Can a Nurse Practitioner Prescribe Medication?
By: Kathleen Gaines MSN, BA, RN, CBC
The ability to prescribe medications is a crucial part of administering quality health care. Although highly educated and trained, the power to independently prescribe medications for nurse practitioners (NPs) varies from state to state.
Currently, only 22 states allow full practice authority, which allows nurse practitioners to prescribe medications without the supervision of a physician. In states with restricted or reduced practice authority, NPs are rallying for full practice authority and securing legislative victories during the pandemic.
Can Nurse Practitioners Prescribe Medication Without Physicians?
Yes, nurse practitioners can prescribe medications in all 50 states. This includes the power to prescribe antibiotics, narcotics, and other schedule II drugs such as Adderall.
However, whether this task requires physicians supervision depends on the practice authority of each state. Some states require additional applications, training, and supervision to prescribe medications, while others grant full practice authority to NPs.
Furthermore, in some states, NPs must enroll in the Prescription Drug Monitoring Program and/or Controlled Substances Reporting System. Physicians also must enroll in these programs in order to monitor opioid prescription distribution and combat the ongoing opioid epidemic.
Nurse Practitioner Practice Authority
Practice authority refers to the powers a nurse practitioner legally has to provide healthcare. These are set forth by the state and require legislation to change.
The American Association of Nurse Practitioners defines three statuses of practice authority:
- “State practice and licensure laws permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.”
- “State practice and licensure laws reduce the ability of NPs to engage in at least one element of NP practice. State law requires a career-long regulated collaborative agreement with another health provider in order for the NP to provide patient care, or it limits the setting of one or more elements of NP practice.”
- “State practice and licensure laws restrict the ability of NPs to engage in at least one element of NP practice. State law requires career-long supervision, delegation or team management by another health provider in order for the NP to provide patient care.”
Nurse Practitioners must be aware of the privileges and limitations in their state’s practice authority.
Nurse Practitioner Prescriptive Authority by State
The practice authority for NPs varies by state. Here's where each state stands as of 2021.
Full Practice Authority States
- New Hampshire
- New Mexico
- North Dakota
- Northern Mariana Islands
- Rhode Island
- South Dakota
- Washington, D.C.
Reduced Practice Authority States
- American Samoa
- New Jersey
- New York
- Puerto Rico
- Virgin Islands
- West Virginia
Restricted Practice Authority States
- North Carolina
- South Carolina
Image Source: AANP
History of Nurse Practitioner Scope of Practice
The history of nurse practitioners dates back to 1965 with the development of its first program at the University of Colorado. Initially developed as a certificate program, it later became a master’s program in the 1970s. By 1973 there were more than 65 NP programs in the United States and a National Association of Pediatric Nurse Practitioners.
In 1989, the passing of the Omnibus Reconciliation Act created limited reimbursement for NPs. With this act, NPs were seen as legitimate healthcare providers in the eyes of the government and insurers.
During the 1990s, nurse practitioners continued to fight for legitimacy in healthcare in the courts and the workplace. The Balanced Budget Act of 1997 granted NPs direct reimbursement and by 2000 NPs were legally able to practice in all 50 states.
In 2004, the American Association of Colleges of Nursing (AACN) began its initiative to require all NP master’s programs to transition into Doctor of Nursing Practice (DNP) programs.
The AACN initially hoped to reach this goal by 2015. However, in a study released in October 2014, the AACN’s Task Force on the Implementation of the DNP stated that less than a quarter of NP programs had transitioned into DNP programs.
Recent Practice Authority Developments
Increased Authority During the Pandemic
COVID-19 is responsible for a recent expansion of the scope of power for many nurse practitioners. Due to the pandemic, the federal government and most states have loosened practice restrictions for NPs across the country.
While these loosened restrictions are only temporary, many NPs hope that their valuable role in pandemic response could lead to permanent changes.
In late May, Kentucky, Louisiana, New Jersey, New York, and Wisconsin temporarily suspended all restrictions, allowing NPs to practice autonomously. An additional 14 states waived some requirements of practice agreements, which expanded prescribing authority and reduced supervision.
Image Source: AANP
Legislation in Texas
Several states, including Texas, have ongoing legislation seeking to increase NP practice authority. Prior to the pandemic, the state unanimously passed HB2250, which allows NPs to have more autonomy.
However, the legislation hasn’t kicked in and NPs in Texas are currently operating under restricted practice.
- NPs practice under the supervision of a physician within a 75-mile radius
- Physicians can’t supervise more than four nurse practitioners at one time
- Physicians review at least 10% of the NP's patient charts randomly each month
- NPs can only prescribe under a physician's supervision and under strict guidelines
- NPs can’t prescribe schedule II drugs such as Adderall, Methadone, and Oxycodone
- Prescriptions written by the nurse practitioner must include the supervising physician's information
- NPs are not allowed to sign death certificates or handicap permits
These restrictions limit the ability of the state’s nurse practitioners to treat patients. Furthermore, it creates overlap and busywork during a time where healthcare workers are stretched thin.
Full Authority at the Department of Veterans Affairs
In December 2016, the Department of Veterans Affairs (VA) issued full practice authority to Certified Nurse Practitioners, Clinical Nurse Specialists, and Certified Nurse Midwives. NPs were granted permission to practice independently without an overseeing physician and the decision overrode state restrictions on NPs practicing independently.
Unfortunately, this has caused concern amongst physicians in the states that have NP restrictions.
Controversy in California
One of the most controversial developments is currently happening in California where Governor Gavin Newsom signed bill AB-890 into law in September 2020 that won’t take effect until 2023.
The legislation allows NPs in California to have full practice authority with some restrictions. While this is a major accomplishment for NP practice authority in the state, many are upset that it will take three years to take effect. It also has some limitations that were not originally included in the legislation.