PRACTICE ISSUES: REGULATION, CERTIFICATION, CLINICAL PRIVILEGES, PRESCRIPTIVE AUTHORITY, AND LIABILITY
Advanced practice registered nurses (APRNs) encounter a variety of professional issues in their practices. Most questions focus on what APRNs can or cannot do within the scope of nursing practice. Although APRNs have made progress in terms of removing barriers to practice, many barriers continue to exist. As health care reform evolves in individual states or on a national level, it will be critical for APRNs to be fully cognizant of legislative or regulatory activity that may impede their ability to perform within their full scope of practice. At the same time, APRNs are expanding their educational focus, bringing forth new issues and challenges. In an ideal world, APRNs would have the same privileges and legal and prescriptive authority across all states.
Proposed models for uniform APRN practice and the progress toward full practice authority will be discussed later in this chapter. In the interim, as APRNs seek new or continued employment, they must consider what regulations will allow or limit their practice in their specific states. In doing so, they can choose positions that are congruent with their educational scopes of practice. They should also know what credentials might be needed to practice in a certain state, institution, or organization. For example, if they choose to practice in a selected state, would they be able to prescribe medications, sign death certificates, admit patients to hospitals, sign worker's compensation claims or disabled parking permits? Would they be required to be supervised by a physician, develop a collaborative agreement, or have restrictions placed on their billing? These are all practice issues that surround regulation, certification, scope of practice, and liability.
The terms regulation, certification, and credentialing as they apply to all APRNs can be very confusing to the public as well as health care providers.
These terms are often used incorrectly, and they can cause misperceptions or confusion among consumers. There are distinct differences in the meaning of each term and the things that APRNs are allowed to do. Understanding these terms will help APRNs carry out their roles while avoiding any barriers that may exist.
A regulation is a law that has been passed by the state or federal legislature and signed by the governor of that state or the president of the United States. Nursing practice is regulated by each state in accordance with state statutes and interpreted through administrative rules. In most states, APRNs are regulated under the authority of a board of nursing. In a review of state APRN regulation in 2014, one state had a separate advanced practice board; advanced practice nurses from three states were controlled by Boards of Nursing and Medicine; one state was regulated by a Nursing Care Quality Assurance Commission and one state regulated APRNs through their state's Education Department (Phillips, 2014). Buppert (2015) provides the state statutes and regulatory rules for each state.
Regulation of APRNs varies from state to state, and changes occur yearly. This variability inhibits APRNs moving from state to state with the same authority and scope of practice. As of 2014, 24 states—with three additional states having pending legislation—have enacted a Nurse Licensure Compact for registered nurses and vocational licensed nurses to increase mobility between states (National Council of State Boards of Nursing, 2014). Only three states—Iowa, Texas, and Utah—have APRN compacts. It is anticipated that Nurse Licensure Compact states will be able to implement the APRN compact in the near future (Nurse Licensure Compact Administrators, 2012).
The road to removing regulatory barriers for APRNs has been bumpy, to say the least. However, thanks to the perseverance and endless efforts of individual and professional advanced practice advocates, APRNs can practice and prescribe medications in every state. That said, however, much more work needs to be done to educate legislators, interprofessional groups, and the public in order to provide access to safe, competent care for all consumers.
A hallmark publication by the committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM) has provided support and foundation for state legislatures to update nurse practice acts to allow APRNs to practice to the full extent of their licenses. The publication, The Future of Nursing. Leading Change, Advancing Health (IOM, 2011), makes four recommendations:
1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
4. Effective workforce planning and policy making require better data collection and an improved information infrastructure, (p. S-3)
The implications of this publication continue to unfold and provide a positive forum for APRNs to remove barriers from practice. It is interesting that the report is not asking or recommending expanding the scope of APRN practice or additional money (American Association of Nurse Practitioners [AANP], 2011). The timing of this publication, along with the Patient Care and Affordable Care Act of 2010 (АСА), has been helpful for nursing and APRNs to promote legislation in their states and encourage provider-neutral terminology. As of 2014, 20 states have full practice authority for nurse practitioners (NPs) (AANP, 2014).