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Department: Advocacy in Practice

Optional prescriptive authority

Does it still make sense?

Novak, Katherine BSN, RN; Kaplan, Louise PhD, ARNP, FNP-BC, FAANP, FAAN

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doi: 10.1097/01.NPR.0000819668.54666.98
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Prescriptive authority for NPs nationwide was difficult to achieve. Idaho was the first state to authorize prescriptive authority for NPs in 1971, although it took 6 years to implement.1 Thirty-five years later, Georgia was the last state to legalize NP prescribing, which permits RNs—including NPs—to administer, order, or dispense drugs through delegated medical authority from a physician or protocol.2 The pursuit of unfettered practice includes prescriptive authority. Why, then, is this precious and hard-earned component of scope of practice an optional part of licensure for NPs in most states, and should it be optional or required?

Prescribing authority

There are several forms of prescriptive authority. In full-practice authority (FPA) states with no transition period, there are no restrictions on prescribing. Some states require a transition period, from less than 1 to up to 5 years, during which collaboration or supervision by a physician is required to achieve FPA.2 In states that require a collaborative or supervisory agreement, prescribing authority is predicated upon obtaining an agreement.1 In a few states, such as Georgia, prescribing is a delegated authority.2 Schedule II controlled substance prescribing is prohibited in Georgia, Oklahoma, and West Virginia, whereas Missouri and Arkansas only allow prescribing of schedule II hydrocodone combination products.3

APRN Consensus Model and prescribing as part of licensure

The 2008 Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education was developed to create a uniform approach to regulation of advanced practice registered nurses (APRNs). The model specifies that the definition of an APRN include that the nurse is prepared to use and prescribe pharmacologic interventions. Furthermore, APRNs are licensed for independent practice.4

The problem with optional prescriptive authority

APRN prescriptive authority is the product of decades of advocacy. Certified registered nurse anesthetists (CRNAs) and clinical nurse specialists (CNSs) still cannot prescribe in some states. Optional prescriptive authority for NPs undermines the argument used to obtain prescriptive authority that it is integral to NP practice. Optional prescriptive authority may invite challenge by physicians and medical associations that oppose FPA and provide them with reasons for opposition. Application for prescriptive authority separate from licensure application or as an option on the application may create confusion and result in applicants inadvertently not obtaining prescriptive authority. This leads to disparities imposed by the regulatory process counter to the goal of the APRN consensus model. Despite all these problems, there is no national guidance regarding the process used to grant prescriptive authority.

Overview of states' procedures for obtaining prescriptive authority

A review of state licensing practices was conducted to determine whether and how many states grant prescriptive authority automatically and/or require it as a part of licensure. There were several limitations to the review. Some state applications are online, and the process can be accessed only when an account is created to apply for a license. Often instructions or reference materials provided inconsistent guidance regarding the process for obtaining prescriptive authority. Consequently, the analysis was incomplete and could only be partially verified. Further complicating analysis is the variation in prescriptive authority privileges and/or processes within some states depending on the APRN role and that some states do not recognize all four APRN roles. Nonetheless, the following overview illustrates the variability of the processes used to obtain prescriptive authority.

Twenty-four states and Washington, DC are considered FPA states for NPs. Eleven of these offer prescriptive authority on an optional basis (AK, AZ, CO, HI, MA, MN, MT, NM, ND, NV, WA). In five states, prescriptive authority is included with licensure and/or it is required, although states varied in whether an applicant could seek an exemption (DE, ID, IA, ME, OR). For example, prescriptive authority is included in licensure for recent graduates in Idaho, but applicants retain the option to opt out. In contrast, Iowa makes prescriptive authority automatic with licensure without the option to decline. The prescriptive authority processes in the remaining eight states and DC could not be verified (CT, DC, MD, NE, NH, RI, SD, VT, WY).

Of the 27 reduced or restricted practice states, only Ohio was found to require prescriptive authority to receive licensure. Ten states were verified as having optional prescriptive authority (AR, CA, GA, IN, LA, OK, PA, SC, WV, WI). It was difficult to categorize the seven states that did not explicitly offer optional prescriptive authority but require a collaborative practice agreement or protocol agreement that may or may not reference prescribing privileges (AL, KY, MO, NJ, NY, NC, TN). The prescriptive authority process in the remaining eight states could not be verified (FL, IL, KS, MI, MS, TX, UT, VA).

In summary, only 6 of 50 states were verified to make prescriptive authority automatic with licensure and/or require it for NPs. All but one of these states is considered an FPA state. Optional prescriptive authority was the most common finding with 21 states offering this option either through the general APRN application or through a separate application process.

Washington State advocacy regarding optional prescriptive authority

ARNPs United of Washington State in March 2021 submitted a request to the advanced practice subcommittee (APSC) of the Washington State Nursing Care Quality Assurance Commission, the state's equivalent of the board of nursing, to consider making prescriptive authority a requirement for licensure. Currently an applicant must opt-in to obtain prescriptive authority. Advanced registered nurse practitioner (ARNP) is the legal Washington title for APRNs. The APSC does not have decision-making authority and makes recommendations to the full commission regarding ARNP practice.

Historically, prescriptive authority for ARNPs in Washington was authorized in 1977 by a law amending the pharmacy statute. It was implemented through rules in 1979 at a time when some applicants could not meet the requirements at the time of initial application for licensure. Not all educational programs leading to licensure as an NP provided the necessary 30 hours of pharmacology and clinical management of drug therapy. Additionally, there was a requirement for the applicant to have engaged in at least 1 year of clinical practice that may not have been feasible for new graduates of certificate programs. Currently, prescriptive authority requires 30 hours of pharmacology education obtained within the 2 years prior to application. New graduates automatically meet the requirement and applicants for licensure by endorsement who have prescriptive authority may be exempt.

A review in 2021 of data provided by the Washington state commission revealed that 4% (336) of ARNP licensees with a Washington address did not have prescriptive authority. By role, 1% of NPs (73), 2% of certified nurse midwives (CNMs) (8), 29% of CRNAs (227), and 47% of CNSs (28) did not have prescriptive authority.

The APSC engaged in robust discussions of the request for prescriptive authority to be a requirement for licensure at several meetings between April and July 2021. Members of the committee and public raised concerns about requiring CRNAs and CNSs to have prescriptive authority. CRNAs in Washington have the option to select, order, and administer schedule II-IV controlled substances subject to facility-specific protocols when anesthesia services are requested by a physician or surgeon.5 This section of the law was adopted prior to ARNPs having schedule II-IV prescriptive authority. Consequently, CRNAs without prescriptive authority may administer anesthetic agents. CNSs often are employed in positions that do not include direct patient care.

The APSC made a recommendation to the full commission to open rules to make prescriptive authority a requirement for licensure allowing an applicant to opt out of the requirement. The recommendation was adopted by the commission in September 2021. Subsequently, staff determined it would be feasible to make the change procedurally rather than using a rule change. The APSC agreed in November 2021 to bring a request to the commission in January 2022 to rescind the decision to open the rules.

ARNPs United agreed to the procedural change for two reasons. As CRNAs have the option to select, order, and administer anesthetic agents, it would not be easy to support a mandate for prescriptive authority. Changing the state law would potentially be divisive if not initiated by CRNAs who are currently working to defeat potential legislation by the state's anesthesiologists' association to create a new anesthesiology assistant profession. Changing the law to require three APRN roles (NP, CNM, CNS) to have prescriptive authority as part of licensure would detract from ARNPs United's current effort to secure reimbursement parity.

What can NPs do and why?

If the state you practice in is one in which the process for application for prescriptive authority was not verified, work with your board of nursing to determine the process. If you live in a state that has optional prescriptive authority, consider efforts to require prescriptive authority as part of licensure. In a 1989 article in this journal, Gene Harkless made the following statement that still resonates. “Nursing's struggle to obtain autonomy in prescriptive authority translates to a social inequality issue. In order to transform the perception of their role as physician dominated, nurses must direct their political and educational activities toward developing true structural and attitudinal autonomy in all aspects of nursing practice.”6 Consider this your clarion call to advocacy.

REFERENCES

1. Kaplan L, Brown MA. The Advanced Practice Registered Nurse as a Prescriber. Hoboken, NJ: John Wiley & Sons Inc.; 2021.
2. Phillips SJ. 34th Annual APRN Legislative Update: trends in APRN practice authority during the COVID-19 global pandemic. Nurse Pract. 2022;47(1):21–47.
3. AANP 2022 nurse practitioner schedule II controlled substance prescriptive authority. 2022. www.aanp.org/advocacy/advocacy-resource/state-issue-maps/nurse-practitioner-schedule-ii-controlled-substance-prescriptive-authority-1.
4. APRN Consensus Work Group & the National Council of State Boards of Nursing. 2008. www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf.
5. Revised Code of Washington, 2020. Title 18 Chapter 18.79 Section 18.79.240. https://app.leg.wa.gov/RCW/default.aspx?cite=18.79.240.
6. Harkless GE. Prescriptive authority: debunking common assumptions. Nurse Pract. 1989;14(8):57–61.
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