Practice authority of nurse practitioners by state

May 10, 2021

Austin Wetmore

Introduction to nurse practitioners

Nurse practitioners, NPs, are an important component of our nation’s healthcare system. Although NPs can practice in a wide range of specialties and subspecialties, most of them work in a primary care or family practice setting. As a result, they represent an integral part of the primary care workforce.

Becoming an NP requires earning a bachelor’s degree in nursing, becoming a licensed registered nurse (RN), completing a graduate-level—either master’s or doctoral— NP degree program, and passing a national board certification examination. After satisfying all of these requirements, which are generally the same across all states, an NP is eligible to become state-licensed. However, the requirements for practicing as an NP once licensed vary widely among states. This means that your scope-of-practice as an NP may be reduced or restricted to requiring supervision by a physician depending on which state you live and practice in.

Professional associations representing NPs, such as the American Association of Nurse Practitioners, advocate for the full practice authority of NPs across all states. This would mean that NPs could independently diagnose, treat, and prescribe medications to patients, without being supervised by a physician. These associations argue that the education and clinical training required to become an NP is sufficient for NPs to practice without physician supervision. Regardless, laws regulating NP practice and full practice authority remain highly inconsistent among states.

Due to state variations regarding the ability to practice as an NP, it is important for interested students to consider how their career could be affected based on the laws in their state. Therefore, this article summarizes restrictions on NP practice for each state so that students can better prepare themselves for a career as an NP.

State profiles of NP practice authority

The scope-of-practice level —full, reduced, or restricted—for NPs is assessed for each state based on the degree to which NPs can independently diagnose and treat patients according to state practice and licensure policies. Furthermore, the prescriptive authority level for NPs —independent or physician-authorized—is assessed for each state based on whether or not NPs can independently prescribe medications to patients. An asterisk (*) next to the scope-of-practice level or prescriptive authority level in the state profile indicates that the completion of an introductory period with physician oversight is required before NPs become eligible to practice or prescribe medications independent of a physician. Definitions for each scope-of-practice level and each prescriptive authority level are given below.

Full scope-of-practice means that NPs can diagnose and treat patients independent of a physician.

Reduced scope-of-practice means that NPs have a reduced authority to diagnose and treat patients. In reduced scope-of-practice states, an NP is required to have a collaborative practice agreement with a licensed and board-certified physician. A collaborative practice agreement is a professional collaboration between a physician and an NP that authorizes the NP to practice. The collaborative practice agreement generally includes a standard written protocol, which is a document that describes the terms of the physician–NP collaboration and lists the specific medical services and acts that the NP is authorized to perform under the collaboration.

Restricted scope-of practice means that NPs have a restricted authority to diagnose and treat patients. In restricted scope-of-practice states, an NP is required to practice under a licensed and board-certified physician, who serves as a delegating physician. The delegating physician supervises the practice of and delegates tasks to the NP to the extent that any diagnosis made or treatment performed by the NP requires oversight and final authorization by the delegating physician.

Independent prescriptive authority means that NPs can prescribe medications independent of physician supervision or collaboration.

Physician-authorized prescriptive authority means NPs can only prescribe medications in collaboration with or under the supervision of a physician.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. The collaborative practice agreement must include a standard written protocol. NPs can prescribe both general medications and controlled substances to the extent detailed in the protocol.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority. They can independently prescribe both general medications and controlled substances.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances. However, NPs are limited in their ability to prescribe refills for controlled substances.

Full scope-of-practice with physician-authorized prescriptive authority

NPs have full independent practice authority requiring no collaboration or oversight by a physician, but a collaborative practice agreement with a physician is required for prescribing general medications and controlled substances with a low risk of misuse, for example Schedule III–V controlled substances. In general, NPs cannot prescribe controlled substances with a high risk of misuse like Schedule II controlled substances.

Restricted scope-of-practice with physician-authorized prescriptive authority

NPs practice under the supervision of a delegating physician. They can prescribe both general medications and controlled substances under the delegating physician.

Full scope-of-practice with independent prescriptive authority*

NPs have full independent practice authority and are able to independently prescribe both general medications and controlled substances after completing an introductory period in which a physician mentors the NP with prescribing duties.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority after an introductory period requiring a collaborative practice agreement with a physician. Although NPs can independently prescribe general medications immediately upon receiving licensure, they must complete an introductory period requiring collaboration with a physician prior to prescribing controlled substances independently.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority after an introductory period requiring a collaborative practice agreement with a physician. NPs can independently prescribe general medications immediately upon receiving licensure, but they have to complete an introductory period requiring collaboration with a physician before they are able to prescribe controlled substances independently.

Reduced scope-of-practice with independent prescriptive authority

NPs practice under a collaborative practice agreement with a physician, although they are able to independently prescribe both general medications and controlled substances.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority after an introductory period requiring supervision by a physician. The terms of the physician supervision during the introductory period must be documented in a standard written protocol. NPs can independently prescribe general medications and controlled substances with a low risk of misuse, e.g., Schedule III–V controlled substances, after completing an introductory period requiring a collaborative practice agreement with a physician. However, NPs have a limited ability to prescribe controlled substances with a high risk of misuse, e.g., Schedule II controlled substances.

Restricted scope-of-practice with physician-authorized prescriptive authority

NPs practice under the supervision of a delegating physician. The terms of the physician supervision must be documented in a written protocol agreement. NPs can prescribe general medications and controlled substances with a low risk of misuse as under the supervision of a physician. However, NPs are not authorized to prescribe controlled substances with a high risk of misuse.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances.

Full scope-of-practice with independent prescriptive authority

With full independent practice authority, NPs can independently prescribe both general medications and controlled substances.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority after an introductory period requiring a collaborative practice agreement with a physician. However, NPs who practice in a hospital or same-day surgical facility are exempt from this requirement and have full independent practice authority immediately upon receiving licensure. NPs can independently prescribe general medications and controlled substances after completing an introductory period requiring collaboration with a physician.

Full scope-of-practice with physician-authorized prescriptive authority

NPs have full independent practice authority, but a collaborative practice agreement with a physician is required to prescribe both general medications and controlled substances.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances. Registration with the Board of Pharmacy is required to prescribe controlled substances.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. NPs can prescribe both general medications and controlled substances to the extent detailed in the agreement.

Full scope-of-practice with physician-authorized prescriptive authority

NPs have full independent practice authority, but a collaborative practice agreement with a physician is required for NPs to prescribe both general medications and controlled substances.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. They can prescribe both general medications and controlled substances to the extent detailed in the agreement.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority after completing an introductory period requiring supervision by a physician. NPs can independently prescribe both general medications and controlled substances after completing an introductory period requiring supervision by a physician.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority and independent prescriptive authority for both general medications and controlled substances after completing an introductory period requiring a collaborative practice agreement with a physician.

Full scope-of-practice with independent prescriptive authority*

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances after completing an introductory period requiring supervision by a physician.

Restricted scope-of-practice with physician-authorized prescriptive authority

NPs practice under the supervision of a delegating physician. The terms of supervision in the physician–NP relationship must be documented in a standard written protocol. NPs can prescribe both general medications and controlled substances to the extent detailed in the protocol under the supervision of a physician.

Full scope-of-practice* with independent prescriptive authority

NPs are granted full independent practice authority after completing an introductory period requiring a collaborative practice agreement with a physician. NPs can independently prescribe both general medications and controlled substances.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. They can prescribe both general medications and controlled substances to the extent detailed in the agreement.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician, and they can prescribe both general medications and controlled substances with a low risk of misuse, e.g., Schedule III–V controlled substances, to the extent detailed in the agreement. However, NPs are not authorized to prescribe controlled substances with a high risk of misuse, e.g., Schedule II controlled substances.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority. They can independently prescribe both general medications and controlled substances.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority and independent prescriptive authority for both general medications and controlled substances after completing an introductory period requiring a collaborative practice agreement with a physician.

Full scope-of-practice with independent prescriptive authority*

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances with a low risk of misuse like Schedule III–V controlled substances, immediately upon receiving licensure. However, NPs have to complete an introductory period requiring collaboration with a physician before they can independently prescribe controlled substances with a high risk of misuse, for example Schedule II controlled substances.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances.

Full scope-of-practice with physician-authorized prescriptive authority

NPs have full independent practice authority, and they can prescribe both general medications and controlled substances under a written collaborative agreement with a physician.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances. Registration with the Board of Pharmacy is required to prescribe controlled substances.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. The collaborative practice agreement must include a standard written protocol. NPs can prescribe both general medications and controlled substances to the extent detailed in the protocol.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. The collaborative practice agreement must include a standard written protocol. NPs can prescribe both general medications and controlled substances to the extent detailed in the protocol.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. The collaborative practice agreement must include a standard written protocol. NPs can prescribe only general medications to the extent detailed in the protocol. However, NPs do not have the authority to prescribe controlled substances.

Full scope-of-practice with physician-authorized prescriptive authority

NPs have full independent practice authority, and they can prescribe both general medications and controlled substances with a low risk of misuse, e.g. Schedule III–V controlled substances, under a written collaborative agreement with a physician. However, NPs do not have the authority to prescribe controlled substances with a high risk of misuse, e.g. Schedule II controlled substances.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. NPs can prescribe both general medications and controlled substances to the extent detailed in the agreement, but controlled substances are subject to supply limits.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances.

Restricted scope-of-practice with physician-authorized prescriptive authority

NPs practice under the supervision of a delegating physician. The conditions of supervision in the physician–NP relationship must be documented in a written protocol agreement. NPs can prescribe both general medications and controlled substances through a separate written collaborative agreement with the delegating physician.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority and independent prescriptive authority for both general medications and controlled substances after completing an introductory period requiring a collaborative practice agreement with a physician.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority and independent prescriptive authority for both general medications and controlled substances after completing an introductory period requiring a collaborative practice agreement with a physician.

Restricted scope-of-practice with physician-authorized prescriptive authority

NPs practice under the supervision of a delegating physician. The conditions of supervision in the physician–NP relationship must be documented in a standard written protocol. NPs can prescribe both general medications and controlled substances to the extent detailed in the protocol.

Full scope-of-practice with independent prescriptive authority*

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances with a low risk of misuse, e.g. Schedule III–V controlled substances, immediately upon receiving licensure. However, NPs have to complete an introductory period requiring collaboration with a physician before they can independently prescribe controlled substances with a high risk of misuse, e.g. Schedule II controlled substances.

Full scope-of-practice* with independent prescriptive authority*

NPs are granted full independent practice authority and independent prescriptive authority for both general medications and controlled substances after completing an introductory period requiring a written collaborative practice agreement with a physician.

Full scope-of-practice* with independent prescriptive authority

NPs are granted full independent practice authority and independent prescriptive authority for both general medications and controlled substances after completing an introductory period requiring a collaborative practice agreement with a physician-led multidisciplinary patient care team. Once the introductory period is successfully completed, NPs are issued a new license indicating the ability to practice independently.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and can independently prescribe both general medications and controlled substances.

Full scope-of-practice with independent prescriptive authority*

NPs have full independent practice authority. After completing an introductory period requiring a collaborative practice agreement with a physician, NPs can independently prescribe general medications and controlled substances with a low risk of misuse, e.g. Schedule III–V controlled substances. However, NPs are not authorized to prescribe controlled substances with a high risk of misuse, e.g. Schedule II controlled substances.

Reduced scope-of-practice with physician-authorized prescriptive authority

NPs practice under a collaborative practice agreement with a physician. The collaborative practice agreement must include a standard written protocol. NPs can prescribe both general medications and controlled substances with a low risk of misuse, e.g. Schedule III–V controlled substances, under the collaborative practice agreement. However, NPs have very limited authority to prescribe controlled substances with a high risk of misuse, e.g., Schedule II controlled substances, and they can do so in only certain rare circumstances.

Full scope-of-practice with independent prescriptive authority

NPs have full independent practice authority, and they can independently prescribe both general medications and controlled substances.

Closing remarks

It is important to note that the information in this article is up-to-date as of February 2021 and also that state laws regulating NP practice and prescriptive authority are frequently changing. Therefore, checking the most recently updated state laws regulating NPs using the links in this article is critical for obtaining the most up-to-date and accurate information.

As a final remark, it is crucial for aspiring NPs to consider how state regulations and laws on NP practice and prescriptive authority may impact their future career as an NP. Being aware of this will make it easier to have a personally fulfilling career.

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