Prescriptive Authority for Advanced Practice Nurses
from Caring For Our Future, Fall 2004
By Jennifer Disabato, MS, RN, CPNP, Nursing Education
As more advanced practice nurses (APNs) have been added to existing and new specialty programs at The Children’s Hospital, many nurses have asked for clarification regarding some APN practices.
One of the more confusing aspects of APN practice is prescriptive authority, or the legal right to prescribe medications for patients. In 1996, the Colorado state legislature passed a law granting APNs the right to prescribe medications through a dependent relationship with a collaborating physician. Through the state nursing practice act, the Colorado Board of Nursing defined the scope of prescribing practices and worked to create specific application requirements for those APNs who desired to expand their practice to include the prescribing of medications.
Historical Background
The prescription of medications intended to cause a beneficial change in the health of patients has been practiced for thousands of years. In the last century, the role of nurses in this practice has changed and grown. In the late 1800s, consumers with health problems obtained their medications directly from pharmacists without consulting a physician. The decision-making about which medication was prescribed depended entirely on the pharmacist’s ability to interpret the patient’s stated symptoms. Federal legislation and strong lobbying by the American Medical Association (AMA) changed this practice in the early 1900s. Physicians slowly gained influence and authority over prescription choices, and consumer decision-making declined.
Although nurses have been counseling patients on medication choices for decades, the role of nurses in medication therapy took a large step backward in 1955 when the American Nurses Association (ANA) developed the Model Nurse Practice Act (MNPA), which explicitly prohibited prescriptive authority of nurses. In the late 1950s and 1960s, nurses gradually gained back some responsibility and took on many tasks once exclusively performed by physicians. Nurses often taught patients how to take their medications, what side effects to watch for, and what benefits to expect. Nurses were accountable for understanding how medications worked and how to evaluate their effectiveness. In 1970, the ANA modified the MNPA to define the role of nurses in prescribing medications. In the last 34 years, nurses have slowly gained recognition as effective and competent care providers with the knowledge and education required for prescriptive authority.
Currently, prescriptive authority for advanced practice nurses, including clinical nurse specialists, nurse practitioners, certified nurse anesthetists and nurse midwives is recognized in all 50 states and the District of Columbia. In many states, prescriptive authority has been extended to optometrists, podiatrists, physician assistants, pharmacists, veterinarians and psychologists. Although prescriptive authority for APNs is widespread, great variability exists from state to state as to the degree of independence of the APN and in the medication that can be prescribed (O’Malley, 2003).
Types of Prescriptive Authority
Prescriptive authority can be independent, dependent or limited in scope. Independent prescriptive authority is available to APNs in 12 states plus the District of Columbia. Independent prescriptive authority does not require physician involvement and allows the APN to substitute for a physician when prescribing medication.
Dependent prescriptive authority is available to advanced practice nurses in 34 states, including Colorado . Dependent prescriptive authority requires a formal agreement and a collaborative relationship with a physician. Collaborative agreements are written, signed documents that may use separate written guidelines or protocols and always include a description of each provider’s responsibilities, criteria for evaluation of the APN’s prescribing activities, and scheduled reviews and updates of the protocols and guidelines. An additional four states limit the scope of prescriptive authority for APNs by excluding the prescription of controlled substances. Currently, Colorado allows APNs to prescribe medication with physician supervision alone (as long as there is a written collaborative agreement) and does not require the additional use of guidelines, protocols, formularies or drug class restrictions.
Process of Obtaining Prescriptive Authority for APNs in Colorado
In Colorado, the first step toward gaining prescriptive authority is to apply to be listed on the State Board of Nursing Advanced Practice Registry. This registry was initiated in 1995 and confers title protection to registered professional nurses qualified to engage in advanced practice. The Advanced Practice Registry does not impact the scope of practice for APNs, but it does provide title protection for certified registered nurse anesthetists (CRNA), certified nurse midwives (CNM), clinical nurse specialists (CNS) and nurse practitioners (NP). To be listed on the advanced practice registry, nurses must submit a transcript from a graduate degree program or proof of completion of a NP program, proof of current certification by a nationally recognized certification agency and a $75 fee. Nurses are then granted an individual registry number and are allowed to use the appropriate title.
Once a registry number is obtained, the APN can apply for prescriptive authority. Requirements include 45 hours of graduate education in each of the following disciplines: advanced health assessment, advanced physiology/psychopathology and advanced pharmacology. APNs also must document 1,800 hours of clinical experience with “adequate interaction between the APN, the MD and the other health professionals” (State of Colorado, 2000) in the five years preceding the application. The APN must identify a supervising physician with whom to collaborate and create a written agreement outlining specific requirements set forth by the State Board of Nursing. Both the APN and the physician must sign this agreement. Weekly interaction between the APN and the physician is required, and experience with specific drugs that are relevant to the scope of practice of the applicant is necessary. The application fee is $150. Prescriptive authority for the state of Colorado is granted with a formal letter and issue of a number that begins with “XRN.”
APNs may be granted authority to prescribe controlled substances for a limited subset of patients, including care for an acute self-limiting condition, care for a stable chronic condition and terminal comfort care. The APN (similar to all physicians) must apply to the Drug Enforcement Agency (DEA) for a DEA number to prescribe controlled substances.
Approval Process for APN Prescriptive Authority at TCH
Once granted prescriptive authority from the state, the APN must get local support from the clinic or hospital where his or her practice is located. At The Children’s Hospital, the Nurse Credential Review Board (NCRB) must credential all APNs. The NCRB reviews the APN’s credentials and the privileges requested to ensure that the job title and scope of practice are consistent with the educational and certification requirements. If the APN determines the need for prescriptive authority in his or her role, it is then necessary to go through the process of application for an XRN number. Once the XRN number has been granted, the APN must file a copy of the signed collaborative agreement and a copy of the letter documenting the XRN number with the NCRB. The NCRB has a template with the required elements for the collaborative agreement available to APNs to individualize for their positions. The NCRB then communicates with the TCH medical board and the pharmacy to finalize the process. The medical board grants the APN adjunct privileges on the medical staff, and the pharmacy maintains an approved list of APNs with prescriptive privileges. If nurses at TCH have any questions about the prescribing ability of APNs working in their unit, they can contact the pharmacy to verify the APN’s prescribing privilege. Advanced practice nurses at TCH who want to prescribe controlled substances also must apply for and send a copy of their DEA number to the TCH pharmacy. The APN must sign medication orders with the appropriate credentials and the XRN number after his or her name.
As with any change in practice, information about the parameters and guidelines regarding prescriptive authority can be somewhat confusing. The APN Council and the NCRB have been communicating updates on the process to individual APNs as well as to nursing directors whose units are impacted by these changes. Physicians who enter into collaborative agreements with APNs, inpatient and outpatient nursing staff and pharmacists all need to be aware of APN prescriptive practice issues.
Advanced practice nurses play a significant role in the delivery of patient care in both inpatient and ambulatory settings. Prescriptive authority for APNs provides another level of continuity and efficiency that ultimately improves the quality of the health-care experience for the patients and families who come to TCH.
References
O’Malley, P. and Mains, J. (2003). Update on Prescriptive Authority for the Clinical Nurse Specialist. Clinical Nurse Specialist. 17:4. pp 191-199.
State of Colorado Board of Nursing. (2000). Chapter XIV: Rules and Regulations to Register Professional Nurses Qualified to Engage in Advanced Practice.
State of Colorado Board of Nursing. (2000). Chapter XV: Rules And Regulations for Prescriptive Authority for Advanced Practice Nurses.
