Despite the efforts to expand the scope of practice guidelines for nurse practitioners around the country, there are some significant restrictions for a lot of nurses. The scope of practice standards are still determined at the state level; hence the role of nurse practitioners in primary care can vary depending on their state of practice. Therefore, in the journey to becoming a PMHNP it is essential to understand the state licensure and certification guidelines. These guidelines will determine the range of roles that the nurse practitioner will be able to play and those that they may be restricted from performing (Lowe et al., 2012). I have reviewed the certification and licensure guidelines for my state, Virginia, and the scope of practice guidelines that will affect my role in the state. The following are the findings of this review.
To practice as an advanced nurse practitioner, one required certification and licensure. The state license in Virginia is issued by the Virginia Board of Nursing (www.dhp.virginia.gov/nursing). The main requirements for a first-time applicant for the nurse practitioner license include the following; one must provide evidence of a current Virginia RN license or a multi-state privilege RN license. Additionally, the state requires verification of a professional certificate in the specialty area that the nurse would like to work in. For example, a PMHNP will require a professional certificate in this area. Applicants for the Nurse Practitioner license are also required to submit their official transcripts from their graduate degree programs in nursing to prove their preparation to be advanced practice nurse practitioners. PMHNP are also required to complete the National Psychiatric Mental Health Nurse Practitioner (Across the Lifespan) Certification (PMHNP-BC) exam conducted by the American Nurses Credentialing Center (ANCC). The exam is taken after the completion of an accredited APRN NP program (Carrick, 2011).
Virginia is one of the few remaining states where advanced practice nurse practitioners are still restricted from exercising their full practice responsibilities. In Virginia, nurse practitioners are not recognized as primary care providers. Therefore, the state does not give them prescriptive authority (AANP, 2020). Nurses can prescribe medications only through a physician relationship that gives them the prescriptive privileges. This means that any prescriptions that are given to patients must always be issued under the authorization of a physician. However, the nurse practitioners can acquire a written agreement from a physician, which allows them to prescribe schedule II-VI controlled substances.
Virginia has a prescription monitoring program (PMP). The program is presented in the form of a 24/7 database that contains information on all dispensed controlled substances in schedule II-IV and those in schedule V for which a prescription is required. The program also monitors any other drugs of concern, THC-A oil and cannabinol that is dispensed in Virginia. The primary purpose of the program is to ensure safe practices in the prescribing and dispensing of controlled substances. The system provides timely information to the health care providers. Additionally, the PMP can be used by professional licensing bodies and law enforcement to identify inappropriate or illegal prescribing and dispensing of controlled substances.
Generally, Virginia still has restrictive requirements that restrict the nurse practitioners’ scope of practice. For example, a PMHNP in Virginia may not be able to diagnose and treat mental health disorders without the authorization of a primary care physician. However, nurse practitioners in Virginia can be granted full practice responsibilities after 9000 hours of practice, which equates to around 5 years of practice. The nurse practitioner’s role is initially restricted, but nurses can eventually be granted their full scope of practice after gaining this experience.
When nurses have the prescription responsibilities, they must acquire the Drug Enforcement Administration (DEA) license, which is required for any provider with prescription responsibilities. This license enables practitioners to legally prescribe and dispense controlled substances. The application for the DEA license is done online on the Department of Justice website. The license can be mailed to the applicant within 30 days.
American Association of Nurse Practitioners (2020). State practice environment. https://www.aanp.org/advocacy/state/state-practice-environment#:~:text=State%20practice%20and%20licensure%20laws,the%20state%20board%20of%20nursing.
Carrick, J. A. (2011). Student achievement and NCLEX-RN success: Problems that persist. Nursing Education Perspectives, 32(2), 78-83.
Lowe, G., Plummer, V., O’Brien, A. P., & Boyd, L. (2012). Time to clarify–the value of advanced practice nursing roles in health care. Journal of advanced nursing, 68(3), 677-685.
It aggravates me that there isn’t a uniform scope of practice for NPs in the United States. By granting NPs full practice autonomy, communities will have increased access to healthcare by NPs (Park, Han, & Pittman, 2020). We need to continue to lobby and advocate for our profession and the livelihood of our patients. Informing patients, physicians and the community of the NPs roles can raise awareness of our functions in healthcare. NPs can assess, diagnose, and provide evidence-based care (Nurse Practitioner Schools, 2021).
I did not know that Virginia does not recognize NPs as primary care providers because NPs already play a key role in primary healthcare settings. There is a growing shortage of primary care medical doctors entering the workforce. NPs can fill that gap and one way is granting them full authority and autonomy to practice and prescribe medications. One study found that there is an increase in NP presence in rural and nonrural primary care settings between 2008-2016 (Barnes et al, 2018). Moldestad and authors (2020) concluded that patients in their study from the Veterans Affairs Healthcare System were satisfied with both NPs and physicians but often preferred NPs because NPs provided a more human connection and holistic approach to care. The authors further stated that NPs are viable primary care providers and recommend full practice authority for all NPs.
Barnes, H., Richards, M. R., McHugh, M. D., & Martsolf, G. (2018). Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners. Health Affairs (Project Hope), 37(6), 908–914. https://doi.org/10.1377/hlthaff.2017.1158
Park, J.,Han, X., & Pittman, P. (2020). Does expanded state scope of practice for nurse practitioners and physician assistants increase primary care utilization in community health centers? Journal of the American Association of Nurse Practitioners, 32(6), 447–460. https://doi.org/10.1097/JXX.0000000000000263
Moldestad, M., Greene, P. A., Sayre, G. G., Neely, E. L., Sulc, C. A., Sales, A. E., Reddy, A., Wong, E. S., & Liu, C. (2020). Comparable, but distinct: Perceptions of primary care provided by physicians and nurse practitioners in full and restricted practice authority states. Journal of Advanced Nursing, 76(11), 3092–3103. https://doi.org/10.1111/jan.14501
Nurse Practitioner Schools. (2021). California nurse practitioners: The fight for full practice authority. Retrieved from https://www.nursepractitionerschools.com/practice-authority/california/
I find it very interesting learning about states that do not allow their nurse practitioners full practice authority. Although I was aware that these states exist, I was unaware of how the agreements with a physician work. As I research more about these agreements, I have learned that many states require that a NP works as part of a patient care team, having specific responsibilities related to the care of the patient. The NP must practice as part of the care team and maintain appropriate collaboration in a written or electronic agreement (Decoded, n.d.). I find this frustrating that a NP must work under collaboration in some states and not others. However, I did find that Virginia looks like they are gaining ground on allowing certain specialties of NPs to practice with full authority. Certified Nurse Midwifes, CRNAs, or Clinical Nurse Specialist will begin to have full practice authority in July of 2022 (Virginia Law, 2021). It does state that other NPs will have to continue to work with a collaboration of a physician. This is a great step forward for your state!
Decoded, T. S. (n.d.). Virginia Decoded. Retrieved from Licensure and practice of nurse practitioners; practice agreements: https://vacode.org/54.1-2957/
Virginia Law. (2021). Retrieved from Code of Virginia: https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2957/
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