if I disagree with a physician about the choice of the most appropriate medication?
How does one adapt when relocating to a state with a different scope of practice?
General questions are often followed by more specific patient‐centered questions. For example:
Am I making the right medication choice?
Is medication the most appropriate treatment option or should non‐pharmacologic approaches be used at this point in the treatment trajectory?
What type of antibiotic should be prescribed to treat a methicillin‐resistant Staphylococcus aureus infection?
When should a person with type 2 diabetes consider beginning insulin therapy?
What is the appropriate medication to manage acute, subacute, or chronic pain?
When faced with the reality of determining specific practice decisions, particularly those about prescribing, the novice APRN may experience a sense of uncertainty. Novice APRNs enter advanced practice step‐by‐step, decision‐by‐decision. Experience is a remarkable teacher, and, gradually, APRNs develop their professional practice and role identity which includes competence in prescribing. APRNs need time to transition into their new role. It is key, however, to emphasize that a novice APRN receiving the wisdom of a trusted colleague is different than the “requirement” for physician supervision. All novice prescribers, including physicians, benefit from this type of support.
Another aspect of adopting the APRN role is to contend with constraints imposed on all prescribers by health plans and healthcare delivery systems. For example, insurers promote the use of generic medications by requiring higher co‐payments or refusing to pay for some brand‐name drugs. Healthcare systems such as the Veterans Health Administration (VA) and health maintenance organizations such as Kaiser Permanente increasingly use formularies. These limit the medications that are paid for by the health plan, which promotes the use of generic drugs. For the most part, use of generic drugs is an important approach to address skyrocketing US healthcare costs, especially if they produce the same outcomes as branded medication. There are situations, however, in which the patient responds differently to generic vs. branded drugs. The APRN can be limited to only the generic, which compromises patient care. When a branded or non‐covered medication is necessary, a particularly time‐consuming, infuriating, and complex challenge is the prior authorization process. Providers must obtain permission from the health plan to make an exception to the policy (Jones et al., 2019).
In the practice setting, the APRN may be confronted with challenges to adopting the role of prescriber. In states with considerable limitations on autonomous prescribing, restrictions may be stipulated in practice agreements. Furthermore, specific clinical practice settings or individual characteristics of the collaborating physicians may limit the APRNs’ decision making, especially when an APRN choses a medication that differs from his or her preference. Collaborative practice agreements may specify that the physician has the ability to override an APRN’s prescribing decision.
The shift from professional preference and tradition to evidence‐based practice has been shown to be a key strategy for achieving quality patient care. Improved models for prescribing that increase the effectiveness of care and reduce error and cost are emerging from the rational prescribing and evidence‐based care movements. These models use clinical practice guidelines and electronic health records, exert more control over pharmaceutical marketing, and promote standards for formularies.
Commitment to these evidence‐informed models is essential for APRNs to improve quality and safety. Recently educated APRNs, steeped in careful attention to rational and evidence‐based prescribing, are likely to encounter situations with colleagues who may be unaware of current medication information. These situations often require assertiveness and communication skills that facilitate collegial sharing about continuously changing knowledge.
Prescriptive authority and responsibility
Changes to prescriptive authority for APRNs may be sponsored by legislators with limited understanding of the clinical abilities of the APRN (Safriet, 2002). Prescriptive authority carries responsibilities, even in states where collaboration or supervision is required. APRNs are accountable to patients, colleagues, the nursing profession, and society for their actions, decisions, and practice. As with any aspect of practice, errors or negligence in prescribing may result in disciplinary or legal action.
With all of the factors that influence the transition of the APRN as a prescriber, there will be a degree of uncertainty, and often anxiety, about prescribing. The transition from the RN role as the medication administrator to the APRN role as the medication prescriber can be viewed as a professionally invigorating challenge or as a distressing situation.
Professional relationships
Implementation of the APRN role requires the development of strong relationships with other healthcare professionals, patients, the profession, and society. The time and effort needed to establish and maintain these relationships may be demanding. The transition from the RN to the APRN role may change APRNs’ relationships with patients less than it changes relationships with other healthcare professionals. The most dramatic change for APRNs is likely to occur with physicians. APRNs’ level of prescribing expertise and the legal requirements of the prescriptive authority will influence relationships with physicians. A physician may be a colleague in the true sense of the word or may serve as a consultant or supervisor. The relationship between an APRN and a physician at its best will be similar to one’s relationship with another APRN colleague: fulfilling, supportive, and truly collaborative with the interests of the patient at its core. A problematic relationship with a collaborating or supervising physician can serve as a barrier to APRN practice and compromise patient care. In those situations, APRNs may experience isolation, invalidation, and marginalization.
It is essential for APRNs to enhance their skills to manage and improve contentious professional relationships. APRNs who skillfully challenge and improve strained collegial relationships can build professional acceptance for all APRNs as well as enhance the quality of their own work life. These are situations where support and collaboration from other APRNs may be particularly effective. Some practices, however, may employ only one APRN, and time for collegial interaction at one’s workplace may be limited.
The practice relationships that are legally required between APRNs and physicians vary from state to state. The majority of states still require some type of collaborative practice and some limit prescribing for specific medications or controlled drugs. For example, Alabama has one of the most restrictive scopes of advanced practice in the United States. Neither CNSs nor CRNAs may prescribe. For NPs and CNMs, prescribing limits include the following:
The drug type, dosage, quantity prescribed, and number of refills shall be authorized and signed by the collaborating physician.
The drug shall be on the formulary recommended by the joint committee and adopted by the State Board of Medical Examiners and the Board of Nursing.
A certified registered NP or a CNM may not initiate a call‐in prescription in the name of the collaborating physician for any drug, whether legend or CS, which the certified registered NP is not authorized to prescribe under the protocol, with certain exceptions (Alabama State Board of Nursing, 2020).
In states with restrictive practice laws, APRNs may be subject to direct oversight of a physician regardless of their expertise. Beyond a legal requirement for collaboration or supervision, physicians may view APRNs differently from how APRNs view themselves. A study
