Full Practice Authority States for Family Nurse Practitioners 2023
Originally published August 20, 2021 and updated February 1, 2023
Being a nurse practitioner (NP) is one of the most challenging yet rewarding careers. Most NPs couldn’t dream of a different career choice. In fact, a recent survey of health care professionals indicated that NPs are more satisfied than other health care disciplines. NPs successfully navigate the complex health care market, while maintaining self-satisfaction, by combining patient-focused care and compassion with advanced training and expertise. Patients consistently rate the care of NPs as outstanding, however, without full practice authority (FPA), NPs are unable to reach their full potential.
The importance of FPA will grow in 2023 and beyond because of an ongoing physician shortage, a growing amount of treatment options, and an increasing complexity and combination of diseases. The Association of American Medical Colleges (AAMC) projects a shortage of up to 124,000 physicians by 2034. Family nurse practitioners (FNPs) empowered by FPA can serve patients of all ages in communities with insufficient primary care physicians. Let’s first define what an FNP is before exploring the impacts of FPA on patient care.
What is a Family Nurse Practitioner?
An FNP is an advanced practice registered nurse (APRN) trained to treat patients of all ages. FNPs can conduct exams, order diagnostic tests, and develop treatment plans. Their extensive education and training means they can work independently where allowed by law.
A Master of Science in Nursing (MSN) with an FNP focus is required for state licensure. Family nurse practitioner programs combined advanced coursework with extensive clinical experiences. Another requirement for FNP licensing is certification by the American Academy of Nurse Practitioners (AANP) or the American Nurses Credentialing Center (ANCC).
A 2019 survey of FNPs by the AANP provides answers to the question, “What does a family nurse practitioner do?” The most common work settings for respondents were hospitals, outpatient clinics, and private practices. FNPs reported the following ailments as their most diagnosed:
- Abdominal pain
- Urinary tract infections
- Gastroesophageal reflux disease
FNPs are prepared to assess and treat countless issues beyond this list. In a single day, an FNP might help patients with infections, metabolic diseases, respiratory issues, and cardiovascular diseases. They also help patients avoid serious health problems with preventive medicine.
What is Full Practice Authority?
According to the AANP, “Full practice authority is the authorization of nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, and initiate and manage treatments—including prescribed medications—under the exclusive licensure authority of the state board of nursing.”
Full practice authority validates the knowledge, skills, and abilities of NPs and recognizes that the state board of nursing is the appropriate oversight agency to regulate NPs. States with FPA legislation allow NPs to operate independently without collaboration from a medical board or supervision from a physician.
Full practice authority states differ from reduced and restricted authority states based on levels of NP autonomy. The AANP notes that NPs in reduced authority states practice under collaborative agreements with physicians. Restricted authority states mandate career-long supervision or delegation by physicians to NPs for patient care.
As of January 2023, 32 states and the District of Columbia have authorized FPA for NPs. FPA legislation is broken down into two sub-categories, FPA on initial licensure and FPA after a provisional period.
Jurisdictions with Full Practice Authority on Initial Licensure
Alaska offers FPA to all NPs, including the ability to prescribe class II – V controlled substances. Prescriptive authority for controlled substances is a separate application than the authority to diagnose and treat medical conditions.
NPs are granted FPA and full prescriptive authority through the Arizona State Board of Nursing. Prior to prescribing medications, NPs must submit a Controlled Substance Prescription Monitoring Program (CSPMP) application and register with the Drug Enforcement Agency (DEA).
Delaware approved FPA for licensed NPs in August 2021. New graduates qualify for APRN licenses if they’ve completed master’s degrees within two years of application.
The Hawaii State Board of Nursing recognizes the full practice authority of NPs. Prior to prescribing medications, NPs must take advanced coursework in pharmacology.
In addition to offering FPA, Idaho has partnered with its neighboring state, Wyoming, to allow NPs to work in both states under a single license. To earn prescriptive authority, NPs must complete 30 hours of qualifying continuing education courses.
NPs in Iowa can treat, diagnose, and prescribe independently. To prescribe controlled substances, up to schedule II, NPs must separately apply for a Controlled Substance Registration and be authorized by the DEA.
NPs in Maryland may practice independently and there is no provisional period. However, in an attempt to curb opioid use, NPs who prescribe narcotics must register with the state’s Prescription Drug Monitoring Program (PDMP).
NPs are granted full practice authority in Montana. However, they must be board certified and have graduated from an accredited NP program that included a preceptorship.
In Nebraska, NPs may work independently and prescribe medications. They must complete 10 hours of pharmacology continuing education every 2 years to maintain prescriptive authority. To order scheduled drugs, they must have an active DEA registration.
NPs in Nevada have FPA. To prescribe medications, NPs must apply for a license from the Nevada Board of Pharmacy.
11. New Hampshire
The New Hampshire Board of Nursing regulates the scope of practice of NPs and grants them FPA after completing the licensure process.
12. New Mexico
In New Mexico, NPs are granted FPA on original licensure and may prescribe medications, including class 11-V scheduled drugs. Prescribing scheduled medications requires registration with the DEA.
13. North Dakota
NPs in North Dakota have FPA, including prescriptive authority. To prescribe medications, they must complete 30 hours of coursework in pharmacology every 3 years. Newly graduated NPs may apply their NP coursework in pharmacology to their 30-hour requirement.
In Oregon, NPs have FPA with prescriptive authority. However, to practice outside of their original population focus, the Oregon Board of Nursing requires an oversight relationship with a physician.
15. Rhode Island
Although NPs may practice independently in Rhode Island, they must be on the Uniform Controlled Substance Registration to prescribe medications.
16. South Dakota
In 2017, changes to South Dakota’s Nurse Practice Act granted NPs FPA. Granting FPA in South Dakota is an important milestone, given the state’s large rural population and need for providers in underserved communities.
17. Washington State
Washington state offers NPs FPA and prescriptive authority, including scheduled drugs. However, applicants who graduated more than 1 year ago must provide documentation that they have worked at least 250 hours as a NP within the past 2 years.
18. District of Columbia
NPs apply for licensure through the Board of Nursing, which is under the Department of Health. To prescribe controlled medications, NPs must complete a separate application to be on the controlled substance registry.
NPs in Wyoming reap the benefits of FPA and have the option of working in the neighboring state, Idaho, with their Wyoming NP license.
States that Offer Full Practice Authority After a Provisional Period
State legislators approved FPA for experienced NPs with Act 412 in 2021. NPs who have completed at least 6,240 hours of a collaborative practice agreement can apply for FPA.
A 2020 state law creating a pathway to FPA took effect in January 2023. NPs with three years of experience can work without collaborative physician agreements in select medical facilities. Assembly Bill 890 offers FPA across all clinical settings by 2026.
NPs in Colorado are granted FPA after completing 1000 hours of practice with provisional prescriptive authority. During the provisional period, there is a requirement for oversight from either a physician or another NP. The collaborative agreement must be registered with the state board of nursing.
Connecticut and Colorado have similar FPA requirements. Like Colorado, NPs have a provisional status before being granted FPA. The provisional period in Connecticut is three years and a minimum of 2000 hours.
Licensed NPs with at least 3,000 supervised practice hours can lead primary care practices without collaborative agreements. State law requires NPs to complete graduate courses in differential diagnosis and pharmacology before independent practice.
State law allows independent practice by NPs and other APRNs once they’ve met minimum practice hours. NPs must demonstrate at least 4,000 hours of supervised experience following national certification for FPA.
State legislators approved a change to nursing licenses in 2022 eliminating prescribing protocol and collaborative agreement requirements for NPs. The new law requires APRNS to hold malpractice insurance and maintain national certification. State officials are still resolving ambiguities around legal distinctions between medical and nursing services.
The Maine board of nursing requires some advanced practice nursing specialties to have 24 months of supervision before applying for independence. NPs may prescribe medications in addition to diagnosing and treating medical conditions.
In 2021, Massachusetts became the 23rd state to authorize FPA for NPs. Under the new law, NPs may apply for full practice authority after completing two years of qualified supervised practice.
NPs that began their practice after July 1st, 2014 work in a collaborative agreement for at least 2080 hours prior to being granted FPA. The board of nursing requires a signed affidavit from the NP confirming the completion of the provisionary period.
11. New York
Changes to the Nurse Practitioner Modernization Act in 2022 created FPA for NPs with 3,600 practice hours or more. Newly licensed NPs can work with experienced NPs or physicians to complete practice hour requirements.
A new state law in 2021 amended NP restrictions for effective FPA. NPs previously required Consultation and Referral agreements with physicians in their first year or 2,000 practice hours. HB 287 supports FPA once NPs complete 1,000 hours of informal mentorship by physicians.
Prior to obtaining FPA in Vermont, NPs must enter into a collaborative agreement with a physician or a NP for two years and a minimum of 2400 hours.
A state law that took effect in July 2022 created FPA opportunities for experienced NPs. Licensed NPs with at least five years of clinical experience can apply for autonomous practice through the state Board of Nursing.
Reduced Practice Authority States
State law limits prescriptive authority for NPs and nurse midwives. A collaborative practice agreement is required to administer Schedule III, IV, or V controlled substances.
NPs in Indiana can only practice and prescribe medication under collaborative practice agreements with primary care physicians. Supervising doctors review at least 5% of NP patient charts involving prescribed medications.
Collaborative agreements with licensed physicians are required for NP prescriptive authority in Kentucky. There is also a physician ownership requirement for facilities where 50% of patients receive pain treatment.
Louisiana law requires collaborative agreements between NPs and physicians for patient care. A 2021 proposal to grant FPA to NPS with at least 4,000 practice hours was not passed by the legislature.
NPs are required to enter collaborative agreements with physicians in order to open their own practices. Collaborating physicians must be located within 75 miles of NP practices and review 20 random patient charts per quarter.
6. New Jersey
State law establishes collaborative agreements between NPs and physicians for patient care. Both parties review one randomly selected case per year as part of their agreement.
NPs must enter into Standard Care Arrangements with physicians to practice in Ohio. State law requires review and renewal of these agreements every two years.
Pennsylvania law recognizes NPs as primary care providers for six patient areas from neonatal to gerontology. There is a collaborative agreement requirement for NPs to prescribe medications. Supervising physicians must regularly evaluate patient records as part of collaborative agreements.
9. West Virginia
NPs in West Virginia are required to enter collaborative agreements with physicians for prescriptive authority. State law allows NPS to prescribe up to three-day supplies of Schedule II medications started by doctors.
APRNs in Wisconsin must secure collaborative agreements with doctors before providing patient care. A 2022 proposal to grant FPA passed the state legislature but was vetoed by the governor.
Restricted Practice Authority States
Georgia law requires collaborative agreements with physicians and written authorization for prescriptive authority. NPs are allowed to independently order diagnostic tests in non-emergency cases under a law passed in 2020.
There is a collaborative agreement requirement for NPs practicing in Michigan. A 2019 change by the state’s Department of Health and Human Services reinforced this requirement for NPs working with Medicaid patients. State law allows NP prescriptions for non-scheduled drugs but requires physician signatures for scheduled drugs.
Collaborating physicians must be located within 75 miles of supervised NPs by the state Board of Nursing.
4. North Carolina
NPs in North Carolina must enter into drug and device agreements with physicians for prescriptive authority. Supervising physicians must also request NP access to managed care network directories for reimbursement.
NPs must enter into collaborative agreements with physicians under Oklahoma law. There is a limit of two supervised NPs per physician.
6. South Carolina
State law requires licensed NPs to enter into collaborative practice agreements with physicians. Supervisors must be licensed in the same practice areas as their NPs for agreements to take effect.
Supervising physicians are required to review 20% of patient charts from NPs every month. There are additional review requirements when NPs prescribe controlled substances or upon patient request.
There are collaborative agreement and prescriptive authority requirements in place for NP practices in Texas. Collaborative agreements may establish fees paid by NPs to supervising physicians.
Benefits of Full Practice Authority
A recent policy brief by the American Association of Nurse Practitioners outlines the tangible benefits of FPA for both patients and providers.
Based on the policy brief, there are five specific reasons NPs need to advocate for FPA
1. It increases patients’ ability to access care.
By eliminating unnecessary legislation that limits the autonomy of NPs, more providers are available to see patients.
2. FPA results in more choices in the health care market.
NPs tend to seek employment in regions that offer more career advancement. When there are more providers per capita, patients have more choices and increased access to health care.
3. It creates a more efficient health care system.
The NP model of education focuses on collaboration. NPs are astute at identifying problems that need further evaluation and facilitating appropriate referrals to specialists.
4. It lowers health care costs.
Multiple studies have demonstrated that NPs provide high quality care at a lower cost than their physician counterparts.
5. It increases job satisfaction among NPs.
Many nurses choose to become NPs because they want to have a more autonomous role and have a larger impact on the health of their patients. Full practice authority allows NPs to accomplish these goals.
NPs Are Advocates for Change
Nurses and NPs consistently advocate for patients’ rights and for increased access to care. The American Nursing Association (ANA) emphasizes the important role of advocacy in nursing. According to the ANA, “Advocacy is a pillar of nursing. Nurses instinctively advocate for their patients, in their workplace, and in their communities; but legislative and political advocacy is no less important to advancing the profession and patient care.”
Echoing the need for political advocacy to advance the profession, NPs have taken their passion for improving patient care to the policy level. A recent study published in the Journal of the American Association of Nurse Practitioners highlights how changes in the health care market, like the passage of the Affordable Care Act in 2010, were leveraged to increase FPA for NPs. Between 2011 and 2016, eight states passed full practice authority legislation for NPs, which is an eight-fold increase from the previous 10 years.
The Expanding Role of Nurse Practitioners
NPs’ scope of practice is still significantly limited in some states despite the fact that NPs are an essential part of the U.S. health care system and have been providing affordable, safe, and quality health care to millions of patients since the 1960s The ability of nurse practitioners to work independently and provide the best care to their patients increases when they are granted full practice authority.
Policies that increase the autonomy of NPs are well founded and improve patients’ access to care. A recent systematic review published in the Journal of Evidence Based Nursing indicates that patients are more satisfied with the care they receive from NPs versus physicians. This may be because NPs tend to have a longer consultation time and do a more thorough investigation of the patient’s chief complaint. Furthermore, the systemic review indicated that there is no decrease in health outcomes when patients are cared for by NPs.
Nurse Practitioners Deserve Full Practice Authority
NPs consistently demonstrate their value in the health care market. Patients are more satisfied with the level of care provided and health care costs are lower in markets in which NPs have FPA. These statistics are not surprising given the rigor of NP education programs. The AANP policy statement on FPA clearly outlines why NPs should be granted FPA throughout the U.S.:
- NPs are required to meet national education standards.
- Prior to practicing, NPs are required to obtain national certification in their specialty.
- The NP model of care encourages collaboration among disciplines.
- NPs are held accountable for the quality of care that they provide by their state board of nursing and the public.
Advocating for Nationwide Full Practice Authority
NPs need to advocate for expanding FPA privileges in the remaining 18 states in which their scope of practice is limited. There are five key ways that expanding FPA privileges benefits the U.S. health care market.
- It increases patients’ ability to access care.
- It results in more choices in the healthcare market.
- It creates a more efficient healthcare system.
- It lowers health care costs.
- It Increases job satisfaction among NPs.
NPs fill a critical role in the U.S. healthcare system. They tend to serve in underserved areas, drive down the cost of health care, and provide phenomenal care. Multiple studies have demonstrated the benefits of FPA for NPs. Furthermore, states that restrict NPs’ scope of practice have a higher shortage of primary care providers and lower standings on national health metrics. Increasing the number of states that offer FPA to NPs improves patient care and advances the profession of NPs.
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By enrolling in one of Marymount’s online NP programs, including MSN-FNP, DNP-FNP, MSN to DNP or Post-Master’s Certificate-FNP you can have a role in leading Nurse Practitioners to Full Practice Authority throughout the United States. Becoming an FNP with Full Practice Authority will help increase compassionate care and improve patient outcomes for all patients.
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Rebecca Brunelle, PNP is a pediatric nurse practitioner with experience in telephone triage, pediatric critical care, and pediatric cardiology. She is currently living in Buenos Aires, Argentina. Since moving abroad, she has kept active in the nursing profession by doing international missions, writing nursing blog posts, and working in copy/editing for nursing curriculum.