NR565 Week 2 Study Guide
Chapter 1: The Role of the Nurse Practitioner as Prescriber
Roles and responsibilities of APRN prescribers
• The responsibility for the final decision on which drug to use and how to
use it is in the hands of the APRN prescriber.
• The degree of autonomy in this role and the breadth of drugs that can be
prescribed vary from state to state based on the nurse practice act of that
state.
• All states have title protection for NPs.
• Only Oregon has mandated third-party reimbursement parity for NP services.
• In all but five states, the control of practice and licensure is within the sole
authority of the state's board of nursing. These five states have joint control in
the board of nursing and the
board of medicine.
• Scope of practice is determined by the individual NP's license under the nurse
practice act of the licensing jurisdiction. Some have a graduated scope based
on experience level. New prescribers need to understand that their
employment sites may restrict this legal scope of practice but cannot extend it.
• In 17 states and the District of Columbia, NPs have independent scope of
practice and prescriptive authority without a requirement or attestation for
physician collaboration, consultation, delegation, or supervision.
• Six states have full autonomous practice and prescriptive authority
following a period of postlicensure/postcertification supervision or
collaboration.
Clinical judgement in prescribing
• Prescribing a drug results from clinical judgment based on a thorough assessment of
the patient and the patient's environment, the determination of medical and nursing
diagnoses, a review of potential
alternative therapies, and specific knowledge about the drug chosen and the disease
process it is designed to treat. In general, the best therapy is the least invasive, least
expensive, and least likely to cause adverse reactions. Frequently, the best choice is to
have lifestyle, nonpharmacological, and pharmacological therapies working together. When
the choice of treatment options is a drug, several questions arise.
• As APRNs prescribe a drug for a given pathophysiology, their nursing background
leads them to place equal emphasis on understanding the impact the drug will have on
the patient.
• Patient education is a central focus of nursing and APRN practice.
• Knowledge and clinical experience shared from the mingling of medical and nursing
perspectives are mutually beneficial to the providers and the patient.
• The APRN can benefit from the in-depth knowledge about the drugs in the physician's
specialty area. The physician can benefit from APRNs’ focus on the impact of the drug on
the patient and from their
patient education skills. In the age of health-care reform, increasing emphasis is being
placed on these latter issues.
,Collaboration with other providers
, • NPs and physicians do work together very effectively on an individual basis and in
collegial care teams. In an era of health-care reform, our joint concerns about patient
care decisions require us to be allies.
• Physicians may offer insight or advice on pharmacological management from their
experience.
• A physician's expertise related to pharmacology is based on understanding
biochemistry and prescribing for a given pathophysiology. The emphasis is on the
disease and the drug, with less
emphasis on the impact on the patient. Patient education by physicians may be
limited or left to a nurse or pharmacist.
• Collaboration with other NPs and APRNs who have prescriptive privileges has
two major advantages.
o On a one-to-one basis dealing with individual patient issues, NPs and APRNs can
share “clinical pearls” from their knowledge base and collaborate to improve the
care of the patient.
o Collaboration on issues related to scope of practice and prescriptive privilege at
the state and national level is critical to obtaining and maintaining the
autonomy of practice needed to provide optimal patient care.
• Collaboration with pharmacists requires an understanding of the educational
preparation for and evolution of the role of the pharmacist. The profession of
pharmacy requires graduate-level preparation for all pharmacists with the granting
of a practice doctorate, the Doctor of Pharmacy (PharmD). PharmDs have extensive
knowledge about pathophysiology and take an active role in determining the best
drug to prescribe. A PharmD can assist by offering expertise on the clinical
management of patients, including available dosage forms, potential adverse
reactions, and drug interactions.
• Both physicians and APRNs increasingly consult PharmDs for their knowledge of
pharmacokinetics and pharmcotherapeutics when prescribing for complex patients.
Autonomy and prescriptive authority
• By January 2004, all states had recognized the NP title, scope of practice, and
prescriptive authority in legislation. Momentum to full autonomy is gaining, with 26
states allowing independent practice for NPs and 21 states allowing independent full
prescribing as of January 2015 (National
Council of State Boards of Nursing [NCSBN], 2015). APRNs in other states have also
gained recognition, although the scope of practice and prescriptive authority is often
more restricted.
• These gains are not written in stone, however, and can be reversed. Despite
continuing research studies (Newland, 2009; Pearson, 2009; Gielen, 2013) that
demonstrate the effectiveness of the role of the APRN in improving patient outcomes,
barriers remain. Major concerns related to prescriptive authority must continue to be
addressed. Not all states have legislation that permits APRNs to prescribe
independently of any required physician involvement. Turf battles continue between
APRNs and physicians at national and many state levels over physician supervision
requirements and co-signatures on prescriptions. The advent of the doctorate of
nursing practice (DNP) degree with its comparable level of education to that of other
health-care providers and a focus on independent practice may address some of these
issues about supervision. However, the American Medical Association continues to
stress the need for physician supervision and final authority for the patient, even for
APRNs who hold the DNP (Partin, 2008; AMA, 2010, 2013). This push for physician
control occurs despite data from malpractice and malfeasance ratios that clearly show
that the rationale for physician supervision is unfounded (Pearson, 2009).
, Drug databases
• Nurses evaluate sources of drug information and learn which ones to trust. For an
APRN, the sources of drug information expand to include the wide array of
professional literature that ranges
from the well-reputed journals to literature from specialty and professional
organizations, the multitude of computerized drug databases (e.g., Micromedix,
Lexicomp, Epocrates), information
Chapter 1: The Role of the Nurse Practitioner as Prescriber
Roles and responsibilities of APRN prescribers
• The responsibility for the final decision on which drug to use and how to
use it is in the hands of the APRN prescriber.
• The degree of autonomy in this role and the breadth of drugs that can be
prescribed vary from state to state based on the nurse practice act of that
state.
• All states have title protection for NPs.
• Only Oregon has mandated third-party reimbursement parity for NP services.
• In all but five states, the control of practice and licensure is within the sole
authority of the state's board of nursing. These five states have joint control in
the board of nursing and the
board of medicine.
• Scope of practice is determined by the individual NP's license under the nurse
practice act of the licensing jurisdiction. Some have a graduated scope based
on experience level. New prescribers need to understand that their
employment sites may restrict this legal scope of practice but cannot extend it.
• In 17 states and the District of Columbia, NPs have independent scope of
practice and prescriptive authority without a requirement or attestation for
physician collaboration, consultation, delegation, or supervision.
• Six states have full autonomous practice and prescriptive authority
following a period of postlicensure/postcertification supervision or
collaboration.
Clinical judgement in prescribing
• Prescribing a drug results from clinical judgment based on a thorough assessment of
the patient and the patient's environment, the determination of medical and nursing
diagnoses, a review of potential
alternative therapies, and specific knowledge about the drug chosen and the disease
process it is designed to treat. In general, the best therapy is the least invasive, least
expensive, and least likely to cause adverse reactions. Frequently, the best choice is to
have lifestyle, nonpharmacological, and pharmacological therapies working together. When
the choice of treatment options is a drug, several questions arise.
• As APRNs prescribe a drug for a given pathophysiology, their nursing background
leads them to place equal emphasis on understanding the impact the drug will have on
the patient.
• Patient education is a central focus of nursing and APRN practice.
• Knowledge and clinical experience shared from the mingling of medical and nursing
perspectives are mutually beneficial to the providers and the patient.
• The APRN can benefit from the in-depth knowledge about the drugs in the physician's
specialty area. The physician can benefit from APRNs’ focus on the impact of the drug on
the patient and from their
patient education skills. In the age of health-care reform, increasing emphasis is being
placed on these latter issues.
,Collaboration with other providers
, • NPs and physicians do work together very effectively on an individual basis and in
collegial care teams. In an era of health-care reform, our joint concerns about patient
care decisions require us to be allies.
• Physicians may offer insight or advice on pharmacological management from their
experience.
• A physician's expertise related to pharmacology is based on understanding
biochemistry and prescribing for a given pathophysiology. The emphasis is on the
disease and the drug, with less
emphasis on the impact on the patient. Patient education by physicians may be
limited or left to a nurse or pharmacist.
• Collaboration with other NPs and APRNs who have prescriptive privileges has
two major advantages.
o On a one-to-one basis dealing with individual patient issues, NPs and APRNs can
share “clinical pearls” from their knowledge base and collaborate to improve the
care of the patient.
o Collaboration on issues related to scope of practice and prescriptive privilege at
the state and national level is critical to obtaining and maintaining the
autonomy of practice needed to provide optimal patient care.
• Collaboration with pharmacists requires an understanding of the educational
preparation for and evolution of the role of the pharmacist. The profession of
pharmacy requires graduate-level preparation for all pharmacists with the granting
of a practice doctorate, the Doctor of Pharmacy (PharmD). PharmDs have extensive
knowledge about pathophysiology and take an active role in determining the best
drug to prescribe. A PharmD can assist by offering expertise on the clinical
management of patients, including available dosage forms, potential adverse
reactions, and drug interactions.
• Both physicians and APRNs increasingly consult PharmDs for their knowledge of
pharmacokinetics and pharmcotherapeutics when prescribing for complex patients.
Autonomy and prescriptive authority
• By January 2004, all states had recognized the NP title, scope of practice, and
prescriptive authority in legislation. Momentum to full autonomy is gaining, with 26
states allowing independent practice for NPs and 21 states allowing independent full
prescribing as of January 2015 (National
Council of State Boards of Nursing [NCSBN], 2015). APRNs in other states have also
gained recognition, although the scope of practice and prescriptive authority is often
more restricted.
• These gains are not written in stone, however, and can be reversed. Despite
continuing research studies (Newland, 2009; Pearson, 2009; Gielen, 2013) that
demonstrate the effectiveness of the role of the APRN in improving patient outcomes,
barriers remain. Major concerns related to prescriptive authority must continue to be
addressed. Not all states have legislation that permits APRNs to prescribe
independently of any required physician involvement. Turf battles continue between
APRNs and physicians at national and many state levels over physician supervision
requirements and co-signatures on prescriptions. The advent of the doctorate of
nursing practice (DNP) degree with its comparable level of education to that of other
health-care providers and a focus on independent practice may address some of these
issues about supervision. However, the American Medical Association continues to
stress the need for physician supervision and final authority for the patient, even for
APRNs who hold the DNP (Partin, 2008; AMA, 2010, 2013). This push for physician
control occurs despite data from malpractice and malfeasance ratios that clearly show
that the rationale for physician supervision is unfounded (Pearson, 2009).
, Drug databases
• Nurses evaluate sources of drug information and learn which ones to trust. For an
APRN, the sources of drug information expand to include the wide array of
professional literature that ranges
from the well-reputed journals to literature from specialty and professional
organizations, the multitude of computerized drug databases (e.g., Micromedix,
Lexicomp, Epocrates), information
