Advanced Practice Nurses and Prescriptive Authority Though the roles of Clinical Nurse Specialist, Nurse Educator and Nurse Administrator are all vital to the health care industry, they are not allowed prescriptive authority per se. However, the role of Nurse Practitioner is intimately connected with the ability to prescribe medications. The developmental history of the Nurse Practitioner shows a determined movement from a single fledgling program in the 1960's toward eventually complete autonomy and financial rewards, despite resistance from other members of the medical community and the Nursing profession itself. Facing a patchwork of varying, sometimes inconsistent and restrictive regulations on the state and federal levels, Nurse Practitioners face serious issues and challenges in several arenas, including but not limited to ethical, legal, political and educational concerns, that hamper their abilities to provide the highest standard of patient care. However, Nurse Practitioners are now using the clout endowed by sheer numbers to promote greater autonomy, more equitable financial rewards and high standards of care.

Introduction

The "Nurse Practitioner" is a relatively new American medical role. First conceived in the 1960's as a restricted diagnostic/nursing hybrid, the discipline of Nurse Practitioner has developed in a patchwork of varying state and federal regulations and legislation. The modern Nurse Practitioner is at once empowered and hampered by state and federal authorities across several vital areas. Fortunately, the sheer number of American Nurse Practitioners gives them the political clout to significantly influence their roles toward eventual autonomy and financial equity.

Changes in Society and Health Care Regarding Prescriptive Authority of Advanced Practice Nurses

Though non-physicians have filled medical care gaps created by the lack of physicians for hundreds of years, the formal category of "Nurse Practitioner" is relatively young. During the 1960's Dr. Henry Silver and a nurse educator named Loretta Ford created an educational program at the University of Colorado to prepare nurses for responding to the lack of physicians in rural areas of Colorado. Taught at the Master's level, this program required a nursing license and patient care experience for admission, and was innovative in that it combined traditional nursing care with the ability to diagnose. The first "Nurse Practitioners' began practicing in the late 1960's. Though the Nursing professional was initially skeptical of this "Physician extender" that seemed to militate against its patient care-focus, as the profession became more defined and as educational programs developed and spread across the county, the Nursing profession eventually welcomed this new role.

While Nurse Practitioners enjoyed some autonomy and greater privileges in their roles, the issue of prescriptive authority proved to be a separate battle that took years and even decades to win. By the mid-1970's state legislatures began considering the possibility of granting prescriptive authority to Nurse Practitioners. Some states eventually granted prescriptive authority through their regulatory bodies while other states eventually granted that authority through their legislative bodies. By 2006, all 50 states and the District of Columbia had granted at least some degree of prescriptive rights to Nurse Practitioners (Buppert, Nurse practitioner's business practice and legal guide, Fourth Edition, 2012, p. 7).

As of the year 2000, approximately 95,000 Nurse Practitioners practiced in every State and the District of Columbia, with varying requirements and authority granted by each State. According to the National Center for Health Workforce Analysis, the 95,000 Nurse Practitioners working in 2000 represented an increase of more than 240% in the number of American Nurse Practitioners since 1992. By 2011, the number of Nurse Practitioners in the United States was more than 135,000 (Crane, 2011) and the American Academy of Nurse Practitioners estimates that 656 million prescriptions per year are written by American Nurse Practitioners (Brown, 2010, p. x). Today, Nurse Practitioners fill numerous roles in nearly every health care situation, fulfilling the Nursing profession's primary focus on the patient's total well-being while exercising the authority to prescribe medication and "order, perform, and interpret" some laboratory tests. In fulfilling these roles, a recent multidisciplinary health care study found that "Nurse Practitioners demonstrate a high level both collaboration and high levels of autonomy" (Klein, 2011, p. 80). Nurse Practitioners are able to practice autonomously in many states, though a number of Nurse Practitioners are supervised by physicians in some capacity (National Center for Health Workforce Analysis - Bureau of Health Professions - Health Resources and Services Administration, 2010, pp. 7-9).

The Family Nurse Practitioner specialty is more flexible than the areas of those specializing in neonatal or acute care, for example. Consequently, Family Nurse Practitioners can practice in a number of health care specialties and usually practice in such areas as: Family Medicine; Urgent Care; Internal Medicine; Pediatrics;...

Admittedly, the Family Nurse Practitioner is limited when it comes to Acute Care or Neonatal complication, for example; however, the route of Family Nurse Practitioner is often chosen because it allows the Nurse Practitioner to practice in many areas (Advanced Practice Recruiters, 2012). Most closely resembling the "general practitioner" of earlier medicine, Family Nurse Practitioners are in ever greater demand due to the lack Family Practice Physicians, particularly in rural and inner-city areas, the increasing number of Baby Boomer patients, and the demands created by uninsured patients who are accessing the health care system through government programs (Advanced Practice Recruiters, 2012). Family Nurse Practitioners are normally found practicing in clinics that provide family medicine to patients of any age and capable of providing health care over the patients' lifetimes. Depending on the patient population of their geographic and clinical areas, Family Nurse Practitioners may concentrate on any age group, usually from toddlers through aged adults. Their prescriptive authority is governed by state legislation and at this time, all 50 states allow Family Nurse Practitioners to prescribe medications (Advanced Practice Recruiters, 2012).
Issues of Prescriptive Authority Affecting Advanced Nursing Roles:

Issues and Challenges:

Today's Nurse Practitioner faces significant legal, ethical, financial, role acquisition and political issues, particularly regarding prescriptive authority. Perhaps the most daunting concern involves the legal regulation of Nurse Practitioners. Regulations governing Nurse Practitioners, including their prescriptive authority, still vary from state to state: "For NPs in 2 states, though, authority to prescribe any schedule of controlled substances is not allowed. Two other states are waiting for final rulemaking before their legislative acts enabling NPs to prescribe controlled substances become effective. For NPs in several states, a variety of restrictions on controlled substances prescribing remain" (Byrne, 2011). Nevertheless, there are some general rules that apply to the prescriptive authority of Nurse Practitioners in every state and the District of Columbia:

" • Any prescription written for a controlled substance will include the NP prescriber's federal U.S. Drug Enforcement Administration (DEA) number, denoting the NP's independent or plenary authority to prescribe in accordance with state scope of practice.

• It is assumed that every prescription will include the standard information expected from all authorized prescribers, such as the prescriber's name, title, license/specialty, ID/Rx number as applicable, practice address, and phone number; the patient's name; the date of the prescription; and the name of the drug, strength, dosage, route, specific directions, quantity, number of refills, and instructions regarding generic substitution.

• The cosignature of a collaborating physician is not required in any state on any prescription that an NP is authorized to write" (Byrne, 2011).

Finally, Nurse Practitioners in Federal facilities, such as Veterans Administration Hospitals, are governed by a separate set of regulations. As an advisory ruling from the State of Massachusetts shows, Federal regulations borrow some aspects of state legislation but are not identical to it (Health and Human Services, 2010).

The modern Nurse Practitioner faces serious ethical concerns, particularly due to the legal restrictions on his or her practice. The limitations placed on Nurse Practitioners pose an ethical problem in providing the highest quality of care for patients. Nurse Practitioner Carla Mills states, "[E]very day I am forced to negotiate around practice restrictions that interfere with my ability to deliver optimal care to my patients" (Mills, 2009). In addition, 46% of Nurse Practitioners reportedly delivered care that they deemed "sub-par" due to insufficient prescriptive authority (Peterson & Simpson, 2010, p. 7). In sum, the very regulations that empower Nurse Practitioners also restrict their abilities so severely that they create serious ethical concerns about the quality of patient care.

Nurse Practitioners are also faced with significant role acquisition and intimately-related political issues, particularly regarding prescriptive authority. As might be expected from the varying state regulations regarding Nurse Practitioners, role acquisition also varies from state to state. Furthermore, some state regulations make the Nurse Practitioner's full acquisition of her role as health care provider next-to-impossible in some circumstances. For example, in Texas, Nurse Practitioners must be supervised by physicians in order to practice; however, The Texas Tribune ran a 2010 article about Prudie Orr, a psychiatric Nurse Practitioner who could not open a practice in Georgetown, Texas because she could not find a doctor who would allow it (Ramshaw, 2010). As Orr stated, she essentially must continue begging in the hope that a single local doctor will allow her to petition, and pay the doctor to "grant her 'prescriptive authority,' essentially keeping an eye…