Trumping Professional Roles: Collaboration of Nurse Practitioners and Physicians for a Better U.S. Health Care System

One Pagers | Oct 15, 2001 Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

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.

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 PracticeNP Practice authorized through State Board of NursingNP Practice authorized by Boards of Nursing and Medicine/others
Scope of NP Practice: Without MD supervision or collaborationNP Practice authorized through State Board of Nursing: AK, AR, AZ, CO, DC, HI, IA, ME, MI, MT, ND, NH, NJ, NM, OK, OR, RI, TX, UT, WA, WV, WYNP Practice authorized by Boards of Nursing and Medicine/others:  
Scope of NP Practice: With MD supervisionNP Practice authorized through State Board of Nursing: CA, FL, GA, ID, LA, MA, SC, WINP Practice authorized by Boards of Nursing and Medicine/others: AL, MS, NC, PA, SD, VA
Scope of NP Practice: With MD collaborationNP Practice authorized through State Board of Nursing: CT, DE, IL, IN, KS, KY, OH, MD, MN, MO, NE, NV, NY, VTNP Practice authorized by Boards of Nursing and Medicine/others: TN

Table 2. NP Prescribing Status by State 2000*

StatusStates
Status: Independent prescribing including controlled substancesStates: AK, AZ, DC, IA, ME, MT, NH, NM, OR, VT, WA, WI, WY
Status: Prescribe with physician collaboration, including controlled substancesStates: 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
Status: Prescribe with physician collaboration, excluding substances and/or with schedule limitsStates: 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(www.medscape.com). Updated November 22, 2002.

The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP. 

Published in American Family Physician, Oct 15, 2001. Am Fam Physician. 2001;64:1325. This series is coordinated by Sumi Sexton, MD, AFP Associate Medical Editor.