2
Embracing the PrescriberRole as an APRN

Louise Kaplan and Marie Annette Brown

This chapter emphasizes the importance of prescriptive authority as a component of advanced practice registered nurse (APRN) practice. An overview describes the development of, and transition to, the APRN role, with an emphasis on prescribing. The framework for rational prescribing rests on knowledge of the patient, knowledge about the nature of the health problem, and treatment using evidence‐based guidelines, standards of care, and strategies for promoting appropriate medication use.

The ability to independently prescribe medications is a hallmark symbol of the legitimacy of advanced practice registered nurses (APRNs). The public often perceives the prescriber role as what ‘defines’ an APRN. Therefore, a goal of APRNs is full practice authority and professional integrity to provide comprehensive patient care. APRNs prescribe medications not only to meet the needs of individual patients and families but also to meet societal needs and the expectations of a fully autonomous profession like nursing. Prescribing is a component of each of the four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse‐midwife (CNM), clinical nurse specialist (CNS), and nurse practitioner (NP). Prescribing is within the scope of practice for NPs and CNMs in all 50 US states but is more limited for CNSs and CRNAs (National Council of State Boards of Nursing [NCSBN], 2020). This chapter provides information for APRNs to enhance expertise and confidence for successful adoption of the fully autonomous prescriber role.

DEVELOPMENT OF THE APRN ROLE

The APRN role began with nurse anesthetists in the late 1800s, preceding anesthesiologists by several decades. Nurse midwives became established in the United States in the early 1900s, while the CNS role evolved in the 1940s and 1950s (Dunphy, 2018). The NP role, formally developed in 1965, has grown the most rapidly, with NPs becoming the largest group of APRNs. Legislatures enacted laws that provided a scope of practice for APRNs consistent with their educational preparation. Over time, APRNs have established themselves as members of the healthcare workforce with a distinct role, a unique education, and essential knowledge and skills to provide care.

APRN scope of practice varies across the United States according to state laws that are the basis of regulation. Advanced practice nursing is controlled by licensure, accreditation, credentialing, and educational preparation, and practice opportunities which require greater expertise. Variation in APRN roles also results from organizational policies that may support or constrain practice. APRNs are responsible for maintaining a high ethical standard in practice, generating knowledge, and appraising and translating evidence to provide quality, comprehensive, patient‐centered care.

Although there has been significant progress in the utilization of APRNs, constraints on consumers’ access to APRNs, legal limitations, and absence of full practice authority in all states continue to limit APRN practice. Constraints on APRNs that limit their practice are most likely due to concerns about professional competition because extensive data exist about APRN quality of care. For decades, studies have demonstrated that APRN care is as or more effective than care delivered by physicians (Brown & Grimes, 1995; Congressional Budget Office, 1979; DesRoches et al., 2017; Dulisse & Cromwell, 2010; Horrocks et al., 2002; Jennings et al., 2015; Landsperger et al., 2016; Laurant et al., 2018; Lenz et al., 2004; Newhouse et al., 2011; Ohman‐Strickland et al., 2008; Prescott & Driscoll, 1980; Safriet, 1992; Simonson et al., 2007; Spitzer et al., 1974; Wright et al., 2011). Many of these studies also validated widespread acceptance of the APRN role and high satisfaction with APRN care.

Increasing demands for APRNs and assessment of their cost‐effectiveness are powerful factors expected to influence the eventual removal of legal barriers remaining in many states. Concurrently, an improved regulatory environment, especially in relationship to prescriptive authority, has helped legitimize and distinguish the APRN role. In states where NPs have full practice authority which includes complete prescriptive authority, the difference between NPs and physician assistants (PAs) is more apparent and often provides an increased incentive to hire NPs. PA practice, which includes prescribing, is always supervised by and is legally linked with a physician. Furthermore, implementation of the Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (see Chapter 4) can assist APRNs to attain full practice authority.

Autonomy is an important professional concept related to full practice authority. The nursing literature on advanced practice confirms it has been difficult to achieve (Ulrich & Soeken, 2005; Weiland, 2008), mainly due to resistance from organized medicine. Even in the presence of team‐based healthcare, some physicians perceive themselves as the apparent leader or supervisor, which reflects a desire to limit and/or control APRN practice for multiple reasons. Physician control of APRN prescribing often has financial benefits for the physician who is paid for “supervision” that is unnecessary given the educational preparation of APRNs in pharmacotherapeutic content. Physician control of nursing practice is inconsistent with true APRN professional autonomy. Autonomy is also a professional and personal sense of the unfettered ability to make decisions in practice when legally granted to a professional through the endorsement of society. “Having genuine NP practice” emerged as the major theme of a qualitative study about NP autonomy that was expressed in four major subthemes: relationships, self‐reliance, self‐empowerment, and defending the NP role (Weiland, 2015). This involved the meaning of the NPs’ practice experience and experience of being an NP. Autonomy extends beyond legal authority. “It is not just in action but in thought that we create our autonomy” (Kaplan & Brown, 2006, p. 37).

DEVELOPMENT OF THE APRN ROLE AND PRESCRIPTIVE AUTHORITY

Prescriptive authority

Prescriptive authority is the legal ability to prescribe drugs and devices, a practice regulated by the states. One aspect of prescriptive authority, controlled substances (CSs), is specifically regulated by the federal government through the Drug Enforcement Administration (DEA) which enforces the Controlled Substances Act of 1970 (Title 21 – Food and Drugs, 1993). Some states have additional regulations and requirements related to prescribing CSs.

Obtaining prescriptive authority for APRNs has presented significant challenges nationwide. Even when prescriptive authority is supported in new legislation, significant roadblocks to implementation often occur, particularly those placed by physicians. In 1971, for example, Idaho became the first state to pass legislation that recognized the NP role and granted prescriptive authority. Although the first Idaho NP entered practice in 1972, opposition from the Board of Medicine resulted in more than one‐dozen drafts of the prescriptive authority rules. The rules were not adopted until 1977, making Idaho the first state to implement prescriptive authority for NPs (personal communication, S. Evans, December 28, 2009). Nearly 30 years later, in 2006, Georgia became the last state to pass a law granting APRNs authority to “order” medications, a variant of prescribing (Phillips, 2007). An example of a current barrier exists in Colorado. After program completion, an APRN must first qualify for provisional prescriptive authority (RXN‐P). Within three years of receiving RXN‐P status, the APRN must complete a 1000 hour mentorship with a physician or APRN with full prescriptive authority (RXN) and develop an articulated plan for safe prescribing to receive full prescriptive authority (Code of Colorado Regulation, 2017).

ADAPTING TO THE APRN’S ROLE AS PRESCRIBER

Transition to the prescribing role

One of the greatest responsibilities for an APRN is that of prescription medication management. Prescribing is not typically a part of the registered nurse (RN) role in most countries including the US, and often requires a major paradigm shift to transition from administering drugs to selecting and prescribing medications. Consequently, the individual APRN’s transition to the prescriber role involves a union between knowledge of pharmacotherapeutics and socialization to the role. APRNs begin gaining knowledge and competencies throughout their graduate education and continue this process through practice. Role socialization to become a prescriber is initiated during APRN education and likewise is part of continuing professional development.

Transition to the prescriber role is part of the larger role transition that the APRN experiences first as a student, then as a novice practitioner, and when scope of practice changes. Schumacher and Meleis (1994) identified five factors that influence role transition. These continue to be relevant for APRNs in today’s practice arena. They are:

1. Personal meaning of the transition
2. Degree of planning for the transition
3. Environmental barriers and supports
4. Level of knowledge and...