Nurse Practitioner Scope of Practice

A nurse practitioner’s Scope of Practice represents the full range of practice privileges allowed by certification and licensure. The American Nurses Association defines the scope of practice as the “who, what, where, when, why and how of nursing practice.” It incorporates the needs of the patient population with regard to evaluation and treatment, including the capacity to be paid for services rendered and the limitations of practice. For example, an NP is able to order diagnostic testing and prescribe medications, which is typically broader in scope than that of an RN. In addition to the practice privileges accorded for core certification within a population focus, specialty certifications can expand an NPs scope of practice through added competency and education in a specialized area of practice.

Each state’s Nurse Practice Act will also define the NPs scope of practice based on that state’s legislation. For example, many states give NPs the authority to prescribe Schedule II controlled medications, while others limit controlled substance prescribing or require the signature of the NP plus that of the collaborating physician.
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Because a nurse practitioner utilizes theoretical knowledge and scientific process in practice, the NP has a unique combination of skills that provide a broad range of practice options. The more commonly recognized responsibilities of an NP include health care provider, educator, consultant, researcher, administrator, and coach. And, because NPs have consistently focused on health promotion and ways to reduce the impact of disease, their services have become well-respected by patients and physician colleagues alike.

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For new NPs, the scope of practice will now extend to the medical diagnosis and treatment of patients with acute, episodic, or chronic medical conditions. Many nurse practitioners working in specialty areas, and especially primary care, must become skilled at using and interpreting a wide range of diagnostic tools. While NPs do not perform complex surgical procedures, NPs can perform some invasive treatment procedures. And, at least one state includes hospital admissions within their practice scope.

Because an NP can work in primary or specialty health care, skills that blend nursing and primary care services can be utilized in a wide variety of settings from large healthcare organizations to small free clinics. Nurse practitioners also provide care in independent and collaborative practices, hospitals, specialty clinics, long-term facilities, surgical centers, family planning clinics, school health centers, hospices, home care agencies, and health maintenance organizations.

Standards of Practice refer to the clinical practice aspects of patient care. An NP should follow national standards of care that are appropriate for practice in a particular setting, such as an ambulatory, acute, or long-term care facility. There are five primary practice standards for patient care, each with several important components:

  • Assessment
  • Diagnosis
  • Development of treatment plans
  • Plan implementation
  • Plan evaluation

Additional responsibilities include health education and promotion, patient advocacy, quality assurance, and collaborative responsibilities. Other standards can include the practitioner’s obligation for staying current within the practice area, self-management of quality issues, and alignment with practice guidelines and legislative policies.

Quality standards of care are determined and monitored by several agencies, including governmental agencies. Examples include the Joint Commission on Accreditation of Healthcare Organizations (now known as the Joint Commission, formerly JCAHO), the Agency for Health Care Research and Quality (AHRQ), the National Committee for Quality Assurance (NCQA), professional societies, and licensing boards. Some states include select standards of care in their laws. These standards can be general in scope and relate to maintaining skill levels, or they can be specific, as in the case of the Montana requirement that 5% of all charts be reviewed by a physician and a peer practitioner.

The American Nurses Association (ANA) has developed the Nursing: Scope and Standards of Practice. This document provides links to the various certifying organizations that have published scope and standards of practice documents detailing the processes of care in evidence-based practice for NPs in most patient population groups, as well as other non-NP APRNs.

Prescriptive Authority

Following the certification process, the new nurse practitioner must apply for the state Board’s prescriptive authority that governs the prescribing of medications. Because individual state nurse practitioner prescribing laws vary and the application process or paperwork may be handled differently, it is wise to become familiar with the process in advance. Typically, the advanced pharmacology education needed before this authority can be granted is completed within the NP academic program. If additional pharmacology course work is needed, it is possible to meet knowledge requirements through accredited continuing education. There may be variations from state to state, but the application process usually requires that the state Board receive proof of pharmacology education, an application form, and a fee.

While differences in state prescribing laws have diminished in recent years, variations in authority still exist. Some states require an NP to be in collaborative practice with a physician and need a written agreement from the physician before providing prescriptive authority. A state Board may also require further detailed information from the physician regarding the types and frequency of drugs that may be prescribed within the practice. Prescribing drugs for family members or people who are not being treated within the practice is usually not allowed.

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One notable difference among states is the policy on prescribing controlled substances. At this time, Alabama and Florida are the only states that do not allow NPs any authority to prescribe controlled substances. Several states do not allow NPs to prescribe controlled substances for weight management or chronic intractable pain, while others have restrictions or limitations on the drug type, dosing, or length of supply.  Finally, a few states require the prescription to show the name of the prescriber and the collaborating physician.

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