Issues Affecting Nurse Practitioners: Prescribing Authority

This essay examines the barriers and issues that affect the role of nurse practitioners in healthcare, with a focus on prescribing authority. The impact of physician resistance, regulation, and legislation on nurse practitioners is explored. The essay also discusses how nurse practitioners can manage these issues within legal and professional boundaries. The subject is relevant to healthcare professionals and students studying nursing or healthcare management.

Running head: ISSUES AFFECTING NURSE PRACTITIONERS
Issues that Affect Nurse Practitioners
Name
University

ISSUES AFFECTING NURSE PRACTITIONERS 2
Abstract
The purpose of this essay is to look at the barrier that impact the role of a nurse practitioner in a
health organization and one issue will be selected to determine how the impact it has on the role
of nurse practitioners in the healthcare system. The aspect of managing the issue will also be
discussed in the paper within the legal and professional boundaries.

ISSUES AFFECTING NURSE PRACTITIONERS 3
Introduction
A nurse practitioner is a healthcare provider with advanced education, training and expert
knowledge in diagnosing, managing and treating complex acute and chronic conditions.
Depending on their state or country’s legislation, they can order for diagnostic tests, prescribe
medication, admit patients in hospitals, request for patient referrals and perform minor, non-
surgical procedures on patients (International Council of Nurses, 2018). Nurse practitioners
began coming to the foreground during the 1960s and their role was formally brought about by
Loretta Ford, a nurse educator, and Henry Silver, a medical doctor, in 1965 (Stewart & DeNisco,
2018, p.4).
The program Ford and Silver created was meant to cater to the underserved and remote
populations who had nursing shortages The first program was meant to be based on pediatrics
but it ended up advancing clinical practice by enabling students to diagnose patients and provide
primary care (2018, p.4). In the 1970s, the nurse practitioner programs grew from funding by the
federal government to deal with doctor shortages especially in the remote parts of the country. In
1971, the state of Idaho became the first to allow nurse practitioners to prescribe medication in
the United States (2018, p.4). In Australia and New Zealand, nurse practitioners obtained their
prescriptive authority in 2001 while in the UK and Canada, nurse practitioners began prescribing
medication in1998 and the early1990s respectively (Fong, Buckley & Cashin, 2015).
Literature Review: Barriers to Nurse Practitioner Role
There are barriers/issues that continue to affect the scope of practice within which nurse
practitioners work one of which is resistance from physicians (Buchsel & Yarbro, p. 66). Nurse
practitioners face resistance especially from doctors because of their expanding role which now

ISSUES AFFECTING NURSE PRACTITIONERS 4
allows them to prescribe medication, diagnose patients and refer them for further treatment.
Many physicians see this as an encroachment on their profession because the difference in roles
between doctors and nurses is diminishing (Elder, Evans & Nizette, 2009, p.72).
There are issues with regulation resulting from rapid population growth which
necessitates changes in health policy to meet the increasing healthcare demands. The most
prominent issues that nurse practitioners face are prescribing medication and being able to
practice independently (Cowen & Moorhead, 2011, p.35). Most of the regulations that govern
this profession are not backed by evidence or research but they instead create a barrier to the
effective practice and provision of care by these nurses (2011, p. 35). Another issue that affects
nurse practitioners is that they have to know and observe both the state and federal legislation of
where they practice.
This affects their job performance because a new bill introduced in government might be
done with the best intention but it can impact on their ability to do their job (2011, p.36). An
example of harmful legislation is the Medical Home Bill of the United States. The original
purpose of this bill was to provide a centralized healthcare delivery system for children with
special needs but this goal was later expanded to cover the needs of adults in a patient-centered
medical home. The legislation that mandated these homes was written to include only physicians
and excluded nurse practitioners despite the fact they played an integral part in these homes
(2011, p.36). The issue that will be analyzed in this essay is prescribing authority and how it
affects nurse practitioners.

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Identification of Potential Issue that Affects the Role of Nurse Practitioners
The prescription of medication over the years has mostly been the preserve of medical
doctors. During the twentieth century, this began to change as nurse practitioners had their scope
of practice expanded to include prescribing medicine (Bellaguarda, Nelson, Padilha & Caravaca-
Morera, 2015). Nurses have had a major impact on how doctors prescribe medication because
they know more about their patients’ preferences and needs. Because they also work as nurses,
they have a base knowledge of their patients which gives them an advantage when prescribing
medication (Elder, Evans & Nizette, 2009).
Prescribing authority is the ability of a healthcare provider to independently provide
patients with prescriptions without having to consult a doctor. The extent of nurse prescribing
varies in the country or state in which they practice (Stokowski, 2018). The types of medications
that nurse practitioners prescribe based on research from the US, New Zealand, the UK and
Canada are pain medication, hypertension drugs and antimicrobials. In Australia, pain
medication and anti-infective drugs are the most commonly prescribed medication by nurse
practitioners (Fong, Buckley & Cashin, 2015).
Prescribing authority can be independent or supplementary. Independent prescribers have
the responsibility to perform an assessment of the patient and prescribe the necessary medication
that will treat the diagnosed condition (Kroezen, Dijk, Groenewegen & Francke, 2011).
Supplementary prescribing is where an independent prescriber (doctor or dentist) voluntarily
partners with a supplementary prescriber (nurse or pharmacist) to prescribe medication. This is
after the supplementary prescriber has assessed and diagnosed the patient. This form of

ISSUES AFFECTING NURSE PRACTITIONERS 6
prescribing is a collaborative or consultative approach with the doctor because direct supervision
is not required (Kroezen et al., 2011).
Issues Affecting Nurse Practitioners Prescribing
In a lot of countries, nurse practitioners face limitations when it comes to prescribing
controlled drugs which are medications that have a high potential for being abused and lead to
severe dependence. These drugs fall under Schedule II, III and IV controlled medication.
Examples include oxycodone, fentanyl, Adderall, morphine, Dilaudid, methadone, Demerol,
steroids, ketamine, xanax, Ativan, Tylenol with Codeine and Valium (DEA, 2018). In Canada,
there is an effort to have nurse practitioners give prescriptions for controlled drugs especially in
primary healthcare to improve access to healthcare and the quality of services being provided in
health facilities (Ambrose & Tarlier, 2013).
Many people in the country visit health facilities to get prescriptions for pain medication
many of which fall under the controlled substances category (Ambrose & Tarlier, 2013).
Canadian medical doctors and dentists are the only professionals allowed under federal law to
prescribe pain medication. This has led to frustration with the nurse practitioners because they
are unable to write prescriptions for patients suffering from chronic pain. This barrier also limits
the number of patients they can treat and it increases patient wait times when they have to
consult with physicians, who also have their patients, to get a prescription (Ambrose & Tarlier,
2013, p.60).
In the United States, a report by the Institute of Medicine (IOM) identified that nurse
practitioners faced stringent legislation on prescribing authority (Iglehart, 2013). According to a
study done by Gadbois, Miller, Tyler and Intrator (2015) between 2001 and 2010, states such as

ISSUES AFFECTING NURSE PRACTITIONERS 7
Montana, New Hampshire, Washington and Alaska had the least amount of restrictions for nurse
prescribing. The study found that in Florida and Alabama, nurse practitioners were not allowed
to prescribe controlled substances while in most of the other states a physician was required to
provide a prescription or oversee the nurse’s prescribing authority (Gadbois et al., 2015).
The IOM found variations in practice regulations for nurses because in some states they
were allowed to examine patients and provide prescription services without having any physician
supervision or collaboration (Iglehart, 2013). Sixteen states together with the District of
Columbia allowed nurse practitioners to perform assessments, diagnosis and prescription
services for their patients without collaborating with physicians or having their supervision
(Iglehart, 2013). Nine states in the US required these nurses to have physician involvement when
they prescribed medication but not when they diagnosed or treated patients.
Twenty four states required physician involvement when nurse practitioners were
diagnosing, treating and prescribing medication. There has been very slow progress in recent
years to have these restrictions removed even with their expanding scope of practice (Iglehart,
2013). The figure in the appendix demonstrates physician involvement in the various states.
There has been an expansion on nurse prescribing in the United Kingdom as a result of
changing government policies. Community based nurses in the 1990s were able to prescribe
medication independently from a limited list of drugs especially for wound management and
bowel care. Changes in legislation in 2006 saw nurse practitioners being able to prescribe
medication that was listed under their scope of practice to treat conditions (Avery & James,
2007). In recent years, nurse practitioners in the United Kingdom work as independent
prescribers and have a responsibility to diagnose, treat and prescribe medication to their patients

ISSUES AFFECTING NURSE PRACTITIONERS 8
in primary and secondary healthcare (McIntosh, Stewart, Forbes-McKay, McCaig &
Cunningham, 2016).
They are referred to as non-medical healthcare professionals (NMP) because they have
education, training and skills to prescribe medication. This category also includes pharmacists,
physiotherapists and paramedics (Graham-Clarke, Rushton, Noblet & Marriott, 2018). The
United Kingdom and Ireland are the only two countries with fair restrictions on prescribing
where doctors and nurse practitioners have equal jurisdiction. Many countries such as Canada,
the United States, Australia, New Zealand and Sweden impose very restrictive conditions on the
independent prescribing authority of nurse practitioners while physicians continue to maintain an
exclusive jurisdiction in prescribing (McIntosh et al., 2016).
This has led to subordinate jurisdictions in the mentioned countries because nurses are
giving prescriptions to harmless medication which are seen as routine while the more complex
prescriptions are handled by medical doctors. Countries such as Sweden place a restriction not
only on the type of medicine nurse practitioners can prescribe but also on the type of patients
they are allowed to examine and treat (McIntosh et al., 2016). The table in the appendix provides
an overall prescriptive authority for nurses in Western European and Anglo-Saxon countries.
The concept of nurse prescribing is fairly new in Australia because it was established
recently. Two thirds of nurse practitioners in Australia are allowed to prescribe medication as
part of their scope of practice (Dunn, Cashin, Buckley & Newman, 2010, p.155). Legislation that
allows nurse practitioners to prescribe has been passed in all the states and territories of Australia
apart from the Northern Territory where it is still being reviewed. The scope of practice is
usually spread across the national and state jurisdictions (Dunn et al., 2010).

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A study conducted by Dunn et al., (2010, p.154) revealed that Australian nurse
practitioners faced a lot of barriers when it came to prescribing because of restrictive legislation
that was inconsistent and complex. The nurses had full legislative authority in all the states but
the types of medication they could prescribe and the ability of the pharmacist to dispense this
medication according to the prescription proved to be inconsistent. The Australian Medical
Association has also voiced its objections to nurse prescribing which has led to constraints in
expanding their scope of practice in the healthcare system (Dunn et al., 2010).
There are nurse practitioner practice protocols in some organizations that are meant to
restrict the practice of these nurses. Dunn et al. (2010, p.154) argue that the use of these
protocols is dangerous because it leads to the loss of independence and critical thinking skills
resulting in misdiagnosis of patients and poor decisions. They also limit and restrict the
capabilities of nurse practitioners to work independently and utilize their advanced training to
treat patients at the primary level of healthcare. This reduces their overall contribution in
providing efficient, effective and quality care in the Australian health system (2010, p.154).
How to Manage Issues of Prescribing within Legal and Professional Boundaries
In the US, the (IOM) developed a report in 2010 with recommendations that nurses
should be allowed to practice without any restrictions or policy barriers and be able to partner
with doctors fully (Altman, Butler & Shern, 2016). The IOM report has influenced the Federal
Trade Commission (FTC) to put pressure on legislators in Missouri and Tennessee to allow nurse
anesthetists to provide pain management without doctor supervision to patients suffering from
chronic pain. Before this, the FTC targeted health markets that were not competitive and it

ISSUES AFFECTING NURSE PRACTITIONERS 10
mostly focused on promoting policies that were more politically based than consumer oriented
(Iglehart, 2013).
Nurse practitioners need to know the limitations imposed on their profession to continue
prescribing in a safe way. They also need to update their training to reflect current practice
standards which in turn increases stakeholder confidence (Blanchflower, 2013). Physicians and
other providers also need to play a supportive role when working with nurse practitioners to
reduce waiting times (Carr, Layzell & Christensen, 2010, p.177). To expand the role of nurse
prescribing, legislation needs to be created that supports the role of nurse practitioners in this
field. Until this is done, nurse practitioners have to continue observing the law that governs their
practice of prescribing medication.
From my observations during my work placement, nurse practitioners lacked support in
prescribing medication from the doctors who worked in the unit. The doctors believed they had
the sole jurisdiction and authority to write orders for their patients. This created some delays in
getting medications for patients who needed new orders urgently because the nurse had to
request for a prescription from the doctor. At times, the doctors did not stay for long in the unit
because they had a lot of patient rounds. This created difficulties for the nurse practitioner
especially if a patient developed complications and needed new medicine. The nurse would have
to go looking for the doctor as he did his rounds in-order to get a prescription.
In my view, allowing nurse practitioners to have independent authority is very beneficial
in provide efficient healthcare. Doctors are overwhelmed already with huge patient loads and it
creates difficulties when urgent medication orders are needed to address a patient’s changing
medical condition. Allowing nurse practitioners to prescribe without having requesting

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prescriptions from doctors or having their supervision will decrease waiting times and prevent
safety issues during the care process. For nurse prescribing to be a success, doctors need to be
supportive and create an environment that fosters partnership.
Conclusion
The barriers that were highlighted in the paper were restrictive legislation on the practice
of nurse practitioners, lack of support especially from medical doctors and restrictive prescribing
authority. The issue that was selected for this topic was prescribing authority and it was
examined based on existing legislation in Canada, the United Kingdom, the US and Australia.
While these countries have legislation that governs the scope of nurse prescribing, it was only the
United Kingdom that had the least restrictive legislation.
Countries such as the US, Canada and Australia had stringent laws which made it hard
for nurse practitioners to have a full prescribing authority. The study found that in the United
States, nurse practitioners can prescribe independently in some states while in others they need
physician supervision for prescriptions only. In other states, nurses required doctor supervision
during patient diagnosis, treatment and prescription while in states such as Florida and Alabama
nurse practitioners had no prescribing authority especially for controlled medications.
In Canada, it was only doctors and dentists that were allowed to prescribe pain
medication. In Australia nurses faced protocols in health institutions which limited their
independence to practice and restricted their ability to prescribe. For nurse practitioners,
overcoming restrictions placed on their practice will remain difficult as long as the current laws
exist. Until changes are made to existing legislation, they must continue to provide safe, effective
and quality care when diagnosing, treating and prescribing.

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Appendix
Physician Involvement in Diagnosing, Treating and Prescribing in the US (Iglehart, 2013)
Prescribing Authority for Nurses in Western European and Anglo-Saxon Countries (Kroezen et
al., 2011)
Prescriptive Authority
Country Independent Collaborative Medical Directives
Australia  
Canada  
Ireland 
New Zealand 
Spain*  
Sweden 
United States  
United Kingdom   
Netherlands*  
*Nurse prescribing is not yet legalized