Career Advice: What are the Requirements for Prescriptive Authority for Advanced Practice Registered Nurses (APRNs)?

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One of the frequent questions I hear from graduate students or practicing advanced practice registered nurses (APNs or APRNs) is about prescriptive authority.

This post will review national and state requirements for APRNs to obtain prescriptive authority and provide online resources for further information. Click Here for Your Free Prescriptive Authority Checklist to track your Prescriptive Authority application!

What is Prescriptive Authority?

Prescriptive authority is defined as “the limited authority to prescribe certain medications according to established protocol.”

Independent prescribing or prescriptive authority for APRNs is defined by Stokowski (2013) as the ability of APRNs to prescribe, without restriction, medications requiring the FDA label of “RX only” (i.e., prescription drugs), including controlled substances; medical devices and equipment; non-pharmacologic therapies/ consultative/ supplementary health or medical treatments or services; durable medical goods; and additional equipment and supplies as needed for patient health and well-being. 

Not all of the four roles recognized by the nursing profession as advanced practice (NP, CNS, CNM, CRNA) are recognized as APRNs in all 50 states or US territories. As a result, not all APRNs are automatically allowed to practice to the full extent of their education and experience. Therefore, not all APRNs are allowed to prescribe independently.  

For example, at the time of this post, only 22 states (plus DC) permit NPs to prescribe without physician oversight; while NPs in Alabama and Florida are not allowed to prescribe controlled substances at all. CNSs and CRNAs have no prescribing authority in 10 U.S. states. Go to the NCSBN website for updated information on all four APRN roles

State nurse practice acts outline the regulations under which nurses can practice.  And while the National Council of State Boards of Nursing (NCSBN) is working hard to get all states on board with the Consensus Model for APRN Regulation (focused on uniformity in state regulations for APRN practice), only 15 states have fully implemented the Consensus Model terminology and requirements and an additional 9 states have implemented 75% or more of the requirements. You can view the state-by-state graphic for Consensus Model implementation on the NCSBN website.

Prescribing Status

Prescriptive authority is frequently designated as either Independent or Limited practice.  Independent, Collaborative, Supervised, or Delegated practice are also labels denoting prescriptive authority (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Full, Reduced, or Restricted are also designations frequently used in national maps to designate practice status and prescribing status.  Read the APRN regulations for your state by searching for your State Board of Nursing (SBON). 

Independent 

Full: APRNs can prescribe independently, without physician collaboration or oversight. 

Not Independent/Limited Prescribing Status

Reduced: APRNs may be able to prescribe certain categories or schedules of medications and/or may have a requirement for physician supervision.  A written agreement, AKA a Collaborative Agreement, must be in place that outlines direct and/or indirect supervision of the APRN by a licensed provider (MD, DO, DDS, or NP).
Restricted: APRNs must have physician oversight to prescribe. A written agreement must be in place.

Anyone who prescribes controlled substances is required to be registered with the Drug Enforcement Administration (DEA). Prescriptive authority for controlled substances is a prerequisite for getting your DEA number(ANA, n.d.). Exceptions are noted in the ANA document. 

The NCSBN has excellent maps on the status of implementation of the Consensus Model, as well as APRN regulations related to independent practice, prescriptive authority, titles, roles, licensure, education, and certification for the US and its territories. 

Who Can be Granted Prescriptive Authority?

While registered nurses (RNs) may discuss the use of medications with their healthcare team colleagues and are frequently consulted about medication recommendations and use by patients, family members, and friends, RNs do not have the authority to prescribe medications. Woo and Robinson (2016) noted that the RN role in medication decisions is in an advisory capacity only.  

APRNs are nurses with a graduate degree in an advanced practice role. The four recognized APRN roles are: certified nurse midwives (CNMs), certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNSs), and nurse practitioners (NPs). APRNs possess a higher level of knowledge and, even if they don’t write prescriptions, they should be consulted as a member of the healthcare team for patient care decisions, which includes decisions about medications. 

Nurse practitioners are the APRNs everyone thinks of when thinking about prescriptive authority – that’s because their role is to diagnose and directly manage a population of patients. Part of direct management is deciding on the best drug and drug combinations for patients under their care. The other three APRN roles may also be granted prescriptive authority or have limited prescriptive privileges per protocols — these expectations are subject to individual state board of nursing regulations and state nurse practice acts (Woo & Robinson, 2016). 

The other three APRN roles take the same core classes in assessment, pathophysiology, and pharmacology as the NP.  They also have role-specific classes and clinical practice hours.  These APRNs may also obtain prescriptive authority or may have limited prescriptive privileges per institutional protocols.  All APRN practice is subject to individual state board of nursing regulations and state nurse practice acts (Woo & Robinson, 2016). 

Physicians have full prescriptive authority, of course.  Physician assistants (PAs) also have prescriptive authority; however, their prescriptive practice is supervised by their collaborating physicians; they do not have independent prescriptive authority (Wynne, Woo, & Olyael, 2002).  Other health care professionals such as optometrists, osteopaths, podiatrists, dentists, and veterinarians may also have prescriptive authority. 

Advanced Knowledge Required of Nurse Prescribers

Formal courses, related to the pharmacotherapeutics, the pathophysiology of disease, the advanced assessment of patients, and clinical diagnosis and management are core requirements for APRNs to obtain prescriptive authority. 

To make informed decisions about patient medications, the APRN requires advanced pharmacology knowledge related to how the drug works in the body – physiologically and psychologically.  Knowledge of disease processes (i.e., diagnosis and management) is important for drug selection and monitoring. Advanced knowledge beyond the baccalaureate level in a multitude of topics such as bioequivalence, bioavailability, cost, potential drug interactions, pharmacokinetics, pharmacodynamics, diagnostics and bioassays, prescription writing, and clinical judgment are important for the safe prescribing and monitoring of medications for patient care (Woo & Robinson, 2016). 

The three Ps” is the phrase used by nurse leaders and faculty to refer to the three core graduate level courses required for advanced clinical practice and prescriptive authority.  In the U.S., all accredited APRN programs include the three Ps.  Advanced Assessment, Advanced Pathophysiology, and Advanced Pharmacology are the core content areas for APRNs. Obviously, the actual titles may vary somewhat depending on the nursing college. 

Courses required for prescriptive authority also include specialty courses in diagnosis and management.  Building on their skills in advanced assessment, pharmacology, and pathophysiology, APRNs need to be able to diagnose the disease processes in their patient population.  Specialty courses that cover diagnosis and management (D&M) are required.  Note that if the course doesn’t specifically identify D&M in the title (e.g., Diagnosis and Management of Acute and Minor Illness), the SBON may ask for a copy of the course syllabus.

Specialty courses that cover diagnosis and management (D&M) are required.  The SBON wants to see that the Applicant for prescriptive authority received clinical and didactic courses in the population foci so that they are prepared to diagnose, manage, and monitor patients appropriately.  Note that if the course doesn’t specifically identify D&M in the title (e.g., Diagnosis and Management of Acute and Minor Illness), the SBON may ask for a copy of the course syllabus for verification purposes.

Faculty Tip: If not in your course title, be sure to have D&M identified in your course description to make this process easier for the SBON to verify required content.  This is especially important for APRNs who are not NPs where D&M is an expectation. To ensure that my CNS students wouldn’t have trouble applying for prescriptive authority if they wanted it, I made sure that D&M was clearly identified in my course descriptions for the CNS specialty courses. 

Common Requirements for Prescriptive Authority Applications

Depending on their state, newly graduated APRNs may apply for prescriptive authority at the same time as they apply for their APRN license or they may be separate applications (Stokowski, 2013).

You will have to read the APRN licensure regulations for your state by searching your State Board of Nursing (SBON) website.  You should find an online application and directions for applying.  While these will vary from state to state, the most common requirements for applications for prescriptive authority are:

  • RN license in Good Standing
    • In some states, APRN licensure is required before applying for prescriptive authority; in others APRN licensure and prescriptive authority are applied for at the same time. In Colorado, APRNs have to be accepted to the SBON Advanced Practice Registry to use the title and practice as an APRN.
  • Graduate degree from an Accredited Program
    • Not all states require a graduate degree – though this is not the norm! I’ve seen graduate degree OR national certification, RN license and national certification, and completion of NP certificate program plus national certification. 
      • These variations may be holdouts from a time when nurses didn’t need a master’s degree to advance their career and they could get advanced schooling and graduate with a “certificate” as an NP, CNS, or nurse midwife.
      • I don’t think you can take any APRN national certifying exam without having graduated from at least a master’s degree program, so this may be a moot point in today’s world. 
      • One state just has national certification as the requirement (the SBON may just be trying to economize their wording.  That is, if you have to have be a nurse and have a master’s degree to take the certification exam, listing RN and Graduate degree is redundant). 
  • National certification in Role/Population Focus
    • National certification is required in the majority of the states and the national APRN organizations encourage all states to require.  Additionally, the Consensus Model regulations identify national certification as a requirement for all APRNs; however, California doesn’t require national certification. 
  • Academic Core Course Preparation
    • Three Ps: Advanced pharmacotherapeutics, Advanced health assessment, Advanced pathophysiology
      • Passing grades for 45 clock hours per course are commonly required (equivalent to three-3 credit, semester-long courses) – but the number of credits and type of content may vary; check with your SBON
      • Psychiatric APRNs may need to have an additional pathophysiology and pharmacology course such as neurobiology, psychopathology, or psychopharmacology to qualify for prescriptive authority
    • Diagnosis and management of problems within the clinical specialty
      • The number of required D&M courses varies; check with your SBON
    • APRN Role preparation course
  • Prescribing practice hours
    • The minimum number of clinical practice hours required to graduate as an APRN and sit for certification exams is 500.  Accredited institutions may require more than 500 hours depending on the role and population focus.
    • Prescribing practice may occur within those supervised practice hours and the APRN may only have to apply for their APRN license to be granted prescriptive authority. 
    • Additional practice hours may be required before the application for prescriptive authority will be processed. 
      • For example, in Colorado, new regulations changed the requirements for preceptorship and mentorship (previously 3600 hours total) for prescriptive authority.
      • Provisional prescriptive authority can be granted with a mentorship agreement for 1000 hours of mentorship with an MD or with an APRN with prescriptive authority, and 3 years of combined RN or APRN clinical experience. The APRN has three years to complete these requirements to then apply for Full Prescriptive Authority.
  • Collaborative Practice Agreement
    • Depending on the state, a collaborative agreement may be required to accompany your application.  Many SBON’s provide a template for you to follow; check their forms registry. 
  • Background check 
  • Official Transcripts from the institution which granted the graduate degree or post-graduate degree or post-graduate certificate as an APRN. 
  • Payment of Fees

This is a lot to remember – so I made you a checklist to help you organize. Click Here for Your Free Prescriptive Authority Checklist!

Mandatory Requirements Once You Obtain Prescriptive Authority

Once acquired, prescriptive authority must be renewed on a scheduled basis.  Frequently, this is renewed concurrently when you renew your Registered Nurse and Advanced Practice Registered Nurse license. 

Some states may require an annual or regular update to your Collaborative Practice Agreement, if this was required with your initial application. 

Additionally, to maintain safe prescribing practices, mandatory continuing education (CE) may be required for renewal.  Specific requirements for CE for every renewal period are usually spelled out in the SBON documents. 

Hope this quick review was helpful! Let me know what questions you have about Prescriptive Authority in the comments!

Excellent Pharmacology Textbooks for APNs

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: A practical approach(4th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.

Woo, T. M., & Robinson, M. L. (2016). Pharmacotherapeutics for nurse practitioner prescribers (4th ed.). Philadelphia, PA: F. A. Davis. 

Online Resources and Products
American Association of Nurse Anesthetists
American College of Nurse Midwives
American Nurses Association

APRN Resources: FAQs about Prescribing Controlled Substances

American Association of Nurse Practitioners

State Practice Environment information

Nurse Practitioner Prescriptive Privilege   

Nurse Practitioner Prescriptive Authority

American Psychiatric Nurses Association

FAQs about Advanced Practice Psychiatric Nurses

National Association of Clinical Nurse Specialists

National Association of Clinical Nurse Specialist’s Position Statement on Prescriptive Privilege for the Clinical Nurse Specialist

National Council of State Boards of Nursing

 

References and Sources

American Association of Nurse Practitioners. (n.d.). Nurse practitioner prescribing privilege. Retrieved from http://www.aanp.org/images/documents/publications/prescriptiveprivilege.pdf

American Nurses Association. (n.d.). FAQs about prescribing controlled substances. Retrieved from http://www.nursingworld.org/DocumentVault/APRN-Resource-Section/FAQ-About-Prescribing-Controlled-Substances.pdf

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: A practical approach(4th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.

Nurse Practitioner Prescriptive Authority. (2015). Retrieved from https://nursinglicensemap.com/advanced-practice-nursing/nurse-practitioner/nurse-practitioner-prescriptive-authority/ 

Prescriptive authority. (n.d.). Medical dictionary. (2009). Retrieved March 3, 2017 from http://medical-dictionary.thefreedictionary.com/prescriptive+authority

Stokowski, L. A. (2013, July 25). APRN prescribing law: A state-by-state summary. Medscape. Updated June 3, 2016. Retrieved from http://www.medscape.com/viewarticle/440315

Woo, T. M., & Robinson, M. L. (2016). Pharmacotherapeutics for nurse practitioner prescribers (4th ed.). Philadelphia, PA: F. A. Davis. 

Wynne, A. L., Woo, T. M., & Olyael, A. J. (2002). Pharmacotherapeutics for nurse practitioner prescribers (2nd ed.). Philadelphia, PA: F. A. Davis.