What is Full Practice Authority for Nurse Practitioners?

Full practice authority is one of the potential benefits of becoming an advanced practice registered nurse (APRN). Registered nurses often work under the supervision of physicians, but a graduate nursing degree can open the door to independent practice. Autonomy in decision-making is an advantage of practice authority, as well as increased capacity to improve patient care or safety from the top down. Independent practice is growing in some states as a solution to increase access to care services for rural patients and other underserved populations.

However, full practice authority is dependent on where you practice in the United States. While many states have moved to expand independent practice opportunities for APRNs, several others limit what such nurses are able to do on their own. To start with, a Master of Science in Nursing is required for any APRN role, including family nurse practitioners (FNPs). Here’s more information on what skills are necessary and which states allow full practice, or restrict it.

What is Full Practice Authority?

APRNs are trained and licensed professionals who work in coordination with other health professionals. According to the American Nurses Association, APRN roles are certified nurse practitioner (including family nurse practitioners), certified nurse midwife, certified registered nurse anesthetist and clinical nurse specialist. They can practice in primary care, specializations such as maternity care and family practice, or private practice, for example. They may also work as patient advocates, health care researchers, administrators or nurse educators.

This level of education, clinical skills, knowledge and experience enables some APRNs to practice independently. According to the American Association of Nurse Practitioners (AANP), "full practice authority" refers to when state laws enable APRNs to "evaluate patients, diagnose, order and interpret diagnostic tests, and initiate and manage medications" under the authority of the state nursing board (a definition last updated in 2015). Typically, the supervision of a physician or physician's assistant is required for nurses. Full practice authority, however, regulates APRN nurses to manage patient care without that oversight.

This autonomy, in turn, increases the accountability and responsibility that APRNs take on in independent practice. It is crucial, as the AANP notes in its 2015 guidance, that nurses adhere to ethical codes, subject themselves to periodic peer review, analyze clinical outcomes and continue to seek professional development. With their responsibility in the health care ecosystem substantially increased, they must be leaders and advocates for policy that improves patient care, patient safety and nurse empowerment.

There are many benefits to full practice authority. Some of the most notable advantages are that:

• Patients are able to reduce their health care costs.
• Patients in rural or underserved areas can access care.
• Patients can receive care from NPs that is equal to that delivered by physicians.
• NPs can be more efficient and effective care providers without having to wait for directions or approval.

Where is Full Independent Practice Allowed?

Geography is a key factor in deciding whether you can pursue full practice authority as an APRN. While a growing number of states are expanding the scope of practice for NPs, FNPs, CNSs and the like, other states have more limited opportunities.

Twenty-two states have laws that allow for full practice authority, according to the AANP and the National Academy of Medicine (formerly the Institute of Medicine), which last updated its information at the end of 2018. Those are:

• Alaska
• Arizona
• Colorado
• Connecticut
• Hawaii
• Idaho
• Iowa
• Maine
• Maryland
• Minnesota
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Mexico
• North Dakota
• Oregon
• Rhode Island
• South Dakota
• Vermont
• Washington
• Wyoming

Additionally, the District of Columbia and the U.S. territories of Guam and Northern Mariana Islands allow for full practice authority.

While nearly half the country regulates full practice authority, the remaining states and territories limit how much autonomy APRNs have. The other two classifications of practice include:

• Reduced practice: This is when state laws reduce the ability of NPs and other APRNs in at least one element of full practice, like prescribing medications. Practice laws may also require a collaborative agreement with another provider to oversee or coordinate patient care. States and territories with reduced practice include Alabama, Arkansas, Delaware, Illinois, Indiana, Kansas, Kentucky, Louisiana, Mississippi, New Jersey, New York, Ohio, Pennsylvania, Utah, West Virginia, Wisconsin, American Samoa, Puerto Rico and the Virgin Islands.
• Restricted practice: This is when state practice laws restrict the ability of NPs and other APRNs in at least one element of practice by mandating career-long supervision or instructions and approval from another health provider for NPs to provide patient care. States with restricted practice include California, Florida, Georgia, Massachusetts, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas and Virginia.

Barriers to Full Practice Authority

Besides the varying state laws that inhibit progress toward full practice authority for APRNs, other obstacles to independent practice exist. This was among the key findings of a 2019 survey from National Council of State Boards of Nursing (NCSBN). In particular, collaborative practice agreements stand out as a barrier: The survey found establishing a CPA can cost up to $50,000 in fees paid to the partnering physician. That upfront cost can be a significant barrier to NPs, which may in turn affect patient care.

“Sometimes it is cost prohibitive for the nurse practitioner or other nurses to go to [an underserved area] because of the cost of the collaborative practice agreement,” said Maryann Alexander, Ph.D., RN, FAAN, chief officer for nursing regulation at the National Council of State Boards of Nursing in Chicago.

Despite this, the survey's results reinforced the notion that the expansion of full practice authority can be a positive for the entire health care industry.

“States that have adopted full practice authority have higher concentration of NPs in rural and underserved areas, rate higher on state health care rankings, and have been associated with decreased hospital readmissions for Medicaid, improved access to preventative care and lower health care costs,” said Taynin Kopanos, vice president of state government affairs for AANP.

Earn Your Degree from Bradley

Interested in pursuing independent practice as a family nurse practitioner? Earning an MSN should be at the top of your list, as the degree is required to be licensed as an APRN. At Bradley, you can complete your MSN-FNP studies entirely online while still working and taking care of family life at home. You can finish coursework on your time, as well as communicate with instructors and network with peers. Bradley allows you to select your own sites for gaining clinical hours, as well as approved preceptors, ensuring you have what you need to get the most of your education. The result is an advanced skill set and deep clinical expertise needed to strive for full practice authority.

Want to learn more about the online MSN-FNP program at Bradley? Contact an enrollment advisor today.

Sources

Scope of Practice for Nurse Practitioners - AANP

State Practice Environment - AANP

Survey Shows Continuing Barriers to APRN Practice - Staff Care

Principles for Advanced Practice Registered Nurse (APRN) Full Practice Authority - ANA