N521 – State’s nurse practice act (NPA) advanced practice nurses (CNPs, CRNAs, CNMs, CNSs prescription regulation discussion essays
Discussion 1

Locate your state’s nurse practice act (NPA) and associated regulations governing prescribing by advanced practice nurses (CNPs, CRNAs, CNMs, CNSs). Answer and discuss the following in this forum:

Does your NPA require the APRN to have a collaborative agreement with a physician? Discuss whether you think the NPA should or should not require the APRN to have a collaborative agreement, and explain why/why not.
Does your NPA require the APRN to have a prescribing agreement with a physician? Discuss whether you think the NPA should or should not require the APRN to have a prescribing agreement, and explain why/why not.
Does your NPA permit APRNs to prescribe all classes (schedules) of medications? Discuss whether you think the NPA should or should not permit APRNs to prescribe all classes of medications, and explain why/why not.
Describe collaborative approaches to treating rashes across the lifespan. Should the CNP treat without a collaborator or consultant? Support your statements based upon evidence.

Remember to respond to at least two of your peers. Please see the Course Syllabus for Discussion Participation Requirements and Grading Criteria.

Discussion 1
1.     Virginia Law requires licensed nurse practitioners to have collaborative agreement with a physician. After a nurse practitioner has practiced for the equivalent of five years full time, they may be issued a license that states they may practice without a physician agreement (Medical Practice Act of the Code of Virginia, 2020). I do not disagree with this, in fact, I think that it would be beneficial for nurse practitioners to have residencies, like that of care providers.
2.     Virginia Law requires licensed nurse practitioners to have a prescribing agreement with a practice and supervising physician for their first two years of practicing as a nurse practitioner. This was put into law through Executive Order 57, that was signed by the Virginia Governor in April of this year. Previously a nurse practitioner had to have practiced for five years before the requirement to have an electronic agreement with a physician would no longer be necessary (Code of Virginia, 1999). Requiring nurse practitioners to have a prescribing agreement during the first two years of practice is sensible. Medication safety should be major focus of all practitioners. From 2009 to 2012 more than half of Americans were on at least one prescription medication (Arcangelo et al., 2017).
3.     VA laws support the prescribing of schedule II through schedule VI, depending on the electronic practice agreement that the nurse practitioner is in. Per Virginia code, schedule VI “Any compound, mixture, or preparation containing any stimulant or depressant drug exempted from Schedules III, IV or V and designated by the Board as subject to this section” but also includes devices which require a physician order to purchase (Medical Practice Act of the Code of Virginia, 2020). With the rise of medical marijuana legalization, there should be an individual licensure available to providers to be able to prescribe this in areas where the practice is accepted.
4.     Skin is the largest organ and one of our first defenses against bacteria, viruses, and injury. Across the life span there are multiple rashes that our patients may experience. Treating rashes in the primary care setting, can be difficult as one disease can present in multiple ways, similar rashes can have differential diagnosis. Collaborating with specialist and more experienced practitioners can prevent the use of unnecessary prescriptions and decrease unnecessary costs.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice. (Fourth Edition). Wolters Kluwer.
Medical Practice Act of the Code of Virginia, Va. Stat. §§ 54.1-2957 (2020). http://www.dhp.virginia.gov/media/dhpweb/docs/nursing/leg/MedPractAct_Nursing.pdf
Code of Virginia, Va. Stat. § 54.1-3455. (1999). https://law.lis.virginia.gov/vacode/title54.1/chapter34/section54.1-3455/
 
Discussion 2
In the state of Connecticut, advanced practice registered nurses (APRNs) such as certified nurse practitioners (CNPs) have full practice authority (FPA).  This means that APRNs are allowed to practice autonomously to the fullest extent of their education, training, knowledge, and skills (AANP, 2020). However, immediately after initial licensure, the Connecticut State Nurse Practice Act (NPA) requires that the APRN enters into an agreement with a licensed practicing physician in the state for a period of three years (Connecticut State Department of Public Health, 2020). This must be in a written agreement as stipulated in the Connecticut general statutes §20-87a(2). I believe there should not be any restrictions on the scope of practice for APRNs whatsoever. Restrictions and requirements for supervision by a physician (even if it is just for the first three years of practice as in the case of Connecticut) hinders the APRN from exercising their knowledge and skills freely (Ortiz et al., 2018; Peterson, 2017; Duncan & Sheppard, 2015). In my opinion, the benefit of the initial 3 years of the agreement allows the APRN to gain valuable experience with a more experienced physician. After those years, the APRN can now practice independently and autonomously in Connecticut.
            In the initial three years after graduating and getting licensure. In the agreement (Conn. Gen. Stat. §20-87a(3)), the physician will supervise the APRN prescribing and decide the level of Schedule II and III controlled substances the APRN can prescribe (Connecticut State Department of Public Health, 2020). Again, not allowing APRNs to prescribe all classes of scheduled medications is hindering their practice and the provision of primary health care (PHC). A collaborative approach to treating rashes across the lifespan involves the CNP treating the patient at first contact (PHC). However, if the condition does not resolve, the CNP should refer the patient to a Dermatologist.

References

American Association of Nurse Practitioners [AANP] (October 20, 2020). State practice environment. https://www.aanp.org/advocacy/state/state-practice-environment
Connecticut State Department of Public Health (2020). Connecticut general statutes chapter 378 – Nursing. https://portal.ct.gov/DPH/Public-Health-Hearing-Office/Board-of-Examiners-for-Nursing/Board-of-Examiners-for-Nursing
Duncan, C.G. & Sheppard, K.G. (2015). Barriers to nurse practitioner full practice authority (FPA): State of the science. International Journal of Nursing Student Scholarship, 2. https://journalhosting.ucalgary.ca/index.php/ijnss/article/view/56778
Ortiz, J., Hofler, R., Bushy, A., Lin, Y-L., Khanijahani, A., & Bitney, A. (2018). Impact of nurse practitioner practice regulations on rural population health outcomes. Healthcare (Basel), 6(2), 65-72. https://doi.org/10.3390/healthcare6020065
Peterson, M.E. (2017). Barriers to practice and the impact on health care: A nurse practitioner focus. Journal of the Advanced Practitioner in Oncology, 8(1), 74-81. https://doi.org/10.6004/jadpro.2017.8.1.6

 
 
Discussion 3
Locate your state’s nurse practice act (NPA) and associated regulations governing prescribing by advanced practice nurses (CNPs, CRNAs, CNMs, CNSs). Answer and discuss the following in this forum:

Does your NPA require the APRN to have a collaborative agreement with a physician? Discuss whether you think the NPA should or should not need the APRN to have a collaborative agreement, and explain why/why not.
Does your NPA require the APRN to have a prescribing agreement with a physician? Discuss whether you think the NPA should or should not require the APRN to have a prescribing agreement, and explain why/why not.
Does your NPA permit APRNs to prescribe all classes (schedules) of medications? Discuss whether you think the NPA should or should not permit APRNs to prescribe all classes of medications, and explain why/why not.

In my state, Idaho, nurse practitioners (NPs) have full practice authority (FPA) within their scope of practice. The scope of practice for NPs relates to the population focus of study and the specific specialization the advanced nurse practitioner obtained. In Idaho, advanced practice focus recognized are family/individual across the lifespan, adult-gerontology, women’s health/gender-related, neonatal, pediatrics, and psychiatric-mental health. A physician collaborative agreement and a prescribing agreement is not required. This means that Idaho state law allows NPs independent responsibility to assess, diagnose, treat, and monitor medical conditions. NPs are permitted to order and interpret tests, order or prescribe nonpharmaceutical therapies, and pharmaceuticals including schedule II through V controlled substances. If NPs received their education after December 31, 2015, they are automatically granted prescriptive authority when they receive their NP Idaho license. Following this, thirty hours of continuing education in advanced nursing pharmacotherapeutics is required upon renewal of license every two years (American Association of Nurse Practitioners, 2020; Idaho Board of Nursing, 2020).
According to studies comparing states that have given NPs FPA with those states with restrictions, states with NP FPA have shown improvement in access of care for populations in rural, underrepresented locations, improved efficiency in care allowing for prompt care rather than delayed care, the cost burden is decreased and promotes patient-centered care allowing patients to choose their primary caregivers (American Association of Nurse Practitioners, 2019). Further studies examine the educational preparation of NPs. Rather than strictly time-based clinicals, NPs educational programs are competency-based, meaning advanced skills must be demonstrated to advance in their program. Along with competency-based knowledge and skillsets, NPs services have been studied and evaluated for years showing that NPs persistently provided superior quality and safe care demonstrated by positive clinical outcomes (American Association of Nurse Practitioners, 2017). I have been studying and reading about NPs’ positive clinical outcomes for years, and it is my humble opinion that NPs should be fully independent. The claim that NPs expanded role in primary care was harmful to patients is not substantiated with studies that show increased patient satisfaction and improved patient care outcomes. Physicians and NPs can and do work together and provide collaborative care that shows ongoing promise for enhancing patient health and health care outcomes. The medical home model demonstrates this collaborative care process that fits the functions of primary care in providing comprehensive and coordinated patient care, patient-centered care, and improved timely access to medical services patients need (Institute of Medicine, 2011; U.S. Department of Health & Human Services, n.d.).

Describe collaborative approaches to treating rashes across the lifespan. Should the CNP treat without a collaborator or consultant? Support your statements based upon evidence.

Some unambiguous rashes that respond well to standard treatment may not need other multidisciplinary specialty input; however, it is essential for the nurse practitioner to recognize if and when skin conditions need further interprofessional collaboration and specialty referrals. Studies show improved patient outcomes when multidisciplinary approaches are used to treat various skin conditions. For instance, patients who do not respond to common acne treatment may need a dermatologist referral for further evaluation and workup for advanced treatment recommendations. Patients with eczema related to allergies would need multidisciplinary care involving an allergist, nutritionist, and dermatologist. Patients with skin cancer would require collaboration and specialty care of a dermatologist, dermatology oncology, radiation, and surgical oncology, etc. (Hilton, 2018; Arcangelo, Peterson, Reinhold, & Wilbur, 2017; LeBovidge, et al., 2016).
References:
American Association of Nurse Practitioners. (2019, December). Issues at a glance: Full practice authority. https://www.aanp.org/advocacy/advocacy-resource/policy-briefs/issues-full-practice-brief
American Association of Nurse Practitioners. (2017). Clinical outcomes: The yardstick of educational effectiveness. https://www.aanp.org/advocacy/advocacy-resource/position-statements/clinical-outcomes-the-yardstick-of-educational-effectiveness
American Association of Nurse Practitioners. (2020, October 20). State practice environment. https://www.aanp.org/advocacy/state/state-practice-environment
Arcangelo, V. P., Peterson, A., Reinhold, J., & Wilbur, V. (2017). Pharmacotherapeutics for advanced practice: A practical approach. Philadelphia: Wolters Kluwer.
Hilton, L. (2018, February 17). Multidisciplinary care improves patient outcomes. https://www.dermatologytimes.com/view/multidisciplinary-care-improves-patient-outcomes
Idaho Board of Nursing. (2020, July 1). Rules of the Idaho Board of Nursing. https://adminrules.idaho.gov/rules/current/24/243401.pdf
Institute of Medicine of the National Academies. (2011). The future of nursing: Leading change, advancing health. Washington, D.C: National Academies Press. https://www.nap.edu/read/12956/chapter/1#iv
LeBovidge, J. S., Elverson, W., Timmons, K., Hawryluk, E., Rea, C., Lee, M., & Schneider, L. (2016, August 1). Multidisciplinary interventions in the management of atopic dermatitis. The Journal of Allergy and Clinical Immunology, 325-334. https://www.jacionline.org/article/S0091-6749(16)30145-2/fulltext
U.S. Department of Health & Human Services. (n.d.). Defining the PCMH. https://pcmh.ahrq.gov/page/defining-pcmh
 
 
 
Discussion 4
The state of Kentucky requires advanced practice registered nurses (APRN) to have a collaborative agreement with a physician.  A collaborative practice requires an agreement with the nurse practitioner and the physician that uses a referral-consultant relationship (Arcangelo et al., 2017, p. 8).  Advanced practice nurses in Kentucky must use a collaborative agreement with a physician to prescribe class II-V drugs until they have been practicing for a minimum of four years.  After four years the advanced practice nurse may practice without a collaborative agreement for the advanced practice registered nurse’s prescriptive authority for nonscheduled legend drugs or the nurse can choose to continue with the agreement (H.R. Resolution KRS 314.011, 2014, p. 5).  According to the federal trade commission (FTC), collaborative agreements lead to an increase in health care costs, reduced quality of patient care, and limiting patients access to healthcare (Hoebelheinrich & Ramirez, 2020, p. 11).   Collaborative approaches to treating a rash include not only the nurse practitioner but also an educator, dermatologist, and physician recommendations.  It would be beneficial to the nurse practitioner if he/she used the guidance from a dermatologist if traditional treatments failed.
 
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: a practical approach (4th ed.). Wolters Kluwer.
H.R. Res. KRS 314.011, 8 Cong. Rec. 1 (2014) (enacted). https://kbn.ky.gov/practice/Documents/ARNPPresAuthSched.pdf
Hoebelheinrich, K., & Ramirez, J. P. (2020). Do Collaborative Practice Agreements Make APRNs Safe Practitioners?. Nebraska Nursing News, 37(1), 1–14. Retrieved December 23, 2020, from https://doi.org/https://center4nursing.nebraska.gov/sites/center4nursing.nebraska.gov/files/doc/Do%20Collaborative%20Practice%20Agreements%20Make%20APRNs%20Safe%20Practitioners%20-%20Hoebelheinrich%20%26%20Ramirez%20%E2%80%93%20Nursing%20News%20Winter%202020.pdf