Where Can Nurse Practitioners Work Without Physician Supervision?

Since the inception of the first Nurse Practitioner education program in 1965, men and women in the profession have experienced great success and heated opposition. Physician organizations have openly opposed the use of Nurse Practitioners as primary care providers, claiming that educational gaps render them unsafe and unqualified to care for patients independently.

Even though the decades-old debate continues, research has proven time and again that Nurse Practitioners are indispensible primary care providers whose ability to treat a wide variety of conditions rivals that of physicians. Moreover, according to the Kaiser Family Foundation (KFF), 58 million Americans live in areas in which the supply of primary care physicians doesn't meet federal standards (the appropriate ratio of providers to patients in a given state). As hundreds of thousands of new patients gain access to medical care via the Affordable Care Act and one-third of primary care doctors retire over the next decade, many Nurse Practitioners are gaining independence and establishing autonomy as they provide medical care without the oversight or management of a physician.

NP Scope of Practice Map

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Understanding Practice Status

Scope of practice guidelines for advanced nursing professions vary by state. Currently, 21 states and the District of Columbia have approved "full practice" status for Nurse Practitioners, a provision that allows them to assess, diagnose, interpret diagnostic tests, and prescribe medications independently.

According to Kaiser Health News, Alaska, New Hampshire, Oregon, and Washington were the first states to offer expanded scope of practice in the 1980s; more rural states, mainly those with physician shortages, followed in the 1990s.

In 2010, full practice status became the recommended model by the Institute of Medicine and the National Council for State Boards of Nursing. Not all states, however, are on board with the measure; 29 continue to mandate reduced or restricted practice regulations for Nurse Practitioners. While the practice guidelines for both of these levels are slightly different depending on location, all require NPs to have either a signed collaboration agreement with a physician or direct oversight from a physician. Not all states require the physician to be physically present or even in the same building with the NP during patient care, but he or she should be available by phone or email.

Independent Care Gaining Steam

Despite aggressive opposition from the medical community, some lawmakers are looking closely at the NP's role  in expanding coverage to underserved areas and easing the burden on the dwindling number of primary care physicians who remain — calling the NP role “necessary for long-term health care.”

Nurse Practitioners have full practice authority in the following states

  • Alaska
  • Arizona
  • Colorado
  • Connecticut
  • District of Columbia
  • Hawaii
  • Idaho
  • Iowa
  • Maine
  • Maryland
  • Minnesota
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Mexico
  • North Dakota
  • Oregon
  • Rhode Island
  • Vermont
  • Washington
  • Wyoming

According to the Kaiser Family Foundation, “in 2013, more than 20 states took legislative or regulatory action favorable to NPs’ ability to practice more fully.” Several states have also approved new legislation for NPs, empowering them to sign death certificates and formal health records and affording them the ability to prescribe certain medications.

With the approval of HB 4334 earlier this year, West Virginia became the latest state to pass legislation allowing Nurse Practitioners to diagnose and treat patients without the oversight of a physician; however, the state still does not allow NPs to prescribe independently. Supporters of the bill hope that a wider scope of practice will allow more than 1,700 NPs to provide health care to communities where physicians are in short supply.

Additionally, states aren't the only entities moving to dismantle practice barriers. In May, the U.S. Department of Veteran Affairs (VA) issued a proposal that would “permit full practice authority of all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.”

Communication and Collaboration in the Future

Health care leaders from nursing and medicine fields agree that there should be more conversations addressing the independence of NPs. Both sides concur that the NP role is vital to the health and delivery of medical care in this nation, but neither can agree on the best way to achieve the goal. As both sides hold strongly to their convictions, there is sure to be more debate — and potentially more autonomy — for Nurse Practitioners.