Nursing Practice and Licensure Discussions

Nursing Practice and Licensure Discussions

Respond to the following Discussions Posts by Students

Discussion 1 Post

by M. R. – Tuesday, March 16,

Number of replies: 1

In the state of Hawaii, nurse practitioners have full independent practice authority, meaning they practice independently with no physician oversight. They are seen as primary caregivers and independent practitioners.  This is in contrast to many states that would require an NP to have a collaborative relationship with a physician.  Yet another scenario is seen in other states, where in the NP would require a specific time frame in practice with a physician before being qualified to branch off into independent practice (Scope of Practice Policy, 2021).

Nursing Practice and Licensure Discussions

This was an eye opener for me, as I did not realize the disparity between different state’s policies.  After reviewing different articles, I believe that there are benefits to both independent practice and mandated practice in collaboration with a physician.  I favor the policy of having a mandated 2-3 years of a collaborative agreement with a physician before transitioning to independent practice.  This would allow new graduate APRNs, especially those working outside of a hospital or HMO wherein physician consultation is more readily available, to have immediate access to expertise outside of one’s scope.  I would compare this to the probationary period of a graduate RN who has just started their nursing career.

“Prescriptive authority means the authority granted by the board to a recognized APRN to verbally, or in writing, direct, order, or designate the preparation of, use of, or manner of using, a drug within the recognized APRN’s scope of practice” (Hawaii Administrative Rules Title 16 Chapter 89).  The state of Hawaii does not require that the APRN with prescriptive authority have a prescribing agreement with a physician.  They do require a separate application for prescriptive authority aside from the APRN license. The state also requires 30 contact hours of recent coursework in advanced pharmacology; coursework is to include advanced pharmacotherapeutics.

As mentioned above, I endorse a specific timeframe of working with a physician before being granted independent prescriptive authority.  I feel this way because although the APRN would have passed the stringent exams and required course and specialty work in order to graduate, I feel that it is in the best interest of the patients that there is the requirement of having physician to work with, to validate and confer with the APRN.

I did consider the argument against having a required Collaborative Practice Agreement (CPA), which points out that such a requirement would limit the ability of the APRN to practice to their full scope and provide care that they are fully capable of safely providing (Gutchell et al., 2014 Nursing Practice and Licensure Discussions). In my experiences, it is always best to err on the side of caution and provide safety nets whenever it is available when it comes to our patients.

APRNs in the state of Hawaii are able to prescribe all classes (schedules) of medications, including “over-the-counter drugs; legend (non-controlled substances) drugs; and controlled substances” (State of Hawaii Board of Nursing, 2016, exhibit A).  On November 3, 2011, the state of Hawaii passed an exclusionary formulary listing the drugs that are excluded from their prescriptive authority in exhibit A of Chapter 89, which included investigational drugs, stimulants and hormones for obesity treatment, human growth hormones, anabolic steroids, performance enhancement hormones, methadone for narcotic addiction, and finally, medical marijuana (Hawaii Administrative Rules Title 16, Chapter 89, subchapter 16, 2013).

I feel that this policy is reasonable, and agree with the NPA’s allowing of APRNs to prescribe all classes of drugs, except for the ones mentioned in the exclusion list.  I feel that this would allow for efficient, streamlined care. In my research I learned about having a collaborative relationship agreement with pharmacists, and thought that would be an excellent idea for when the NP is working independently of a physician.

As some rashes along the life span can become medical emergencies, I support a collaborative approach to provide the best individualized, quality care to our patients.  “In any setting, pharmacist-NP collaborations, and team-based care more generally, present opportunities for improved patient care and improved patient outcomes” (Funk et al., 2019). Philopena et al. (2020) identify common rashes, as well as the less common rashes that could pose serious dangers for a pediatric patient.  In cases such as this, consult with emergency room physicians or pediatric specialist would be critical.

Nursing Practice and Licensure Discussions References

Discussion Post 2.

Discussion 1

by Rolly – Wednesday, March 17,

Number of replies: 6

  1. The New Mexico State practice and licensure laws permit all NPs to evaluate, diagnose, order and interpret diagnostic tests, initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing. They could practice without a collaborative agreement with a physician. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, and the National Council of State Boards of Nursing (n.d.). I personally agree that being new to a profession, we all need guidance. I think few years of training having someone readily available when you need help would benefit not only the practitioners self-confidence but also to promote patient safety. It all comes up to how experienced you are in the field.
  2. In my state, Nurse practitioners are given full independence in giving recommendations regarding health care needs of patients, family and community including the prescription and distribution of drugs and substances included in Schedules II through V. They are not bonded with a prescribing agreement with a physician (New Mexico Nurse Practitioner Council, n.d.). I agree to my state’s NPA when it comes to giving prescriptions without collaborative agreement with a physician for here in our state, we have very few practitioners. People especially in the rural areas do not have the means to go find a provider for refills. Thus, APRN’s need to adhere to the state policy of licensure and continuing education requirement for personal advantage.
  3. Certified nurse practitioners in New Mexico need to fulfill all requirements for prescriptive authority such as continuing education hours, they need to maintain a Controlled substance license at the New Mexico Board of Pharmacy, they must register with the Board of Pharmacy’s Prescription Monitoring Program (PMP) and be regular participants in PMP inquiry and reporting, so they could prescribe dangerous drugs and controlled substances independently included in Schedules II through V of the Controlled Substances Act. Due to very limited numbers of practitioners, I agree to this Practice Act to cater the needs of many.
  4. Some straightforward rashes that result well with the standard treatment could be treated in a clinic with a APRN. However, it is necessary for an APRN to know when a certain rash would need a specialty referral. According to my readings, there is an improved patient outcome when multidisciplinary team is involved to treat a skin issue. Take for instance, a person with eczema secondary to allergies would benefit from a nutritionist, allergist, and a dermatologist. Skin cancer patients could take the advantage of seeing a dermatologist, oncologist, radiation as well as surgical. Thus, appropriate and cautious intervention and referral would definitely help for unnecessary health care cost (Onselen, J. V. (2016).

Nursing Practice and Licensure Discussions References:

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