? Yes If so, which Schedules? Schedules II-V changes? Not at present. VOL. 11 NO. 2 FEBRUARY 2007 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 101
OPPORTUNITIES FOR NPs COMING UP IN AJNP Continued from page 97 Mid-Coast Mental Health Center is a full-service, state licensed behavioral health center that provides outpatient services to those of all ages who are facing life stresses, behavioral health problems or a mental illness. Since opening our doors in 1965, we are constantly expanding our services to meet the growing needs of our community. Our services include psychiatry services, case management, residential services and crisis care. PSYCHIATRIC NURSE PRACTITIONERS Rockland, ME Full-time, day shift positions available Join a team of nursing professionals committed to providing quality health care services to our community! Working collectively in a collegial atmosphere, provide psychiatric diagnosis and treatment focusing on supportive psychotherapy and medication management. Additionally, provide services to patients from diverse backgrounds, primarily chronically ill clients, and ensure appropriate documentation, team support and collaboration with therapists and community support workers. All candidates must hold a state of Maine Nurse Practitioner licensure and have a minimum of two years experience. Pen Bay Healthcare provides competitive salaries, an excellent benefits package, generous paid time off, and the opportunity to join a multi-faceted organization. Interested candidates are encouraged to apply online at www.penbayhealthcare.org or for questions or assistance, please contact us at (207) 701-4406. EOE Mid-Coast Mental Health is a member of the Pen Bay Healthcare family of services. WHEN YOU RE READY FOR MORE IN YOUR CAREER, GO TO www.penbayhealthcare.org Help others. Help yourself. Nurse Practitioner positions now available Provide in-patient mental status assessments Conduct short-term counseling services Staff in the Comprehensive Psychiatric Emergency Program Requirements: NP specialization in psychiatry Clinical experience in psychiatry preferred Current or eligible for NYS RN and NP Licensure What you need. When you need it. United Health Services Hospitals is ranked in the top 10% in employee satisfaction nationwide. To learn more or apply, www.uhs.net EOE Leadership Skills Development Among Nurse Practitioners, by Sharon Judkins, RN, PhD, CNAA, BC and Anne- Gret Friedrich-Cuntz, RN, MS Nausea and Vomiting of Pregnancy: Clinical Management, by Lauren P. Hunter, PhD, CNM, WHNP, FACNM; Christine Ann Sullivan, PhD, CNM, FNP; Robert E. Young, MD, FACOG; and Charles E. Weber, PharmD All Bugs Aren t Bad: Probiotics in the Treatment of Pediatric Atopic Dermatitis, by Gabrielle Schuerman, MA, RN, FNP Role of Decision-Making in Women s Self-Diagnosis and Management of Vaginitis, by Petra Goodman, RN, PhD; JoAnne Herman, RN, PhD; Carolyn L. Murdaugh, RN, PhD; Linda D. Moneyham, RN, DNS; and Kenneth D. Phillips, RN, PhD Tick-Borne Illnesses: Beyond Lyme Disease, by LCDR Barbara Ann Mullen, NC, USN, MSN, APRN,BC Appropriate Use of Antibiotics in Community- Acquired Lower Respiratory Tract Infections, by Mary Knudtson, DNSc, NP 102 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS FEBRUARY 2007 VOL. 11 NO. 2