Chapter 6: Advanced Practice & Prescriptive Authority Flashcards
A HISTORICAL PERSPECTIVE: THE APRN & PRESCRIPTIVE AUTHORITY (PA)
Title protection originally limited to CRNAs and CNMs
Many practice acts prohibited prescribing of medication by nurses, regardless of specialty or status
Licensure for the professions is a state issue, therefore progress was uneven and slow
Most rapid progress in needy states: primary care burden, shortage of primary care physicians
Federal monies for APN education made preparatory programs more standardized
The first forms of prescriptive authority involved joint decisions from Boards of Nursing/Medicine and/or Pharmacy
Formularies or other limiting regulations were common
The requirement of physician supervision, oversight, and/or collaboration was also common
CONVINCING THE DECISION-MAKERS
Substantiation of differential diagnosis and clinical decision-making skills
Educational programs that prepare for an independent prescribing role
Visible advocates from the physician community
PRESCRIPTIVE AUTHORITY (PA) AND Nurse Practitioners(NP)
PA became an issue with the advent of the NP in primary care practice
Depending on physicians to prescribe created problems of patient access and continuity of care
PA reinforces the credibility of the NP in practice
PRESCRIPTIVE AUTHORITY AND CNM
Expanded PA became critical as CNM practice began to include gynecological management
Federal monies for education boosted standardization of the role
Consumer enthusiasm for the role helped build the case for PA
PRESCRIPTIVE AUTHORITYAND CNS
There is a growing need to prescribe, especially among psychiatric and mental health CNSs, but many CNSs have antipathy about this privilege
Some states do not provide title recognition for CNSs
PRESCRIPTIVE AUTHORITY AND CRNA
CRNAs long have had the authority to prescribe anesthesia; they do not consider ordering and administering anesthesia as falling under the rubric of prescriptive authority in its traditional sense
The PA issue has surfaced as CRNAs are increasingly involved in pain management
CURRENT PRESCRIPTIVE AUTHORITY
NPs — Have plenary authority in 16 states and the District of Columbia; some state-to-state variation, including limitations on controlled drugs
CNMs — Prescribe in 50 states and the District of Columbia, with variable limitations in the area of controlled drugs and some state-to-state variability
CNSs — Are authorized to prescribe medications in some fashion in two-thirds of the states
CRNAs — The authority of CRNAs to select and administer anesthesia has long been recognized. Broader prescriptive authority is legal in 30 states; twenty three of those states require collaboration with or supervision by a physician
CHANGE TO AUTHORIZE PA
Statutory
-Amendments to nurse practice acts
-New statutes separate from nurse practice act
Regulatory
-Changes to states’ administrative codes through the development of regulations
A LAW AN ADMINISTRATIVE CODE
The processes
Variability linked to states’ rights
PATTERNS OF REGULATION FOR PRESCRIPTIVE AUTHORITY
An established formulary or list of drugs that the APRN can prescribe
An exclusionary formulary that allows the APRN to prescribe all drugs, with a short list of forbidden drugs
An individualized collaborative formulary established by the APRN
A collaborating physician with an open formulary that sets no prescribing limits on the APRN
NP–PHYSICIAN RELATIONSHIP IN THE LAW TO PRACTICE OR PRESCRIBE MEDICATION
No collaborative arrangements with physicians, plenary authority (one-third of states)
Supervisory or delegated authority (less than one-fourth of states)
Collaborative or consulting arrangement (remainder of states)
CNM–PHYSICIAN RELATIONSHIP IN THE LAW TO PRACTICE OR PRESCRIBE MEDICATION
One-fourth of states have no requirements
One-fourth require a supervising physician
The remainder require some kind of collaborative/consultative relationship
CRNA–PHYSICIAN AND CNS–PHYSICIAN RELATIONSHIPS IN THE LAW TO PRACTICE OR PRESCRIBE MEDICATION
Nurse anesthetists have supervising or cooperating physicians in most states
CNSs tend to have the same requirements as NPs in the states in which they have prescriptive authority
BARRIERS TO PRESCRIPTIVE PRACTICE
Lobbying from the medical community to “protect the public,” despite proof of safety, therapeutic effectiveness, and cost efficiency
Subsequent limitations in state law, which prevail
Confusion about the role and scope of the APRN among pharmacists, insurers, institutions, and accreditation entities
