This paper examines the evolving role of advanced practice registered nurses (APRNs), with a focus on prescriptive authority, credentialing, and collaborative practice agreements in the United States. It traces Georgia's delayed adoption of APRN prescriptive authority, details the regulatory frameworks governing nurse practitioners in Georgia and Indiana, and compares prescribing freedom across multiple states. The paper also evaluates how APRNs participate in managed care and quality initiatives, drawing on peer-reviewed research to highlight patient outcome advantages. Finally, it surveys advanced practice nursing programs in England, Singapore, and Finland, contrasting effective and ineffective approaches to deploying APRN expertise.
The role of the advanced practice nurse (APN) has changed and evolved over the years to the point where an APN has more authority, more respect, and more responsibility. This paper delves into those responsibilities and reviews both the intelligent use of the APRN and the not-so-intelligent use of these well-trained healthcare professionals.
Until a few years ago, the State of Georgia was the only state in the U.S. that did not authorize APRNs to prescribe medicines for their patients. Cathy Jordan, a pediatric APRN and professor at the Nell Hodgson Woodruff School of Nursing, explains the general scope and role of an APRN. APRNs conduct physical exams as part of their routine, take medical histories, and provide treatment for "acute minor illnesses and injuries." They manage chronic illnesses, supervise and interpret lab tests and X-rays, and educate and counsel their patients (Jordan, 2000). In addition, Jordan explains that APRNs order drugs and diagnostic studies according to the protocol within which they work.
Until 2006, APRNs in Georgia could call a prescription into a pharmacy — using the authority of the attending physician — but could not write that prescription themselves. In her article, Jordan insisted that without the prescriptive authority other states extend to their APRNs, the advanced practice nurse is forced to hunt down the physician to sign the prescription rather than doing so independently. Time and talent are wasted in this scenario, Jordan asserts.
Jordan references a Journal of the American Medical Association (JAMA) study that followed 1,316 adults randomly assigned to "the ambulatory care of either nurse practitioners or physicians" (p. 4). In this study, nurse practitioners had virtually the same authority and requirements as primary care physicians and, according to Jordan, "no statistically significant difference in patient outcomes was found" (p. 4).
Moreover, research presented by Jordan reflects that "APRNs have better patient outcomes in illnesses where communication with patients is integral to recovery and wellness" (p. 4). Patients tend to prefer APRNs because APRNs do the "bulk of patient education," listen more closely to patients than physicians do, and have more time to counsel patients (Jordan, p. 4). In Georgia, nurse practitioners "historically have been the significant and sometimes the only health care providers" working with low-income and elderly people in rural areas in particular (Jordan, p. 4). Jordan therefore urged the Georgia Legislature to pass legislation granting APRNs prescriptive authority.
In the State of Georgia, rules for nurse practitioners were adopted on June 28, 2006. Under Rule 410-12-01, the nurse practitioner (NP) must have met the required educational and certification standards and been authorized to practice according to state-produced rules. The advanced practice registered nurse is authorized by the Georgia Board of Nursing to "perform advanced nursing functions" along with "certain medical acts," including but not limited to "ordering drugs, treatments, and diagnostic studies" (Georgia Board of Nursing).
In the "Rules for Nurse Practitioners" (410-12-03), the Georgia Board of Nursing does not explicitly mention prescriptive authority for the APRN, but the rules generalize that the nurse practitioner must show "evidence of advanced pharmacology within the curriculum, or as a separate course."
The Drugs and Narcotics Agency of the State of Georgia describes the Georgia Medical Practice Act OCGA 43-34-26.1 in the document "Dispensing Practitioners Georgia Laws, Rules, and Regulations" (Karsten, 2006). The document covers a number of important areas, defining what "nurse protocol," "dispense," and "controlled substance" each mean (Karsten, p. 11).
On page 12 of that document, the law authorizes a "certified nurse practitioner" to legally order "dangerous drugs, medical treatments, and diagnostic studies" (Karsten, p. 12). Moreover, a physician may "delegate to a nurse the authority to order dangerous drugs" in accordance with a "dispensing procedure" and under the authority of an order issued in conformity with a nurse protocol or job description.
In the Frequently Asked Questions section of that document, the question is posed: "May a nurse practitioner dispense prescription medications?" The answer is "Yes — a nurse practitioner may dispense prescription medications," but that practitioner may not allow an assistant to dispense the medication to the patient without the practitioner's physical presence and personal supervision (Karsten, 2006). Additionally, prescription drugs dispensed by a practitioner cannot be "transferred to another practitioner or pharmacist for subsequent filing." While a practitioner's assistant may keep an inventory of medications, type labels, count pills, and maintain records, the assistant may not "compound prescriptions" (Karsten).
The prescriptive authority to prescribe legend drugs in Indiana is based first — as it is in Georgia — on completing at least a Master's degree, followed by a background check to determine whether the nurse practitioner has been arrested or denied a license by another jurisdiction. The advanced practice nurse applicant in Indiana must have completed at least two semester hours of a graduate pharmacology course and must provide "proof of collaboration with a licensed practitioner," amounting to a written agreement specifying how the practitioner collaborates with the APRN. In fact, the advanced practice nurse in Indiana must demonstrate the "time and manner of the licensed practitioner's review of the advanced practice nurse's prescribing practices" (Indiana Administrative Code, p. 2).
The advanced practice nurse in Indiana who wishes to have the authority to prescribe medications must also complete a "controlled substances registration and a federal Drug Enforcement Administration registration" (Indiana Administrative Code, p. 3).
"Credentialing process and hospital privileging for APRNs"
"State-by-state physician collaboration and prescribing rules"
"APRN roles in managed care and international comparisons"
The value of the advanced practice nurse — when properly trained and placed in a position where he or she can provide beneficial services — is gaining ground in the United States and Finland, but not in Singapore or England. This paper has reviewed the specific requirements an RN must complete prior to becoming an APRN in Georgia, Illinois, and Indiana. More importantly, because APRNs are able to write prescriptions and carry out other responsibilities that have historically fallen to physicians, these well-trained nurses are becoming more valuable than ever before, and their work deserves to be honored and encouraged.
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