The Advanced Practice Registered Nurse as a Prescriber. Группа авторов
APRNs in Idaho were the first authorized to prescribe medication in 1971, though it took six years for rules to be written and prescriptive authority to be implemented. Most, but not all, APRNs have now been granted prescriptive authority in all states. In California, for example, clinical nurse specialists and nurse anesthetists do not have prescriptive authority (Phillips, 2020). APRNs have repeatedly demonstrated that they provide effective, high‐quality care, including prescribing medications. Nonetheless, APRNs in over half of the United States confront prescribing barriers imposed by state law on a daily basis. These barriers include requirements for supervision or collaboration, restrictions on prescribing controlled substances, and limitations on the type and quantity of medications that can be prescribed. Other barriers are imposed by federal law, such as the conditions under which an APRN may prescribe buprenorphine for substance use disorder.
As a consequence of prescribing barriers, many APRNs are unable to practice to the full extent of their educational preparation, knowledge, and abilities. This negatively affects patient care and the healthcare system overall. Practice constraints handicap the APRN who is unable to fulfill roles in outpatient and inpatient settings. These restrictions continue despite an increased demand for primary, specialty, and acute care providers, and the integration of primary care practices into large health systems. APRNs are in more demand with shortages of primary care providers, particularly to work with the underserved and as those living in rural areas increase. Nurses have a rich history of dedication to social justice and service to marginalized communities. Successful implementation of healthcare reforms in the years to come requires APRNs to be full partners with other health professionals, which necessitates the removal of barriers to allow APRNs to practice to the full extent of their education and expertise.
Washington State as an exemplar
A legislature must pass a bill to enable any changes in the scope of practice for ARPNs. The law typically cannot be implemented until the Board of Nursing adopts rules that specify the intent of the law. Scope of practice changes can take months to years to finalize. The history of APRN prescribing in Washington State begins with a 1977 law that authorized APRNs to prescribe legend drugs (medications requiring a prescription). However, dispensing medications and prescribing controlled substances were prohibited. The Board of Nursing then wrote rules that authorized APRNs to prescribe Schedule V drugs in 1982 and dispensing was added in 1983. It was not until 2000, after more than a decade of lobbying, that APRNs in Washington State obtained Schedule II–IV prescriptive authority.
This long‐sought authority came with a price. For the first time since APRN practice was authorized by the legislature in 1973, physician involvement in APRN practice was mandated. APRNs who wanted II–IV prescriptive authority were required to obtain a Joint Practice Agreement (JPA) with a physician. Slowly over the next four years many APRNs began obtaining Schedule II–IV prescriptive authority. However, until the JPA was removed, over one‐third of APRNs chose not to obtain II–IV prescriptive authority. This contradicted the expectation of APRN leaders in the state that nearly all APRNs would want the legal ability to prescribe controlled substances even if it was only utilized occasionally. We conducted research in Washington State to understand this unexpected phenomenon (Kaplan & Brown, 2004, 2007, 2009; Kaplan et al., 2006, 2010).
The findings of our research serve as a basis of understanding how APRNs may or may not transition to full prescriptive authority and practice when provided the opportunity. It also offers lessons learned about the need to prepare APRNs for a major transition in scope of practice. Change may cause concern for some who have adapted to the status quo, even if prescribing barriers limited their ability to practice. Many of these findings are discussed in Chapter 3. They will enhance your understanding about APRN prescribing practice, the consequences of limiting APRN practice, and the poorly understood experience of transition to a new scope of practice. It is not surprising, however, that APRNs respond to new practice authority with the natural ambivalence that accompanies most change processes.
OVERVIEW OF CHAPTERS
Chapter 2 guides the reader through an analysis of the role and responsibilities of the APRN as a prescriber. The ability to independently prescribe medications symbolizes the legitimacy of APRNs. The public often perceives the prescribing role as what defines the legitimacy of APRNs. This chapter includes an overview of the development of the APRN role and prescriptive authority, the essential nature of autonomy, and the process of transition to the prescribing role. The chapter emphasizes the shift from prescribing medication based on professional preference and tradition to rational prescribing and evidence‐based practice as strategies to achieve quality patient‐centered care.
Given the multiple factors that influence the transition of the APRN to the prescriber role, there is an understandable degree of uncertainty and concern about prescribing. Challenges about the transition from a role that requires administration of medications and prescribed treatments as a registered nurse to the role of manager of care and prescriber as an APRN are delineated in Chapter 2. Change can be a professionally invigorating challenge rather than a distressing situation. It is understandable, however, that many role transitions are characterized by uncertainty and even fear along with the excitement and promise of change.
Chapter 3 highlights the multitude of challenges and opportunities that APRNs confront when prescribing medication. Laws, regulations, and policies, as well as the attitudes of other health professionals often limit prescribing. These are external barriers to an APRN’s adoption of the prescribing role. Internal barriers also can diminish an APRN’s interest in fully autonomous practice and can be overlooked in an analysis of barriers to APRN prescribing. Internal barriers to “stepping up” are invisible or unacknowledged factors within the individual APRN, and include personal characteristics such as conflict avoidance or the “need to be liked.” Strategies to overcome internal and external prescribing barriers are offered as a way to generate enthusiasm among APRNs for facilitating change as well as to deepen their courage to take the inherent risks in full practice authority.
Chapter 4 details the laws, regulations, and professional issues that affect prescribing. These include state laws, Board of Nursing rules, and interprofessional constraints. Fully autonomous prescribing is contrasted with examples of restricted prescribing authority. Restrictions include the requirement for physician supervision, the need to use formularies, and the lack of authority to prescribe controlled substances.
The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education was a landmark agreement developed over several years of dialogue and negotiation by representatives of education, state Boards of Nursing, and professional practice organizations. Discussion of the Consensus Model highlights the need for standardized regulation that achieves fully autonomous practice with full prescriptive authority and universal adoption of the term APRN. This chapter can assist APRNs across the nation to visualize and positively anticipate their future practice and prescribing.
Chapter 5 provides an overview of APRN and registered nurse (RN) prescribing globally. Overall, more countries have adopted RN prescribing than APRN prescribing. The nurse practitioner (NP) role is the most widespread of the four APRN roles, particularly because midwifery is not always a nursing role worldwide. The chapter discusses different approaches to RN and NP prescribing such as through task sharing, formularies, and independent authority.
Chapter 6 coaches APRNs to deal with difficult and often complex clinical situations that are inherent in human relationships and professional interactions, even among experienced and dedicated APRNs. These situations often create anxiety and may even generate anger when the APRN feels ill‐prepared to deal with them. The basic tenet is that these are not problem