Are you interested in entering the world of healthcare? There are a multitude of careers in medicine you can pursue. One is a nurse practitioner (NP). Most NPs provide direct patient care. You may be responsible for the primary, specialty, or urgent care of individuals. NPs work in a variety of settings including hospitals, clinics, homes and virtually anywhere individuals seek health care. You can choose to work with all ages or specialize in a subset of the population such as geriatrics, pediatrics, or adult medicine. You can have a positive impact on an individual’s health and make a true difference in their lives. NPs play a crucial part of today’s healthcare system.
Each state regulates the practice environment for its NPs. You may choose to work in a Restricted, Reduced, or Full Practice Authority (FPA) state. According to the American Academy of Nurse Practitioners (2022), NPs in a FPA state may evaluate, diagnose, order, and interpret diagnostic testing, and manage the care of patients independently and exclusively under their state board of nursing without physician oversight.
Already a NP? You may be wondering how the state regulations directly affect your practice. The following information will give state specific details regarding each practice environment for NPs.
What are the types of Practice Environments for NPs?
Restricted
Restricted states require physician oversight for NPs with at least one key element of NP practice restricted by state regulations. In order to practice, you may need some degree of supervision by a physician throughout your career as a NP to provide patient care. A Collaborative Practice (CPA) is necessary between a physician and NP.
Reduced
Although NPs have significant independence in a reduced practice state, at least one of the NP’s key elements of practice is “reduced” by state regulations. For example, as a NP you may not be allowed to sign a death certificate. A CPA between a NP and physician is necessary here as well to provide patient care.
Full
As opposed to “restricted” and “reduced”, a NP can practice autonomously and independently if they work in a FPA state. A NP in this state will practice to the fullest extent of their license without physician oversight.
States with Restricted Authority for Nurse Practitioners
California
The only western state to specify this, a California NP must always work with physician oversight and a CPA.
Florida
Though Florida is experiencing a physician shortage presently, many NPs are still restricted. For experienced NPs in primary care, FPA may be approved (Gov. DeSantis signed this into law in 2020). Check with the Florida Board of Nursing.
Georgia
Despite urgent healthcare needs in Georgia, their NPs are still currently restricted. They must have a physician’s supervision and CPA to function in their field of expertise.
Michigan
NPs in Michigan are not allowed to practice without a CPA and physician oversight at this time.
Missouri
Missouri NPs are also significantly restricted. They must always collaborate with a doctor.
North Carolina
For a NP to work in North Carolina, a physician must be in a CPA and continuously available for collaboration regarding evaluation of care, referral, and consultation.
Oklahoma
Oklahoma requires a CPA between NPs and physicians. For a NP to prescribe medications, they must be under the supervision of a physician.
South Carolina
A signed CPA must be held between a physician and a NP to operate in South Carolina. In the area of “nurse practitioner autonomy”, this state ranks poorly with many restrictions.
Tennessee
With the supervision of a physician, medications can be prescribed by NPs in Tennessee. This state is also considered highly restrictive for NP autonomy.
Texas
NPs can treat/prescribe for patients in Texas, so long as they have a prescriptive authority agreement with a collaborating physician who is licensed in Texas. Both the Texas Medical Board and Texas Board of Nursing monitor the collaborative relationships in the state.
Virginia
A bill was signed in 2018 that would allow NPs with five years of experience to be certified to practice independently. Otherwise, a CPA is required for NP practice.
States with Full-Practice Authority for Nurse Practitioners
Alaska
FPA is held by nurse practitioners in Alaska. This means that they can analyze tests, diagnose/evaluate patients, and manage treatment plans. Though not all professionals in the field can, in some cases, NPs may be able to apply for the ability to prescribe certain controlled substances, Schedules ll to V.
Arizona
FPA applies to NPs in Arizona. As in most states, before prescribing any medications to patients, they must register with the Drug Enforcement Agency (DEA) and apply to a program referred to as a Controlled Substance Prescription Monitoring Program (CSPMP).
Colorado
Colorado NPs have FPA. After putting in 1000 hours with a mentor providing provisional prescriptive authority, they may also gain full prescriptive authority. They cannot sign death certificates.
Connecticut
Connecticut NPs have FPA. There are certain regulations regarding Schedule II drugs, but otherwise Connecticut NPs may write prescriptions independently.
Delaware
FPA can be held by NPs in Delaware. A CPA is required for Schedule II drugs.
District of Columbia
NPs working in the District of Columbia can have full practice autonomy if they have a national NP certification, a graduate degree, and RN license.
Hawaii
Though FPA is held by all of Hawaii’s NPs, the state may indeed have one of the smallest pools of licensed professionals in the field. They have full practice and prescriptive authority.
Idaho
Idaho NPs have FPA. To earn prescriptive authority, they must complete 30 hours of qualifying CE (continuing education) courses.
Iowa
Without physician supervision, Iowa NPs can treat, diagnose, and advise patients. ARNPs (advanced registered nurse practitioners) may also own independent practices. NPs may also hold prescriptive authority.
Kansas
In April 2022, Kansas NPs gained FPA. A CPA is no longer needed to practice in Kansas.
Maine
FPA is held by Maine NPs. Medications can be prescribed by those with an APRN license.
Maryland
Without physician supervision, NPs in Maryland can treat patients.
Massachusetts
NPs in Massachusetts have independent practice authority to manage patient care.
Minnesota
FPA is held by NPs in Minnesota. A variety of medications may be prescribed/dispensed by them as well if they have an APRN license.
Montana
Physician supervision is not needed by NPs in Montana. APRNs can prescribe medications if they successfully apply for prescriptive authority.
Nebraska
Along with FPA, Nebraska NPs need physician collaboration for the first 2000 hours of prescriptive authority.
Nevada
FPA is held by Nevada NPs. APRNs must have either 2 years or 2,000 hours of clinical experience or a protocol approved by a collaborating physician to prescribe Schedule II drugs.
New Hampshire
In New Hampshire, FPA is held by those with APRN licensure. They may also prescribe a variety of non-controlled and controlled substances.
New Mexico
NPs in New Mexico independently diagnose, care for and develop treatment plans for patients. Controlled substances (Schedule ll through V) can be prescribed if they receive state certification and register with the DEA.
New York
A NP with more than 3600 hours of qualifying experience can have FPA in New York.
North Dakota
Patients can be treated independently by NPs in North Dakota with FPA.
Oregon
FPA is held by Oregon’s NPs, who are among the highest paid in the United States. Full prescriptive authority is held by those with APRN licensure.
Rhode Island
Without physician supervision, NPs have FPA in Rhode Island.
South Dakota
Nurse practitioners in South Dakota have FPA as well. For prescriptive authority, NPs must have practiced over 1,040 hours.
Vermont
While Vermont is a FPA state, the first 24 months (or 2400 hours) of NP practice must be completed with a CPA in place between physician and NP.
Washington
Without physician surveillance, patients may be diagnosed and treated independently by Washington NPs.
Wyoming
With some of the most lenient licensure guidelines in the nation, FPA is held by NPs in Wyoming.
States with Reduced Authority for Nurse Practitioners
Alabama
To deliver care to patients, Alabama NPs must collaborate with a physician. Alabama NPs require physician collaboration to prescribe medications. They can sign handicap parking permits and death certificates with physician collaboration. They cannot sign sports physicals.
Arkansas
In Fall of 2022, NPs with 6240 hours of practice in the state are able to apply for full practice authority including prescriptive authority. NPs can sign for disabled person placards. They can order physical therapy but have certain limitations regarding prescribing controlled substances such as Schedule II medications and signing POLSTs.
Illinois
NPs who complete at least 250 hours of continuing education and 4000 hours of clinical experience after board certification are allowed to have FPA in Illinois. Until requirements are met, a NP in Illinois would need to practice with a CPA with a collaborating physician.
Indiana
NPs in Indiana must collaborate with a supervising physician to practice with prescriptive authority.
Kentucky
A highly restrictive state, Kentucky limits their NPs more than many of the other US states. NPs need a separate written CPA for prescriptive authority with a physician for purposes of prescribing controlled substances for a certain timeframe.
Louisiana
Louisiana NPs must have a CPA for practice and prescriptive authority.
Mississippi
A CPA must be entered into with a physician for practice and prescriptive authority. A NP may prescribe prescription drugs and Schedules II-V controlled substances after completing a Mississippi State Board of Nursing approved educational program. An NP may open a freestanding clinic or their own practice with a CPA.
New Jersey
Though currently reduced and requiring a CPA between physician and NPs, FPA may soon be granted to NPs in New Jersey.
Ohio
Severely restricted in Ohio, NPs operate under what is considered an “outdated” set of practice regulations put forth by the state. A CPA is required. Advocates are currently pushing for fewer restrictions on the state’s NPs.
Pennsylvania
In Pennsylvania, CPAs are required to practice and prescribe. NPs may prescribe Schedule II-V drugs with a CPA in place.
Utah
NPs in Utah require a CPA with a physician to practice currently.
Wisconsin
Wisconsin remains under reduced practice for NPs. A NP cannot practice or prescribe independently without a CPA with a physician.
West Virginia
In West Virginia, NPs require a CPA with a physician for practice and prescriptive authority. They cannot prescribe Schedule II drugs.
Important to Note
The state-by-state regulation information above frequently changes and represents the best information available at the time of publication. For the most current regulations, the appropriate state nursing board should be checked to verify the information and get the latest updates.
In many states, the push to grant FPA to NPs is due to a shortage of physicians and to improve access to care. This became a particular problem when COVID-19 hit and has continued to be problematic. In many reduced and restricted states, the idea of FPA is up for legislative vote and approval. By checking with the appropriate Board of Nursing and the latest developments, you’ll get a better idea of what duties you will be able to perform as a nurse practitioner and where you can advocate for full practice authority.
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Reference:
American Academy of Nurse Practitioners (AANP). (2022, March 15). State practice environment. American Academy of Nurse Practitioners. Retrieved July 28, 2022, from https://www.aanp.org/advocacy/state/state-practice-environment.
