Expanding Scope of Practice Laws May Not be Enough for NPs

Nurse practitioners have enjoyed recent gains when it comes to scope of practice laws regulating their abilities.  Fear over a primary care shortage and changes to health care law have led many to point to nurse practitioners as an important part of the solution to our country's health care woes.  But, are advancements in scope of practice laws really making a difference in "real life"?

Working as a nurse practitioner in the emergency department, I couldn't give you an accurate assessment of scope of practice laws in my state based on what I see at work.  For billing purposes, a physician signs all of my charts for privately insured patients.  To comply with Medicare's even stricter billing standards, a physician briefly visits my Medicare patients at the bedside so my company can receive full payment for the visit.  The State of Tennessee, however requires that a physician sign only twenty percent of my charts and does not require a physician to see any of my patients in person.

Hospital policies further impact my role as an NP.  Hospital administrative policies require a physician to review and sign my orders in the emergency department.  When I diagnose a patient with a condition requiring admission, a physician must be the one to contact the hospitalist and write admission orders interrupting the flow of the emergency department.  This level of oversight is required by hospital administration rather than state law.

Most nurse practitioners have similar experiences in their practice and a recent study in the Journal of Professional Nursing suggests that the organizational culture in health care settings often hinders utilization of NPs to the full extent of their abilities.  Although state laws are changing, the role of nurse practitioners in daily practice is not keeping pace. 

Author of the study, Dr. Lusine Poghosyan, says "Organizational policies can often trump governmental policies, keeping the contribution of the nurse practitioner unrecognized and preventing them from making the fullest contribution possible to effective patient care".  Nurse practitioners participating in the study reported that their role was often poorly understood by senior leadership.  Billing considerations were also frequently cited as a factor in limiting the NP scope of practice.

On the positive side, nurse practitioners in Dr. Lusine's study reported that the longer they worked with physicians, the more they were trusted and given the autonomy to practice independently.  This is what I have personally seen in my practice.  While organizational policies and billing practices have not consistently changed along with scope of practice laws, administrators and patients themselves are slowly becoming more familiar with the NP role.

Although it can be frustrating for nurse practitioners to be limited in their practice despite legal advancements, practice is slowly evolving to match new state scope of practice laws.