HAWAII, APRN BOARD REGULATION, AND PRACTICE SCOPE

State of Hawaii APRNs are regulated by a board of nursing and are required to maintain an active RN license simultaneously. (NurseLicensure.org, n.d.). The State of Hawaii recognizes nurse practitioners, clinical nurse specialists, certified nursing midwives, and nurse anesthetists (NurseLicensure.org, n.d.). To be eligible for national certification as an APRN, a graduate degree must be obtained from an accredited university, where the program “must prepare the nurse to provide direct care in one of the four recognized roles (NP, CNS, CNM, CRNA)” as the “board does not accept master’s programs that are not focused on direct practice with individuals”. (NurseLicensure.org, n.d.). License renewals are performed every two, odd-numbered years. (NurseLicensure.org, n.d.) Discussion: Professional Nursing and State-Level Regulations.

Hawaii APRNs who want prescriptive authority, are required to hold a specialty certification in addition to their accredited master’s degree with “30 contact hours of recent coursework in advanced pharmacology; coursework to include advanced pharmacotherapeutics”. (NurseLicensure.org, n.d.). it is renewable every two years, with required continued NP certification, as well as proof of continuing education. (NurseLicensure.org, n.d.). Notably, a “nurse anesthetist does not need to apply for prescriptive authority to administer anesthesia”. (NurseLicensure.org, n.d.).

State of Hawaii APRNs are classified under a full practice environment, where “State practice and licensure laws permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.” (American Association of Nurse Practitioners, n.d.) Discussion: Professional Nursing and State-Level Regulations. This would translate into an APRN practicing within a full practice scope, for example, with the ability to assess, diagnose, treat, and prescribe medications to patients independently and without physician oversight.

FLORIDA, APRN BOARD REGULATION, AND PRACTICE SCOPE-COMPARE & CONTRAST TO HAWAII

APRNs in the State of Florida are termed Advanced Registered Nurse Practitioners (ARNPs) in contrast to Hawaii who terms advanced practice nurses as APRNs. In Florida, CRNAs and CNMs can credential as ARNPs.  (NurseLicensure.org, n.d.). Another contrast to Hawaii is that CNSs are not able to credential as an ARNP and would have to undergo a different licensing process. (NurseLicensure.org, n.d.). Like Hawaii, being a RN in Florida is required for credentialing as an ARNP. With regards to educational requirements, Florida requires students to complete a master’s degree or post master’s degree, with some noted exceptions for those graduating before 1998 without a master’s degree as a CRNA. (NurseLicensure.org, n.d.). This is an exception not noted with Hawaii. Florida also requires “a two-hour course in prevention of medical errors”, liability insurance is required, and ARNP functions must be delineated in protocols or a “collaboration agreement with a doctor or dentist; protocol must be submitted on a set timeline after employment commences”. (NurseLicensure.org, n.d.). Discussion: Professional Nursing and State-Level Regulations The medical errors course, liability insurance, and submission of work protocols or collaborative agreement are not noted to be required by the State of Hawaii.

In stark contrast to Hawaii APRNs full practice environment, Florida State APRNs are classified under a restricted practice environment, described as “State practice and licensure laws restrict the ability of NPs to engage in at least one element of NP practice” and that “State law requires career-long supervision, delegation or team management by another health provider in order for the NP to provide patient care”. (American Association of Nurse Practitioners, n.d.). This explanation on the NP practice scope in Florida, therefore, explains the reasoning for the collaboration agreement or protocol evidence that Floridians must submit to their board for NP eligibility. (NurseLicensure.org, n.d.) Discussion: Professional Nursing and State-Level Regulations.

The restricted practice environment of Florida NPs requiring physician oversight with patient care is a definite contrast to the latitude of a full practice environment that State of Hawaii APRNs are allowed, where they operate with a “full scope practice authority”, to diagnose, treat, and prescribe medications to patients. (Boland et al., 2019). I would imagine that with this restricted practice environment, should I per se have become a NP within the Florida State, I would have to, for example, ensure that I adhere to the patient care protocols or collaborative agreement with my overseeing physician to ensure compliance with Florida State Board of Nursing Regulations. (NurseLicensure.org, n.d.). I also did not note that NPs have prescriptive eligibility in Florida, while Hawaii does. (NurseLicensure.org, n.d.) Discussion: Professional Nursing and State-Level Regulations.

The ACA increased access for under-insured and uninsured U.S. residents, who are estimated to number more than 50 million. This law/program also had a significant impact on the estimated 6,400 shortage areas in the United States, including 66 million Americans who have limited access to primary care. (ANA, 2011)

Restricted practice states such as Florida could very well be seen as a health care access barrier to primary care for patients within the state, as providers are in short supply to address the demand. (Milstead & Short, 2017). “The need for APRNs to work in a variety of settings, but particularly in primary care, has been enormous, but their usefulness has been dependent on lifting practice restrictions in their state of licensure”. (Milstead & Short, 2017, p. 78).

References

American Association of Nurse Practitioners. (n.d.). State practice environment. Retrieved September 26,

2021, from, https://www.aanp.org/advocacy/state/state-practice-environment

American Nurses Association. (n.d). APRN state law and regulation. Retrieved September 26, 2021, from,

https://www.nursingworld.org/practice-policy/advocacy/state/aprn-state-law-and-regulation/

Boland, M., Qureshi, K., Loos, J. (2019, November). Spotlight on nursing. Hawaii Journal Social Welfare,

78(11): 349–350. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6847999/

Milstead, J. A., Short, N. M.  (2017). Health Policy and Politics (6th Ed). [[VitalSource Bookshelf version]].

NurseLicensure.org. (n.d.). Advanced practice registered nurse license requirements in Hawaii.

Retrieved September 26, 2021, from, https://www.nursinglicensure.org/np-state/hawaii-nurse-practitioner/

NurseLicensure.org. (n.d.). Advanced practice registered nurse license requirements in Florida.

Retrieved September 26, 2021, from, https://www.nursinglicensure.org/np-state/florida-nurse-practitioner/

Great post! I am surprised on the information about Florida. I had heard FL changed APRN practice significantly, but base don your post, it is still very restrictive. Is there information on why FL is so restrictive? Or why do you think they are very restrictive?

Hi Dr. Lamphrect! Thank you for your response. According to Blore (2021), A nurse practitioner professor at Barry University commented that Florida is a restrictive state with the scope of practice authority for nurse practitioners because there is a very large population of physicians within the state of Florida where the “medical association here is very tightknit and practices an old-school way of thinking”. Discussion: Professional Nursing and State-Level Regulations

Apparently, in March of 2021, Howard (2020) states that The Florida State Legislature passed a set of bills that allowed for primary care nurse practitioners to operate as independent providers; But did not grant all nurse practitioners this independence. Howard (2020) was not specific as to which specialty was excluded. Howell et al. (2021) state that “all APRNs must carry malpractice insurance or demonstrate proof of financial responsibility” and that nurse practitioners must submit proof of this every two years.

References

Blore, J. (2021, August 4). Florida nurse practitioners: The fight for full practice authority. Nurse Practitioner Schools. Retrieved

September 30, 2021, from, https://www.nursepractitionerschools.com/practice-authority/florida/

Howard, Chase. (2020, July 3). Florida aprn independent practice update. Florida Healthcare Law Firm. Retrieved

September 30, 2021, from, https://www.floridahealthcarelawfirm.com/aprnindependentpractice/

Howell, Buchan & Strong. (2021, March). New rules of Florida’s newly enacted autonomous aprn law. Retrieved September 30,

2021, from, https://www.floridahealthcareattorney.com/2021/03/new-rules-for-floridas-newly-enacted-autonomous-aprn-law/

Good day to you Dr. Lamprecht. I wanted to add to my first post reply about finding that the Florida nurse practitioner scope of practice was set into law last year of 2020. This is in contrast to the information I found initially indicating that Florida was a restrictive state. It was interesting that even after viewing the Florida board of nursing website, The American Association of Nurse Practitioners (n.d.) website, The American Nurses Association (n.d.) website, and the NurseLicensure.org (n.d.) website, that the information on these respective websites was not updated on the change from restrictive to autonomous practice authority for nurse practitioners in Florida. Setting the query with full practice authority, I noted some law firm websites described the change to independent practice for nurse practitioners. (Howell et al., 2021). (Howard, 2020). Howell et al. (2021) state that for a primary care nurse practitioner the law allows for autonomous practice if requirements are met, some of which are: “at least 3,000 clinical practice hours under the supervision of an allopathic or osteopathic physician within the past 5 years” and “may include clinical instructional hours”; “three graduate-level semester hours, or the equivalent, in differential diagnosis and 3 graduate-level semester hours, or the equivalent, in pharmacology completed within the past 5 years”.

References

American Association of Nurse Practitioners. (n.d.). State practice environment. Retrieved September 26,

2021, from, https://www.aanp.org/advocacy/state/state-practice-environment

American Nurses Association. (n.d). APRN state law and regulation. Retrieved September 26, 2021, from,

https://www.nursingworld.org/practice-policy/advocacy/state/aprn-state-law-and-regulation/

Florida Board of Nursing. (n.d.). Retrieved September 23, 2021, from, https://floridasnursing.gov/

Howard, Chase. (2020, July 3). Florida aprn independent practice update. Florida Healthcare Law Firm. Retrieved

September 30, 2021, from, https://www.floridahealthcarelawfirm.com/aprnindependentpractice/

Howell, Buchan & Strong. (2021, March). New rules of Florida’s newly enacted autonomous aprn law. Retrieved September 30,

2021, from, https://www.floridahealthcareattorney.com/2021/03/new-rules-for-floridas-newly-enacted-autonomous-aprn-law/

NurseLicensure.org. (n.d.). Advanced practice registered nurse license requirements in Florida.

Retrieved September 26, 2021, from, https://www.nursinglicensure.org/np-state/florida-nurse-practitioner/

The nursing regulatory bodies (NRBs) that comprise NCSBN protect the public’s health and welfare by assuring that safe and competent nursing care is provided by licensed nurses. (NCSBN. n.d) Each state regulates its unique nursing practice; therefore, the scope of nursing practice varies from state to state. It is Nurse’s legal and professional responsibility to understand their legal scope of practice and follow it. All state across the country has its unique Nurse Practice Act (NPA) that comprises APRNs roles and certifications. (Milstead& Short,2019) Many aspects of the NPA are similar, but other dynamics of the NPA allow for the vast difference in the practicing authority and autonomy of advanced practice registered nurses (Milstead &Short,2019). NPA gets guidance from the National Council of State Boards Nursing. According to the NCSBN, each state board requires APRNs to obtain a graduate degree in nursing and pass national certification within the specialty track of their graduate program. In as much as different states tend to have unique regulations for the Advance Practice Registered Nurse, their main aim is securing the interest of public health safety by regulating the activities of the health care professionals (Milstead, 2019)

Furthermore, NPS is prepared to serve as care providers who prescribe medication, order laboratory tests, sign death certificates, issue handicap placards, refer patients to specialists, and take on other responsibilities. But different states have different opinions about their scope of practice and giving them Full Practice Authority. States like Texas restrict NP ability to practice to the full extent of their education, experience, and credentials. In Texas, there is a prescriptions restriction for NP. The prescriptive authority in Texas requires a separate application, a written “prescriptive delegation” from a supervising physician, DEA registration for controlled substances, and registration with the TX Department of Public Safety, and recently, Texas eliminated the requirement of on-site physician supervision. Discussion: Professional Nursing and State-Level Regulations Consistent with strict supervision guidelines, an NP in TEXAS can only do a prescription under physician supervision.

Furthermore, they may only prescribe a 30-day supply of medications but cannot prescribe schedule 2 drugs such as Lortab or Adderall. All prescriptions written by the nurse practitioner must include the supervising physician’s name, address, DEA number, and phone number. Meanwhile, States like Oregon allow NP full prescriptive authority with APRN licensure. Secondly, Texas state statutes and regulations needlessly require Texas APRNs to secure a physician to delegate their authority for many elements of care. In contrast to Oregon state, where the APRNs practice independently.

In addition, as earlier mentioned, NPs are trained to function as care providers who prescribe medication, sign certificates of death, issue handicap placards, refer patients to see specialists, request lab tests, and take on other responsibilities. Master’s or doctoral preparation and national board certification are required for entry-level practice (AANP, 2006). Nurses can adhere to the regulations by fully completing the mandatory education levels to become nurse specialists. Compliance with regulations helps them identify the specific area of professional engagement and the boundary of their operations.

Conclusively though, the main goal for Advance Practice Registered to Nurse health professional activity regulations is securing the interest of the public health and safety. NPS may serve as a great help to substitute physicians for working in rural areas and underserviced areas; hence removing the unnecessary regulations of the collaborative practice agreement will expand access to high-quality health care in the areas that need it. Discussion: Professional Nursing and State-Level Regulations.

Reference

American Association of Nurse Practitioners. (2018). https://www.aanp.org/advocacy/state/state-practice-environment

Milstead, J. A., & Short, N. M. (2019). Health policy and politics: A nurse’s guide (6th ed.). Burlington, MA: Jones & Bartlett Learning.

Texas Board of Nursing – Advanced Practice Information. (2013) Retrieved from https://www.bon.texas.gov/

National Council of State Boards of Nursing | NCSBN (n.d) Retrieved from https://www.ncsbn.org/index.htm

Oregon State Board of Nursing (n.d) Retrieved from https://www.oregon.gov/.

Great post! Is there a rationale provided for why NP practice on CSII’s is so restrictive?

Great post,

Nurse practitioners (NP) have a major role in providing health care services in a variety of health care settings (Hain, Fleck, May 31, 2014). It would serve the public best if NP’s are provided the opportunity to practice at full scope. Physician shortages delay patient care, practicing NP’s if permitted have the opportunity to close the gap on provider shortages.

References

Hain, D., Fleck, L., (May 31, 2014) “Barriers to Nurse Practitioner Practice that Impact Healthcare Redesign” OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 2. Discussion: Professional Nursing and State-Level Regulations

Great post!  I think it’s interesting how Oregon gives full prescriptive authority to APRN.

In order to ensure public safety in the United States, all 50 states are supervised by Nursing Regulatory Bodies (NRB).  These jurisdictional government entities are meant to safeguard the nursing practice through regulations and safety adherence.  Their mission is to protect public health by providing outlined standards and scope of practice for nurses and monitoring license compliance (About U.S. nursing regulatory bodies 2021) Discussion: Professional Nursing and State-Level Regulations.

In California, it is the Board of Registered Nursing (BRN) that certifies APRN.  The role of an NP in California allows for physical diagnosis along with management and treatment of illness.  In addition, NP’s may also perform psychosocial assessments (Advanced practice and public health Nurse certification 2021).  California falls under the “restrictive practice” state.  This stipulates that NPs must have career-long supervision by another provider or team practice in order to provide patient care (State practice environment 2021).  Furthermore, furnishing(ordering) of medications and controlled substances by a NP must be done under the supervision of a physician or surgeon.  The NP must also consult with a physician or surgeon to initiate or modify home health treatment, seek collaboration with a physician after a physical examination to certify an individual as disabled and the ordering of medical equipment for a patient (General Information: Nurse Practitioner Practice (PDF) 2021) Discussion: Professional Nursing and State-Level Regulations.

Conversely, Massachusetts (MA) is deemed a “full practice” state.  In a full practice state, an APRN can assess and evaluate patients, provide a diagnosis, interpret laboratory tests and implement treatments, including prescribing controlled substances without the supervision of a physician.  This is in far contrast to California, as APRN in Massachusetts are permitted to perform these tasks under their nursing licensure of their state board.  In fact, the MA model is the recommended model by the National Academy of Medicine (State practice environment 2021).

I live in California, which as stated previously is a more restrictive state in regards to APRN practice.  Yet, I believe APRN may still practice within their full scope as dictated by state regulations.  For example, If an APRN believes a post-operative orthopedic patient requires a controlled substance, such as an opioid, they may still prescribe it.  However, it will require the approval of the supervising physician.  Another example would be ordering a continuous passive motion machine (CPM) for the same patient to use at home.  This would be another instance of a similar consensus required between the supervising physician and APRN.  Thus, it is possible to practice with full scope in CA in regards to utilizing full skill set and education, however, it would require an extra step of receiving approval for treatment plans Discussion: Professional Nursing and State-Level Regulations.

References

About U.S. nursing regulatory bodies. NCSBN. (2021). Retrieved September 29, 2021, from https://www.ncsbn.org/about-nursing-regulatory-bodies.htm.

Advanced practice and public health Nurse certification. California Board of Registered Nursing. (2021). Retrieved September 29, 2021, from https://www.rn.ca.gov/applicants/ad-pract.shtml.

State of California Department of Consumer Affairs . (2021). General Information: Nurse Practitioner Practice (PDF). Board of Registered Nursing . Retrieved from file:///C:/Users/15592/AppData/Local/Temp/npr-b-23-1.pdf.

State practice environment. American Association of Nurse Practitioners. (2021). Retrieved September 29, 2021, from https://www.aanp.org/advocacy/state/state-practice-environment.