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Professional Roles and Reimbursement

THE NURSE PRACTITIONER ROLE

History

Loretta C. Ford, PhD, RN, FAAN, and Henry K. Silver, MD, started the first nurse practitioner (NP) program at the University of Colorado in 1965. Initially, it was a certificate program and later became a master’s program in the 1970s. The first NPs were pediatric NPs who practiced in poor rural areas where there were no physicians (because of a severe shortage of primary care physicians).

Regulation of Nurse Practitioners

Educational Requirements

An NP must meet the minimal educational requirements that are mandated by the nurse practice act of the state (where he or she plans to practice).

State Nurse Practice Act

The nurse practice act is enacted into law by the state legislature. Therefore the NP’s legal right to practice is derived from the state legislature. Each state has its own nurse practice act that contains regulations that dictate the educational requirements, responsibilities, and the scope of practice for NPs and for other nurses (e.g., RNs, licensed practical nurses, midwives, etc.) who practice in the state. NP practice is not regulated by the federal government, the AMA, or the DHHS..

State Board of Nursing

The state board of nursing (SBON) is responsible for enforcing the state’s nurse practice act. The SBON is a formal governmental agency that has the statutory authority to regulate nursing practice. The SBON has the legal authority to license, monitor, and to discipline nurses. The SBON is also authorized to revoke a nurse’s license (after formal hearings).

Title Protection

Professional designations, such as RN, or NP, advanced registered nurse practitioner [ARNP], or advanced practice registered nurse [APRN]), are protected by law. It is illegal for any person to use these titles without a valid license. Title protection is under mandate by a state’s nurse practice act. Title protection protects the public from unlicensed “nurses.”

Licensure and Certification

Licensure is a legal requirement to practice as an NP. It is obtained through a governmental entity, the SBON. The NP must meet the minimal educational and clinical requirements in order to become licensed.

478Certification is generally a “voluntary” process and is done through a nongovernmental entity such as a professional nursing association or specialty organization. The majority of states in the United States now mandate board certification (or certification) as a condition to obtain licensure.

Standards of Professional Nursing Practice

Standards are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty are expected to perform (Bickford, Marion, & Gazaway, 2015). According to the American Nurses Association (ANA), these include both the Standards of Practice and the Standards of Professional Performance (Bickford, Marion, & Gazaway, 2015). They are developed by professional societies (e.g., ANA) as well as specialty organizations. For example, the American Association of Nurse Practitioners (AANP) publishes Standards of Practice for Nurse Practitioners (AANP, 2013).

Collaborative Practice Agreements

A written agreement between a supervising physician and NP outlining the NP’s role and responsibility to the clinical practice. A copy of the collaborative practice agreement must be kept at the NP’s practice setting and mailed to the state board of nursing. Most states require an annual review of the agreement that contains signatures of the individuals involved and dates.

The state practice environment differs for each specific state. Some states allow full practice under the exclusive authority of the SBON. Some states allow reduced practice, and some have restricted practice. In these states, the NP must be under the supervision or delegation of an outside health discipline such as the Board of Medicine.

Agreements With Physicians and Dentists

NPs can sign collaborative practice agreements with physicians (MDs), osteopaths (doctors of osteopathy [DOs]), and dentists/dental surgeons (doctors of medicine in dentistry [DMDs]/doctors of dental surgery [DDSs]). Chiropractors (DCs) and naturopaths (NDs) are not considered physicians under nurse practice acts. Physicians are the only practitioners who can legally sign a death certificate.

Prescription Privileges

The majority of states require NPs to have a written practice protocol with a supervising physician in order to prescribe drugs. The protocol usually contains the list of drugs (by name, by class, or by condition) that an NP is allowed to prescribe. As of January 1, 2017, all states now allow NPs to prescribe certain controlled drugs, but with limitations.

Prescription Pads

The NP’s prescription pad should contain the following:

  NP’s name, designation, and license number

  Clinic’s name, address, and phone number; if the practice has several clinics, the other clinics where the NP practices should also be listed on the pad

  To reduce fraud, it is best if the drug enforcement agent (DEA) number is not list (only for controlled substance prescriptions)

Food and Drug Administration (FDA) Controlled Substances

  Tamper-resistant prescription pads are required by Medicare and Medicaid, as well as when prescribing FDA controlled substances.

  A controlled substance prescription can be typed, but it must be signed by the prescribing practitioner the day it is issued.

479FDA Schedule II Drug Prescriptions

  Substances in this schedule have a high potential for abuse with severe psychological or physical dependence.

  These cannot be called in. They must be written on tamper-resistant pads and signed by the prescriber (not stamped).

  There is some variation among the different state laws regarding prescriptions of Schedule II drugs.

Examples:

Codeine, morphine, hydrocodone, oxycodone, opium, fentanyl, methadone, amphetamines, etc.

E-Prescribing (Electronic Prescriptions)

  A method of sending prescriptions electronically directly to the pharmacy

  Preferred method of prescribing by Medicare and Medicaid

The Four Generations of Nurses

This may be the first time that four generations of nurses are working side by side. Each generation behaves differently. Table 27.1 describes each generation.

Table 27.1 Generation Types

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