August 10, 2009
NURSE PRACTITIONERS (APRNS)
By: John Kasprak, Senior Attorney
You asked for information on nurse practitioners in Connecticut, including their scope of practice and the meaning of the term “collaborative practice.” You also want to know how Maine and Massachusetts address these issues.
In Connecticut, nurse practitioners are licensed as advanced practice registered nurses (APRNs) by the Department of Public Health (DPH). As of October 2008, 2,526 APRNs with Connecticut home or work addresses held unexpired licenses. APRNs are recognized as primary care providers in Connecticut. DPH's database does not list APRN specialties. But applying an American Academy of Nurse Practitioners (AANP) database to Connecticut's number of licensed APRNs suggests 1,667 APRNs work in primary care settings in Connecticut (see “Assessment of Primary Care Capacity in Connecticut,” UConn Center for Public Health and Health Policy, December 2008).
Connecticut law requires APRNs to work in collaborative relationships with physicians. Collaboration means a mutually agreed upon relationship between an APRN and a physician who is educated, trained, or has experience related to the APRN's work. APRNs working in a collaborative relationship with a physician may prescribe, dispense, and administer medications, including Schedule II to V controlled substances that are expressly specified in their written collaborative agreement.
In Maine, an APRN must practice for at least 24 months under the supervision of a licensed physician or be employed by a clinic or hospital with a licensed physician as a medical director. After the 24 month period, the APRN can practice independently. Maine defines APRNs as primary care providers.
Massachusetts does not recognize advanced practice nurses (APNs) as primary care providers. All APNs practice according to written guidelines developed in collaboration between the nurse and a supervising physician.
Connecticut uses the term “advanced practice registered nurse” for licensure purposes rather than “nurse practitioner.” DPH licenses APRNs who must meet the following licensure requirements:
1. maintain a Connecticut license as a registered nurse;
2. (2) hold and maintain current certification as a nurse practitioner, a clinical nurse specialist, or a nurse anesthetist from one of the following national certifying bodies: The American Nurses' Association, the Nurses' Association of the American College of Obstetricians and Gynecologists Certification Corporation, the National Board of Pediatric Nurse Practitioners and Associates, the American Association of Nurse Anesthetists, or other appropriate national certifying bodies approved by the Connecticut Board of Examiners for Nursing;
3. (3) complete 30 hours of pharmacology education for advanced practice nursing; and
4. (4) if first certified by one of the national bodies listed above after December 31, 1994, hold a master's degree in nursing or in a related field recognized for certification as either a nurse practitioner, a clinical nurse specialist, or a nurse anesthetist by one of the bodies above (CGS § 20-94a(a)).
APRNS are recognized in statute as primary care providers. (For example, see CGS § 19a-7d (DPH primary care direct services program) and 17a-248 (birth-to-three program)). APRNs can hold hospital privileges (see attached Yale-New Haven Hospital “Core Privileges,” for example).
Scope of Practice
Advanced practice registered nursing is defined as the performance of advanced level nursing practice activities that, by virtue of postbasic specialized education and experience, are appropriate to and may be performed by an APRN. The APRN performs acts of diagnosis, and treatment of alterations in health status and must collaborate with a Connecticut-licensed physician. In all settings, the APRN may, in collaboration with a licensed physician, prescribe, dispense, and administer medical therapeutics and corrective measures and may request, sign for, receive, and dispense drug samples. A licensed APRN maintaining current certification from the American Association of Nurse Anesthetists who is prescribing and administering medical therapeutics during surgery may only do so if the physician who is medically directing the prescriptive activity is physically present in the setting where the surgery is taking place (CGS § 20-87a(b)).
The law defines “collaboration” as a mutually agreed upon relationship between an APRN and a physician who is educated, trained, or has relevant experience that is related to the work of the APRN. The collaboration must address a reasonable and appropriate level of consultation and referral, patient coverage in the absence of the APRN, a method to review patient outcomes, and a method of disclosing the relationship to the patient (CGS § 20-87a(b)).
Concerning an APRN's prescriptive authority, the collaboration between the APRN and a physician must be in writing and must address the level of Schedule II and III controlled substances that the APRN may prescribe. The collaboration must also provide a method to review patient outcomes, including the review of medical therapeutics, corrective measures, laboratory tests, and other diagnostic procedures that the APRN may prescribe, dispense, and administer (CGS § 20-87a(b)).
The Maine Board of Nursing (BON) authorizes and regulates APRN practice. A certified nurse practitioner (CNP) who qualifies as an APRN must practice for at least 24 months under the supervision of a licensed physician or must be employed by a clinic or hospital that has a medical director who is a licensed physician. The CNP must submit written evidence to the board upon completion of the required clinical experience. After this 24 month period, the APRN can practice independently.
The APRN scope of practice in Maine, as defined in regulation, includes standards of the national certifying body and “consultation with or referral to medical and other health care providers when required by client health care needs” (see “Twentieth Annual Legislative Update,” The Nurse Practitioner, Vol. 33 No. 1, January 2008).
APRNs are defined as primary care providers and may be credentialed as allied staff for hospital privileges, but this credential does not grant admitting privileges.
They may prescribe and dispense drugs or devices, including Schedule II to V controlled substances, according to BON rules.
The Massachusetts BON regulates the practice of advanced practice nurses (APNs). All APNs practice in accordance with written guidelines developed in collaboration with the nurse and supervising physician. In all cases, the written guidelines “designate a physician who shall provide medical direction as is customarily accepted in the specialty area” (see “Twentieth Annual Legislative Update” above).
If practicing in an institution, the nursing and medical administrative staff must approve the guidelines. If there is no nursing and medical administrative staff, the guidelines must be approved by the BON.
Rules and regulations governing the ordering of tests, therapeutics, and prescriptions are promulgated by the BON in conjunction with the Massachusetts Board of Medicine. All other APN areas of scope of practice are under the BON.
In regard to prescriptive authority, authorized APNs have prescribing guidelines mutually developed and agreed to by the nurse and supervising physician. These guidelines must include a defined mechanism to monitor prescribing practices, including review with the supervising physician at least every three months, except for initial prescription of Schedule II drugs, which require review within 96 hours.
Massachusetts does not recognize APNs as primary care providers.