NURS 8100 Policy and State Boards of Nursing
NURS 8100 Policy and State Boards of Nursing
Regulations Promulgated through Maryland Board of Nursing.
In the state of Maryland some of the advanced practice registered nurses (APRNs) include certified midwives, nurse anesthetist, certified nurse practioner (NP) and a clinical nurse specialist. This should be similar to other states too. At a minimum and from personal experience Maryland board of nursing has to give permission to practice as an NP and there are basic requirements that have to be met to qualify to be certified. Not all the regulations that are set forth by the state of Maryland for APRN to practice are recent but they are however all currently used.
Code of Maryland regulations (COMAR) are the compilation of the state of Maryland regulations that help govern the state, (Maryland.org, n.d). Health care is not an exception and APRNP have to abide by the COMAR regulations. According to COMAR, (2020), APRNs can perform multiple functions independently. These include comprehensive assessments, complete a death certificate, do not resuscitate orders, interpret diagnostic and laboratory tests, prescribe medications, provide care and give referrals to other providers. An NP can also practice as a registered nurse and for those who have certifications for mental health, they can admit a client on an involuntary basis for treatment.
How State Regulations Are Supported within Place of Employment
The place of employment has set standards at the same level of practice as expected by the state but for some treatment approaches the expectation is to defer to the primary physician or the medical director. Establishing this baseline helps achieve the expected standards and also remain in compliance with the COMAR and federal regulations. The place is very supportive that when the NP completes an admission assessment, the doctor does not have to double check unless there is a concern.
As a nurse practioner, at the place of work there are multiple activities that can be performed independently. These tasks include but not limited to giving orders for medications and treatment, reviewing diagnostic tests, and responding to families as required. One task that is permitted by the state of Maryland but not encouraged at the place of work is signing of certificates of incapacity. (A. Speer, personal communication, July 26, 2021). The primary physician and the psychiatrist sign the Maryland order for life sustaining treatment (MOLST) also and only encourage the NP to sign it if they are not available. This is a task that is authorized by COMAR regulations.
How States Differ in Terms of Scope of Practice
Different states have different prescriptive authorities and conditions that they give to their APRNs. There are those states that are referred to as independent states which allow APRN independent prescribing and there are those which do not, (Schirle & McCabe, 2016). Barriers to practice are not uncommon even when the states are flexible, health care settings can still impose different strict policies and procedures. This leads to restriction of some aspects of patient care and limited access to providers despite the states having full practice authority, (Schorn, Myers, Barroso, Hande, Hudson, Kim & Kleinpell 2022).
Impact on Professional Nurses across the United States.
Some nurses have opted to relocate or work where there is more prescriptive authority. Some nurses also have opted not to relocate but get licensures in neighboring states that can give them more autonomy. There are also nurses who have opted to work in other areas where they are needed. These areas include working as lobbyists, researchers, nurse educators and consultants. In this aspect their full potential is more effectively utilized.
Maryland.org (n.d), Division of state documents. http://www.dsd.state.md.us/COMAR/ComarHome.html
Schirle, L., & McCabe, B. E. (2016). State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice registered nurse prescribing states. Nursing Outlook, 64(1), 86–93. https://doi.org/10.1016/j.outlook.2015.10.003
Schorn, M. N., Myers, C., Barroso, J., Hande, K., Hudson, T., Kim, J., & Kleinpell, R. (2022). Results of a National Survey: Ongoing Barriers to APRN Practice in the United States. Policy, Politics & Nursing Practice, 23(2), 118–129. https://doi.org/10.1177/15271544221076524
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For many years, as advanced as the State of Massachusetts was on many fronts, the profession of nursing was not one of them. Up until January 6, 2021, ARNP’s we had be given temporary (full) practice authority due to the Covid Pandemic. When signed in January 2021, we were the last New England State to give ARNP’s full practice authority, and the 23rd State to pass this regulation across the United States (Health Leaders, 2021).
The Health System I work for is woefully behind adjusting policies and procedures to reflect this new amendment to ARNP’s practice authority within the state. We have a significant need for primary care providers within the Commonwealth and with this change, ARNP’s can practice independently and as primary care providers with their own panel of patients (AANP, 2021, Mass.gov, 2021). Up until a few months ago, I had to have the physician I work with listed as my supervising provider. Other policies came to question as they were completely unnecessary. According to the medical groups administrative leadership, primary care panels by APRN’s is in the works, but likely won’t occur system wide for 18-24 months (Personal Communication, April 24, 2022).
There is significant variability across the United States regarding practice Authority. According to AANP (2021), 29* states (*including Guam, Northern Marina Islands and Washington, DC) have full practice authority, 16* states (*including American Samoa, Puerto Rico and US Virgin Islands) have reduced practice authority and 11 have restricted practice authority (Nurse Journal, 2022. Full practice authority is defined as an NP practicing to the full scope of licensure without a supervising physician. Reduced practice authority means NP’s can perform parts of their scope independently and parts with supervision. Rarely does this include diagnostic testing and diagnosis and treatment but more often medication oversight. Restricted practice authority states require NP’s to work solely under the supervision of a physician (AANP, 2021, Nurse Journal, 2022).
Professional nurses, regardless of area of practice, have demonstrated competencies to be able to practice in a full scope capacity without supervision. By minimizing scope across the United States, we are ultimately denying access to healthcare by a qualified provider (AANP, 2021). Most advanced practice nurses, especially if they have Doctorate level education, have more years of school and clinical than that of their physician colleagues (Nurse Journal, 2022). Lack of recognition and utilization of our extensive capabilities, may undermine the professions’ ability for growth and respect.
American Academy of Nurse Practitioners (AANP). (2021). Information and resources for Massachusetts NPs. https://www.aanp.org/advocacy/massachusetts
Health Leaders (2021). Massachusetts is the 23rd state to allow NPs to practice independently. https://www.healthleadersmedia.com/nursing/nurse-practitioners-massachusetts-granted-full-practice-authority
Mass.gov. (2022). 244 CMR 4.00: Advanced practice registered nursing. https://www.mass.gov/doc/244-cmr-4-advanced-practice-registered-nursing/download
Nurse Journal. (2022). Nurse practitioner practice authority: A state-by-state guide. https://nursejournal.org/nurse-practitioner/np-practice-authority-by-state/
The Illinois state board of nursing has made several amendments to advanced nursing practice regulations. The board created a pathway for APRNs working in hospitals, hospital-affiliated settings, and ambulatory surgery centers to offer most advanced practice nursing care with no career-long collaborative agreement (Illinois General Assembly, n.d.). A written collaborative agreement is needed for all APRNs engaged in clinical practice, except those privileged to practice in a hospital, hospital affiliate, or ambulatory surgical treatment center. However, if an APRN engages in clinical practice outside of a hospital, hospital affiliate, or ambulatory surgical treatment center must have a written collaborative agreement (Illinois General Assembly, n.d.). Besides, APRNs must have an ongoing relationship with a physician to prescribe benzodiazepines and some other scheduled agents.
The state regulations are supported in my current place of employment since the organization’s leadership allows APRNs to practice within their full scope of education without a collaborative agreement with a physician. APRNs in our organization are authorized to: conduct patient assessment; diagnose; order, perform, and interpret diagnostic tests; order treatments; provide palliative and end-of-life care; provide advanced counseling, patient education, and patient advocacy.
The scope of APRN practice differs across various states in the US. Various states grant APRNs Full practice authority, while others have Reduced and Restricted practice. States with Full practice allow APRNs to practice within their full scope of education (Peterson, 2018). APRNs with Reduced practice are required to have a collaborative agreement with a physician to engage in the elements of APRN practice. Besides, states with restricted practice need supervision and delegation to practice. The APRN scope of practice disparity negatively affects APRN professional practice since APRNs in some states are not allowed to practice as their counterparts in other states. Patients in states with Full practice have more access to healthcare since APRNs act as primary care providers (Ortiz et al., 2018).
Illinois General Assembly. (n.d.). Nurse Practice Act. https://ilga.gov/legislation/ilcs/ilcs4
Ortiz, J., Hofler, R., Bushy, A., Lin, Y. L., Khanijahani, A., & Bitney, A. (2018). Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes. Healthcare (Basel, Switzerland), 6(2), 65. https://doi.org/10.3390/healthcare6020065
Peterson, M. E. (2018). Barriers to Practice and the Impact on Health Care: A Nurse Practitioner Focus. Journal of the advanced practitioner in oncology, 8(1), 74–81.