Nurse Practitioner Autonomy, Scope of Practice, and Collaborative Practice Agreements
By Bradley Byars
Nurse Practitioner – Scope of Practice Overview
A nurse practitioner (NP) is an advanced practice registered nurse who has completed additional education and training in a specialty area, such as family practice or pediatrics. NPs are licensed to diagnose and treat medical conditions, order and interpret diagnostic tests, and prescribe medications. However, the specific scope of practice for NPs can vary depending on the laws and regulations in the state where they are practicing, as well as the policies of the facility or organization where they are working.
In general, NPs can provide a wide range of healthcare services, but they may not have the same level of independence as physicians. Additionally, NPs may be required to work under the supervision or collaboration of a physician or to have their practice governed by protocols or guidelines established by a physician or healthcare facility. Scope of practice issues for NPs can arise in a variety of contexts, such as when an NP is seeking to expand their scope of practice beyond what is currently allowed by law or when there is a disagreement between an NP and a physician over the appropriate level of care for a patient. In such cases, it may be necessary to consult with legal counsel or to seek a formal determination from the relevant regulatory agency.
In Florida, nurse practitioners are regulated by the Florida Board of Nursing and the Florida Department of Health. Under Florida law, NPs can practice and prescribe medication independently. Still, they may be required to follow certain protocols or guidelines established by a collaborating or supervising physician or healthcare facility. Florida allows NPs to practice within their area of specialty and to diagnose and treat medical conditions, order and interpret diagnostic tests, and prescribe medications. However, NPs may not perform certain tasks reserved for physicians, such as performing surgery or delivering babies. Further, NPs must also hold a current, active nursing license and must meet certain education and training requirements in order to be eligible to practice. NPs must also renew their license on a regular basis and meet continuing education requirements in order to maintain their eligibility to practice. Overall, Florida law provides NPs with a relatively broad scope of practice, but there may be some limitations or restrictions on their ability to provide certain types of care.
Collaborative Practice Agreements
A collaborative practice agreement is a legally binding document that outlines the roles and responsibilities of a nurse practitioner (NP) and a collaborating physician in providing healthcare services. Collaborative practice agreements may be required by law or entered into voluntarily by the NP and the physician.
There are a variety of reasons why an NP may need a collaborative practice agreement, including:
To meet state regulations: Some states have laws that require NPs to work under the supervision or collaboration of a physician in order to practice. In these states, an NP may be required to enter into a collaborative practice agreement with a physician in order to meet the legal requirements for practice.
To expand their scope of practice: In some cases, an NP may wish to expand their scope of practice beyond what is currently allowed by law or by their current practice setting. A collaborative practice agreement may allow an NP to do this by outlining the specific tasks or procedures that the NP is authorized to perform and the conditions under which they may be performed.
To improve patient care: Collaborative practice agreements can help to ensure that patients receive high-quality care by establishing clear lines of communication and responsibility between NPs and collaborating physicians. This can be particularly important in cases where the NP and physician have different areas of expertise or when the patient has complex healthcare needs.
Overall, collaborative practice agreements can be an important tool for NPs seeking to practice to the full extent of their education and training while ensuring that patients receive high-quality care.
Nurse Practitioner- Independent Practice
In Florida, nurse practitioners (NPs) are allowed to practice independently without the oversight of a physician. In order to practice independently, NPs must meet the following requirements:
1. Hold a current, active nursing license: NPs must hold a current, active nursing license in order to practice in Florida. In order to obtain a nursing license, NPs must meet education and training requirements and pass a licensure exam.
2. Meet education and training requirements: NPs must complete a master’s or doctoral degree program in nursing and must also complete additional training in a specialized area of practice, such as family practice or pediatrics.
3. Obtain prescriptive authority via DEA license: In order to prescribe medications, NPs must obtain prescriptive authority from the Florida Board of Nursing and the Florida Department of Health. To obtain prescriptive authority, NPs must meet certain education and training requirements and pass a certification exam.
4. Renew their license regularly: NPs must renew their license on a regular basis and must also meet continuing education requirements in order to maintain their eligibility to practice.
Florida Legislative Update
In 2020, the Florida Legislature changed the law to allow Advanced Practice Registered Nurses (APRNs) eligible to hold the status of independent practitioner. Under the law, as written, APRNs who meet certain criteria to practice primary care or midwifery without physician supervision or a protocol are given this status. The Board of Nursing has preliminarily defined the term “primary care practice”to mean:
“Primary care practice – includes physical and mental health promotion, assessment, evaluation, disease prevention, health maintenance, counseling, patient education, diagnosis, and treatment of acute and chronic illnesses, including behavioral and mental health conditions.”
The law provides eligibility requirements to become an autonomous APRN. Those requirements, among others, include having the following:
1. At least 3,000 clinical practice hours under the supervision of an allopathic or osteopathic physician within the past five years. These hours may include clinical instructional hours. [See Section 464.0123(1)(c) F.S. for complete requirements];
2. Three graduate-level semester hours, or the equivalent, in differential diagnosis and 3 graduate-level semester hours, or the equivalent, in pharmacology completed within the past five years (documentation required); and,
3. Not be subject to disciplinary action as specified in Section 456.072 F.S. or Section 464.018 F.S., or any similar disciplinary action in any state or jurisdiction within the past five years.
It should be noted that there is no fee for filing an application with the Department of Health (DOH) to become registered as an autonomous APRN. Once registered, the autonomous APRN continues to be subject to review and investigation, and discipline for any violations of ethical standards and violations of the Nurse Practice Act, Chapter 464, Florida Statutes. Furthermore, the new law requires that an APRN practicing autonomously report “adverse incidents” to the DOH, which must investigate each report and decide whether the APRN is subject to discipline.
At the beginning of 2021, the Board established a preliminary definition of “standards of practice,” which states:
“Advanced practice registered nurses who are registered pursuant to Section 464.0123, F.S., shall engage in autonomous practice only in a manner that meets the General Standard of Practice. The General Standard of Practice shall be that standard of practice, care, skill, and treatment which, in light of all relevant surrounding circ*mstances, is recognized as acceptable and appropriate by reasonably prudent similarly situated health care providers.”
All APRNs must carry malpractice insurance or demonstrate proof of financial responsibility. Any applicant for licensure must submit proof of coverage or financial responsibility as a prerequisite to licensure/certification and biennial renewal. The APRN must have professional liability coverage of at least $100,000 per claim, with a minimum annual aggregate of at least $300,000, or an unexpired irrevocable letter of credit in the amount of at least $100,000 per claim with a minimum aggregate availability of at least $300,000 and which is payable to the APRN as beneficiary.
When dealing with insurance coverage issues, it is advisable to consult an experienced licensed insurance agent to ensure you are covered to the extent the law requires. Remember, too, that this is a “minimum’ requirement for the level of insurance coverage mandated by law. Depending upon the type of practice and patient population, some ARPNs are wise to discuss with their insurance agent obtaining greater coverage depending upon the risk involved. Remember, this insurance coverage protects the APRN too, and coverage greater than $ 100,000 per claim may be wise.
The new law provides detailed requirements which set forth parameters of what an autonomous or independent APRN can do. Section 464.123, Florida Statutes states:
(3) PRACTICE REQUIREMENTS.-
(a) An advanced practice registered nurse who is registered under this section may:
1. Engage in autonomous practice only in primary care, including family medicine, general pediatrics, and general internal medicine, as defined by board rule.
2. For certified nurse midwives to engage in autonomous practice in the performance of the acts listed in s. 464.012(4)(c).
3. Perform the general functions of an advanced practice registered nurse under s. 464.012(3) related to primary care.
4. For a patient who requires the services of a health care facility, as defined in s. 408.032(8):
(a) Admit the patient to the facility.
(b) Manage the care received by the patient in the facility.
(c) Discharge the patient from the facility unless prohibited by federal law or rule.
5. Provide a signature, certification, stamp, verification, affidavit, or endorsem*nt that is otherwise required by law to be provided by a physician, except an advanced practice registered nurse registered under this section may not issue a physician certification under s. 381.986.
(b) A certified nurse midwife must have a written patient transfer agreement with a hospital and a written referral agreement with a physician licensed under chapter 458 or chapter 459 to engage in nurse-midwifery.
(c) An advanced practice registered nurse engaging in autonomous practice under this section may not perform any surgical procedure other than a subcutaneous procedure.
(d) The board shall adopt rules, in consultation with the council created in subsection (4), establishing standards of practice for an advanced practice registered nurse registered under this section.
Florida law has been changed to allow APRNs to register as autonomous practitioners. The law contains both requirements and limitations. Not all APRNs may desire to register as “autonomous” APRNs. Naturally, those employed by an organization or healthcare facility, or physician clinic will see no need for this licensure status. Those wishing to “hang their own shingle,” form a clinic, or independent practice will have to abide by the requirements of the law as set forth in Section 464.123, Florida Statutes, see https://flsenate.gov/Laws/Statutes/2020/0464.0123the rules of the Board of Nursing and other provisions of law. Additionally, the new Florida law does not override requirements set forth in CMS and DEA regulations.
