NPs Must Adhere to State Scope-of-Practice Regulations

Abstract

In implementing a new healthcare role, one of the consistent legal challenges nurse practitioners (NPs) have faced is that of scope of practice. Without national regulations, each state was forced to pass legislation outlining the scope of practice of NPs, resulting in substantial variability among states in what NPs are authorized to do. Scope of practice is one of the legal tenants battered over the years as the NP role has matured and developed. When states initially crafted NP legislation, many of them implemented a fairly narrow scope of practice with lots of physician oversight. This was essential to get legislation passed, and NPs said, “We just need to get our foot in the door, and we can pass broader legislation later.” As the NP role has gained acceptance and credibility, many states have returned to the legislature time and again in attempts to broaden practice legislation, but many of these legislative overtures have met with physician resistance, branding new legislation as incursions into traditional physician “turf.” Resistance to changes in state NP legislation has usually been strongest from organized medical groups that have supplied both money and resources to help state medical organizations fight legislative changes. NP diligence and lobbying has often overcome medical resistance at the state level. Successful efforts, such as those of the NPs in Maryland to remove the requirement for a letter of collaboration with physicians to practice, may be heralded as the first of many other states' drive to shrug off this restrictive legislation. Some scope-of-practice legislation was outgrown through changes in the NP role over time. Before there were acute care NP programs, NPs might leave primary care programs to practice in ICUs or other acute care settings. Some adult, pediatric, or geriatric NPs practiced in acute care settings for years, but if they change their site of employment, they now meet resistance from their own boards of nursing if they do not have the acute care NP credential. Some adult or geriatric NPs gradually began to see younger and younger patients. Other NPs developed expertise in mental health and began seeing psychiatric patients. Because these NPs were both competent and supported by the physicians with whom they worked, their practice expanded into areas in which they had no formal academic preparation. Again, when these NPs attempt to change practice sites, however, boards of nursing enforce strict requirements for NPs to have preparation as psychiatric NPs or pediatric NPs or have age restrictions for GNPs to follow. So the development of new specialty NP programs, new credentialing examinations, and greater adherence to state scope of practice regulations have changed practice over the years. NPs are often a mobile group and may have licensure in several states. This means an NP may be authorized to do things in one state that are prohibited in another. Just because an NP is competent to practice doesn't mean that she or he has the authorization to do so without certain academic credentials. It is therefore mandatory, to reduce liability, that NPs understand the scope of practice within their state and practice only within their arena of authorized practice.