Trumping professional roles: Collaboration of nurse practitioners and physicians for a better U.S. health care system

Professional turf battles have yielded variations in the scope of practice for nurse practitioners (NPs) obstructing collaboration with physicians that would enhance patient care. Patients would be better served if NPs and physicians worked together to develop better combined models of education and service that take advantage of the benefits of both professions' contributions to care.

Fryer GE, Dovey SM, and Green LA

The legal status and regulation of NPs varies significantly from state to state. Currently, 21 states and the District of Columbia allow some degree of independent practice for NPs, and the rest require collaboration or supervision by a physician (Table 1). Twelve states and the District of Columbia allow independent NP prescribing, while the rest require physician collaboration with other limitations (Table 2). Even licensing authority and classification varies by state.

**Table 1: Legal Status of Nurse Practitioners by State 2000**
Scope of NP Practice	NP Practice authorized through State Board of Nursing	NP Practice authorized by Boards of Nursing and Medicine/others
Without MD supervision or collaboration	AK, AR, AZ, CO, DC, HI, IA, ME, MI, MT, ND, NH, NJ, NM, OK, OR, RI, TX, UT, WA, WV, WY
With MD supervision	CA, FL, GA, ID, LA, MA, SC, WI	AL, MS, NC, PA, SD, VA
With MD collaboration	CT, DE, IL, IN, KS, KY, OH, MD, MN, MO, NE, NV, NY, VT	TN

**Table 2: NP Prescribing Status by State 2000**
Status	States
Independent prescribing including controlled substances	AK, AZ, DC, IA, ME, MT, NH, NM, OR, VT, WA, WI, WY
Prescribe with physician collaboration, including controlled substances	AR, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, KS, MA, MD, MI, MN, NC, ND, NE, NJ, NY, OK, PA, RI, SC, SD, TN, UT, WV
Prescribe with physician collaboration, excluding substances and/or with schedule limits	AL, KY, LA, MO, MS, NV, OH, TX, VA

These variations exemplify and exacerbate a growing professional schism. Although many NPs and physicians enjoy successful collaborations, regulatory variations and the professional turf battles that cause this gap threaten to make such collaboration more difficult.

The credible evidence showing that collaboration improves health outcomes for patients entreats the two professions to put cooperation before professional roles. NPs and physicians should work together to create new models of integrated education and collaborative care with patients as the focus. A combined, sustained effort is urgently needed to permit new policies for redesigning and improving the U.S. health care system.

Note: The tables in this one-pager were accurate in 2000 but are an oversimplification of complex state laws and regulations and are meant to convey the variability described in the text. The tables should not be used literally for any means. More current information is available from other sources, including www.medscape.com. Updated November 22, 2002.

Phillips RL, Green LA, Fryer GE, Dovey SM. Trumping professional roles: Collaboration of nurse practitioners and physicians for a better U.S. health care system. Am Fam Physician 2001;64:1325.

October 2001