In many states, the laws that establish nurse practitioner (NP) roles are in flux. This guide defines a nurse practitioner's scope of practice, explains the three levels of practice authority, and lists states by practice authority. Read on to understand how practice authority can affect your career as a nurse practitioner.
What is Scope of Practice?
Scope of practice refers to the professional activities that each state authorizes nurses or other clinical staff to perform. An NP's scope of practice can include assessing a patient's condition, ordering tests, interpreting results and making diagnoses, prescribing medication, and ordering treatments.
Scope of practice varies by state. In some states, NPs must work under a physician's supervision or in collaboration with a physician, while other states allow nurse practitioners to practice independently.
How Scope of Practice Relates to Practice Authority
Scope of practice falls into three main categories, or levels, of practice authority: full, reduced, or restricted practice authority.
In full practice authority states, nurse practitioners can perform the full scope of practice without a supervising or collaborating physician. They can diagnose a patient, order tests, prescribe medication, and operate their own independent practices. Nurse practitioner independent practice states may require a certain level of experience working under a physician’s supervision or require additional training before allowing full practice authority. Because these requirements are not permanent, these states are still considered full practice authority states.
In reduced practice states, nurse practitioners can perform some of their scope of practice without physician supervision. These restrictions typically involve operating their own practices or prescribing certain types of medications. They rarely involve the nurse practitioner’s ability to order tests or diagnose conditions. For example, a nurse practitioner might need to be part of a practice that is supervised by a physician, rather than running their own practice, but within that practice, can operate with relative autonomy.
In restricted practice states, nurse practitioners must work under the supervision of a physician for all of their scope of practice. While they may have extensive autonomy in some nurse practitioner functions, they are not acting as independent practitioners. However, some states may loosen restrictions as the NP gains experience.
State-by-State NP Practice Authority
States by Nurse Practitioner Practice Authority
Each state establishes its own NP practice authority regulations. This list provides the latest nurse practitioner scope of practice by state or territory.
Full Practice Authority States/Territories
Reduced Practice Authority States
Restricted Practice Authority States
The Push for Full Practice Authority
Expanding NP practice authority produces many benefits for healthcare consumers. It increases the availability of healthcare providers who can diagnose and treat health conditions; expands the availability of family practitioners during current and projected shortages; and because nurse practitioner salaries are lower than physician salaries, provides care at a lower cost.
However, many individuals and organizations, especially physician organizations, express concerns that many conditions that should be diagnosed and treated only by physicians are instead being treated by NPs and that healthcare payers, especially insurance companies, may pressure healthcare providers to use NPs instead of physicians. This, they argue, can result in a lower quality of care and outcomes for patients with complex or serious health conditions.
Physicians also earn more from supervising NPs and would lose out on this revenue source if NPs could practice independently. Given the rapid growth in full practice authority states, it seems that state legislators believe in the positive impact of expanding NP practice authority.
Learn how you can get involved in the push for NP full-practice authority with our advocacy guide.
Recent NP Practice Authority Legislation
- In November 2022, California's nurse practitioner association approved rules that would allow for expanded scope of practice for NPs in the state. Starting in January 2023, nurse practitioners who have completed three years of clinical practice in California will be authorized to work without contractual physician supervision in healthcare settings with at least one practicing physician or surgeon on staff. This means that nurse practitioners who qualify will still be able to consult a physician if necessary.
- In February 2021, Pennsylvania State Bill 25 was introduced. The measures in this bill include expanding the scope of practice for certified NPs. The bill is currently pending.
- As of July 1, 2020, under HB 607, advanced practice registered nurses in Florida who have completed 3,000 hours under the supervision of an MD or a DO in the last five years can apply for an unrestricted license.
- In 2018, South Carolina removed the previous requirement that collaborating or supervising physicians be located within a 45-mile radius of the NP's practice and raised the number of NPs that a physician can supervise or collaborate with from three to six.
Frequently Asked Questions About Nurse Practitioner Practice Authority
How does nurse practitioner authority vary by state?
Each state establishes the laws that govern nursing scope of practice. In full practice authority states, NPs can establish independent practices. In other states, NPs may need to work under a physician or with a physician, though they otherwise can diagnose and treat patients without limitations. Other states limit certain NP functions, such as prescribing medications.
In what states can an NP practice independently?
Currently, Alaska, Arizona, Colorado, Connecticut, Delaware, Hawaii, Idaho, Iowa, Kansas, Maine, Maryland, Massachusetts, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oregon, Rhode Island, South Dakota, Vermont, Washington, and Wyoming are full practice authority states. However, this list is likely to grow as more states consider legislation to expand NP authority.
Are NPs licensed by state?
All nurses, including NPs, are licensed by the state in which they practice or by a multi-state license. State boards of nursing establish the criteria for becoming licensed. These criteria include graduating from an accredited program and passing a certification examination, as well as maintaining licensing through continuing education.
Where are NPs able to practice independently?
Currently, NPs can practice independently in 26 states and in Washington, D.C. In other states, while NPs may perform many of their job functions with a high level of independence, they must work in collaboration with or under the supervision of a physician.
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