5 Worst States for Nurse Practitioner Practice

States are increasingly passing laws allowing nurse practitioners more freedom in their practice. Some legislators are even running marketing campaigns attempting to lure NPs from other states within their boarders on the basis of more favorable scope of practice legislation. But, some states lag behind in the NP independent practice movement (ahem, Deep South, we’re looking at you).

Which states fall notoriously short when it comes to granting nurse practitioners freedom in their practice?

1. Florida

If you want to work in healthcare, Florida should be at the bottom of your list of dream destinations. Yes, the Sunshine State may have palms, sun, and sand, but state laws may make your day job a less than illuminating experience.

Florida’s nurse practitioner supervision laws are among some of the strictest in the nation. State law requires that nurse practitioners work under the supervision of a physician when it comes to practice and prescribing. Even when working within a physician supervision agreement, NPs practicing in Florida are not allowed to prescribe controlled substances. This is a major setback, especially considering the state is facing a significant shortage of primary care providers.

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2. Alabama

With the highest rate of obesity in the nation and over 25 percent of its residents smokers, you would think Alabama could use nurse practitioners more than ever. Unfortunately, the state’s legislators don’t feel the same. Not only must nurse practitioners work in collaboration with a physician, the physician must be physically on site with the NP ten percent of the time.

Prescribing laws in Alabama are similarly strict for nurse practitioners. NPs working in Alabama may only prescribe Schedule III, IV and V medications limiting their utility in certain settings.

3. North Carolina

While known for its predictably strong college basketball teams, laws concerning NPs in North Carolina are far from a slam dunk. Like our prior two picks, nurse practitioners practicing in North Caorlina must work in collaboration with a physician. Not only does North Carolina require a collaborative agreement with an MD, nurse practitioners are also restricted within this arrangement. For example, nurse practitioners may only refill certain controlled substances a limited number of times. Complex rules and regulations when it comes to prescribing and supervision limit NPs ability to practice in the Tar Heel State. 

4. Georgia

The last state to grant nurse practitioners the ability to prescribe, Georigia still lags perilously behind when it comes to scope of practice laws. NPs practicing in the Peach State are not allowed to prescribe Schedule II controlled substances. Nurse practitioners in Georgia must also practice under a so called “delegating physician”. Georgia may be one of the fastest growing states in the nation, but it’s view of nurse practitioners remains limited.  

5. Oklahoma

Oklahoma is as all-American as they come. Famous for cowboys, Tornado Alley, and outlaws, the Sooner state has an adventurous spirit. Unfortunately, these ideals do not extend to laws governing nurse practitioners. NPs practicing in Oklahoma are prohibited from prescribing Schedule II controlled substances not to mention, they must be supervised by a physician in order to prescribe. Sorry Sooner’s, the NP scope of practice in Oklahoma leaves something to be desired.

While the West might be best when it comes to nurse practitioner scope of practice laws, the South presents a pretty sorry picture. How do scope of practice laws in your state affect your practice?


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50 thoughts on “5 Worst States for Nurse Practitioner Practice”

  1. Cynthia Malowitz, NP

    Did you not research the laws in Texas? Not only can we not prescribe Schedule II medications, but we’re limited in the number of refills we can give for controlled substances. We must have a collaborative agreement with a physician who, in turn, delegates us the “right” to diagnose and prescribe medication. This is the ONLY STATE that requires a face-to-face meeting with the physician every month. Seriously…we’re #2 “worst of the worst” states to practice! I know, because I own a practice and if something happened to my collaborating physician, then I can’t make another diagnosis nor prescribe a medication. Oh yeah…they don’t do that for free. Ours is the only profession that has to PAY another profession in order to practice our trade.

  2. Y’all forgot to mention Texas. Just as strict as the others! Hopefully, if we can band together, we can elicit change and growth in our profession!

  3. Katherine A. Darling

    Don’t come to Arkansas if you want to practice to the full extent of your education and certification. Collaboration is required for prescribing, and yes, some pay dearly for an “agreement”. Schedule IIs are prohibited. Lots and lots of state reimbursement hurdles.

  4. Kathleenhaycraft@yahoo.com

    Really. Read the smith jacobs report. Missouri comes in dead last. Stats not opinions. Also, please stop using midlevels call us pa or np or both.

  5. Patricia Wallace, MSH, MN, ARNP-C

    I am not a mid-level professional. I have and continue to be of the highest level advanced professional nurse provider; achieving, maintaining and applying medical and nursing science education and training.
    It has always been an affront to be referred to by that erroneous term. You may delete it from your lexicon.
    Florida 49 Year Nurse

  6. It’s been a culture shock to move from practice in New York to North Carolina. I will never give up my NY license(s). Oh how I miss u NY !!!!

  7. Scott Anderson, FNP, MBA

    North Carolina definitely earns their position in the top five worst states for nurse practitioners. In this state, you are not even recognized as a licensed nurse practitioner within the state unless you have a collaborative agreement signed by a licensed North Carolina physician. One of many reasons why I am currently looking outside this state for new opportunities.

  8. Not what the original post was about but since people are stuck on the term mid-level I have no problem with the term. The 5 states listed as the worst for NPs are so partially because of these restrictions. Until NPs can practice independently in the other 30 states, they are mid-level. By different measures in all 30 of those states NPs cannot diagnosis, treat or prescribe without a physicians supervision. The “nurse” in NP bother me more than mid-level

  9. Matthew Lindquist PMHNP, BC

    Though I feel for my colleagues in Oklahoma and Georgia, Missouri is probably more backward than either one. 1. Must have a collaborative agreement. 2. Physician must be within 30 miles to practice. 50 if it is a designated rural community, 3. Physician must review 25% of the charts of patients being prescribed medications. 4 No schedule II. 5. Schedule III, IV, and V requires a list of approved medications be submitted with the application for controlled substance prescribing which the collaborating physician is allowing you to prescribe. Add to this that a group of physicians got the legislators to have to hear a bill potentially making it a felony for someone like a DNP to be called doctor in a hospital setting, and you may have just found the worst state to practice in. Fortunately that bill failed.

  10. The sunny south is not sunny for nurse practitioners unfortunately. The midlevel term must go… No profession will tolerate such derogatory name calling!!!

  11. NP’s are Unable to prescribe schedule II’s in south carolina & also must work under a physicians supervision.

  12. SC is the worst. Not only can we not prescribe schedule II controlled substances, but we can’t sign for handicap stickers for patients, must get a physician signature. Since Hydrocodone containing products are now schedule II, tell me again why we have to pay $800 + for a DEA license???

  13. I live in Alabama haven’t seen my Dr in over a year she doesn’t even come in the office and if you ask to see her your denied by the nurse practioner that is over that office sad you can’t see a Dr. Anymore but still get charged the same and nurses are not doctors

  14. I’m glad I don’t live or practice in any of these states, including the ones not listed that have been brought up (ie. Missouri, ect). I’m staying right where I am.

  15. I am not as offended by the term mid level as others as I am new to the NP role, however, am aware in many instances it is demeaning. Our organization uses APCs, Advanced Practice Clinicians.

  16. Sites like this are a huge part of the problem. NPs and PAs are well trained care providers and are most definitely NOT mid level anything! I’m offended that we are classified in this manner and think this must have been dreamed up by the “experts” aka doctors

  17. I’ve been practicing under physician “supervision” since 1992 in Florida, and I’ve been an RN since the 1980s. It’s beyond ridiculous that I can’t work and get reimbursed independently by now. I can’t even prescribe Tylenol without a protocol, and I have a doctorate degree in Nursing.

  18. Notice all on the list are southern states? Nursing at every level is still considered a suitable career for women. Men in Texas prefer we just stay home and wash their underwear. Texas is horrendous! How did we not make the list? In all seriousness, the northern states have always been light years ahead with regards to equality and equity. This translates to any number of issues, including lack autonomy and fiscal inequity for NP’s. We may need to take a few notes from our fellow NP’s above the Mason Dixon line. Let’s start by saying NO to pay that is below our education and experience. Then, let’s get politically active and force the change. Complaining is fun. It’s a great start. Now that we have identified the problem(s), I vote we decide what we want and how we want it, then go after our goals.

  19. Florida passed law nurse practitioners can prescribe narcotics. No thanks. I have seen too many doctors sued when the patient dies due to an overdose. With more responsibility comes more liability. The doctors are just going to use this law to benefit themselves like dumping their problem narcotic patients on nurse practitioners on us to reduce their liability…work load…ect. I’ve already told my employer that I will not get a DEA license. I refuse to do it.

  20. Worked in one of 5 worst GA for 4 yrs., the best state WA for 10 yrs., then TX for nearly 4 more and now going to try the number 2 state on the best of list NM. I see a pattern developing……

  21. These least progressive states are all conservative voting zones that obviously don’t believe the research indicating outcomes of NP directed treatment is as good or better than that directed by physicians. This is yet another illustration of the power and influence of the AMA over a political spectrum that is not swayed by facts.

  22. Stop using the term midlevel. I’m not a midlevel to anyone. And do your research. There are many states that are restrictive to NPs. MO is at the top of that list.

  23. Michigan should definitely be added to this list.

    While I love my job, there are definite restrictions our practice ability. In addition, I feel the people of the great mitten state are very physician driven. I don’t think there is a lot of knowledge for who we are and the great care we deliver.

  24. Please stop your belly aching. If you wanted to me medical doctors, you should have studied harder and gotten into medical school. But you didn’t. You did your bachelor’s in nursing and then might have done some extra coursework to get a “master’s” level NP designation. Your training is mid-level compared to physicians. Deal with your choices like adults.

    1. Many of us have doctorate degrees, and we didn’t become doctors because we want to take a holistic approach to patient care…seeing the whole person as one…not like the medical model of seeing an organ system and ignoring the rest of the patient.

      1. this comment is idiotic deb. you think your 2 year online program is more “holistic” than physicians who spend entire 4 years in medicine first studying the WHOLE body before another 4 years to specialize in a segment?

  25. Mississppi definitely should be added to the worst list. First year new graduates need work 720 supervised hours by a MD to get DEA license. Meanwhile, new NPs need meet up with a Board site visitor every two months and your supervising MD must meet with the site visitor every three months to discuss your performance. NPS are treated like step children especially new graduates in MS. I am on my way out, heard NPs in D. C. Oregon and VA are in much better place and can seeing patients and prescribe independently without Physician on site

  26. Given that a nurse practitioner with 30 years of experience cost my wife and I our first child, I may not be sympathetic to please for “less supervision…” There is a profound difference in training and that cannot be denied, ignored or wished away. Every day, in my practice, I see referrals from NPs and PAs who have made significant diagnostic errors. These errors have lead to inappropriate medication use which has then resulted in deleterious medication complications and side effects… all of which arose from basic errors in medical decision making. I know I am not the only physician seeing this trend. If a self-delcared “professional” does not have the wisdom to understand when s/he is practicing beyond their scope of training…. well, I guess that is what trial lawyers are for.

    1. Dr. Kel,
      I am a NP and must agree you’ve made some great points. I am very sorry to hear of you and your wife very unfortunate experience. It shouldn’t have happened. That said, you would agree that physicians by large, made a lot more mistakes than NPs, often with far greater consequences. Prior to becoming a NP, I worked for many years in the hospital and out-patient settings, in such areas as ED, ICU, PACU, case management, endoscopy, dialysis, and home health. I have worked at such “prestigious” instititions as Emory Hospital and University of Pennsylvania Hospital, to name a few. During those years as a nurse, I have seen and heard of nurses averting errors made by physicians, took blame for their errors, and watching their backs. In ICU, many new doctors had no experience and the seasoned ICU nurses would take them under their wings and teach them, then as they learn and gain the skills they become confident and untimately gained expertise. The same is true when a new NP enters the role of APN…the role is new, with far greater responsibility. The Industrial Age, and particularly our society have placed an almost “god-like” halo around the heads of physicians. They are seen as “gods” because the “healed” the sick, “raised’ the dead, and made the “lame” walk again. True to a point, but much of these “miracles” are due to super excellent nursing care and modern technology. I have seen and worked with some very, very smart nurses. Many have reached the top of their nursing ladder and went on to become NPs with PhDs, DNPs. I have asked many, why not just become a physician but they all said no, they prefer the personal touch and intimacy they had with their patients. I also have known a few who had gone on to become physicians. I agree it took a lot of training, education, and practice to become a great physician, but so does a great NP!! As a new NP, I wouldn’t want to do what you do, not before I am at least 5 years in. Then again, it all depends on the training received on the job, additional advanced education, seminars, and professional conferences. NPs/PAs are not asking to practice as neurosurgeons, heart surgeons, radiologists, anesthesiologists, orthopedic surgeons, oncologists, and hematologists, to name a few. They are just asking to practice within scope of their education and training. NPs can do a lot of things a physician can do because they are educated and trained at a certain level. May Bachelors degree was 4 years and my MSN took 3 years plus I have over 23 years combined nursing experience in the areas mentioned prior. Now if I want to do more, I agree I should get the education and training, but I don’t want to be a rocket scientist, I just want to be a family nurse practitioner and refer those out of my scope of practice and/or more complicated to the experts! From many reliable research, physicians made more errors, are sued more often, order the wrong imaging/labs, performs procedures on the wrong body parts/wrong person , and missed more diagnoses than any NP, singularly or combined.

      1. JEnnifer,
        so if Doctors with extensive training and supervision can make mistakes, does it seem wise to then release nurse practitioners to independent practice after 2 years of online schooling?
        Do you know that many nurse practitioner programs do not even require any nursing experience or background?
        The respectable nurse practitioners in my time were trusted and seasoned nurses who knew the limits of knowledge and experience. The new crop of nurse practitioners tend to have limited to no experience, do all of their education online and make up the rest with arrogance – completely unaware of how little they know.
        Honor will be restored to the NP profession when the organization puts up a gate and some standards about who they let become independent practitioners. Right now it’s literally anyone.
        Also the best doctors are humble and know that they do not know everything. Many new crops of NPs are so limited in knowledge that the think they know everything.

  27. Wow, West coast I will stay. No one is trying to be a medical doctor. Rest assure when their shortage starts impacting care they will loosen their antiquated restrictions so NPs can practice their full scope

  28. @ Dr. Kel.

    Blah, blah, blah Dr. Kel!! If you were an actual doctor you wouldn’t have time to be on here bashing NP’s. Why don’t you just report the NP’s and PA’s from your everyday practice if there are so many diagnostic errors with inappropriate medication use resulting in deleterious medication complications and side effects? Maybe you’re making errors yourself!! Just because whatever the NP’s and PA’s decided to do for their patient is not what you would have done, doesn’t make it wrong!!!! We are all practicing medicine with a strong emphasis on practicing!!!! There is no exact answer all the time. The main focus should be the patient not how much shade can be thrown at the “midlevels”!!! Get a life!!!

  29. Anonymous and concerned

    For those quoting studies where np’s provide superior care that is more cost effective please reread your studies critically. These are highly flawed studies.

    It is called an advanced nursing degree, not a medical degree. Stop faking and portraying to the public that you can practice medicine independently. If you want to do that, go to medical school! How egotistical can you be to put such lies out there? Recognize your limitations and stop pretending to be physicians.

  30. Stop belly aching about the awful nurse practitioners who make mistakes – EVERYONE MAKES MISTAKES, MDs included! No one is perfect, it comes down to the individual provider. Some of you can put down NPs all you want, but who helps train your precious doctors when they’re in school and don’t know which end of a needle goes in the patient? NURSES & NURSE PRACTITIONERS! I’ve stopped doctors from making medication errors too many times to count. It comes down to the training, education, work experience and individual ability to admit you don’t know something and finding a resource for help when you need it. I have no problem telling a patient I’m not sure of something and want to do research before I proceed, or referring them to a specialist when an issue is beyond what can or should be handled by a primary care practitioner. Many people prefer to see nurse practitioners because NPs tend to be kinder to their patients and can actually demonstrate to their patients that they care about them as individuals and want to help them be their healthiest selves. I chose not to go to med school because I didn’t want to lose my ability to have compassion – most MDs I’ve come across are so full of themselves they treat patients like peasants who have been granted the honor of being treated by them; that might have a little something to do with the NP trend. Not everyone thinks being a doctor is such hot crap- get over yourselves.

  31. I am talking from a patient’s perspective, and from a future healthcare provider trying to decide which path to take. There is not a whole profession superior and better than the other. There are individuals in each profession that are great, and do a better job than many of the people in the “superior” or “inferior” professions. There are individuals in each profession that are so horrible that you wonder how they are still there. There are doctors who think they are so superior that they fail to see their errors and take patients lives or ruin patient’s lives in the process. A lot of doctors do things that should cost their license, but they keep practicing because anyone who decides to report them might lose their job/license instead, or reports go ignored. They continue practicing until they take one or more lives or someone sues the hospital. There are nurses that have horrible bedside manners, and/or do things that put patients at risk, and even kill patients. There are PAs that pretend they know everything, and order unrelated exams, missing the actual diagnosing, and putting people at risk. There are also doctors, nurses, and PAs, that are selfless, and are mature enough not to argue about who is superior or inferior and work as a team with their coworkers to give the best care to their patients. There are doctors that understand that other healthcare providers are needed, and that without them, patients would not survive/recover. They understand that those providers are as important as them, and are not inferior, but just have a different role in the patient care. As a patient I’ve had horrible doctors, ok doctors, and great doctors. I had a bad experience with a PA, and a great experience with a NP. I know enough to say that not all PAs are bad, and not all NPs are good. I also understand that doctors don’t know everything, and I shouldn’t blindly believe everything a doctor says, and accept every treatment they give. A patient’s care is a team work, everyone should be involved, including the patient. Doctors are not dictators who have the only say and everyone has follow others, and nurses are not followers that are only there to follow doctors’ orders without a say. Good healthcare providers know their limits, but also speak up when something doesn’t seem right, and put patient’s well being first. They also admit when they are wrong, and when to ask for help.


    As a APRN / FNP student. I am a Nurse, I never wanted or even considered to be a doctor. My dream was nursing. The connections, heart to heart and being able to take care of a person holistically is what motivates me as a bedside nurse , manager of team and even an instructor. I have worked with many phenomenal physicians, NP /PA’s Nurses and CNA’s. We as a cohesive team is what patient care is all about. I have a lot to learn, I never compare my self to a “doctor” or will ever ” mislead” anyone into thinking that is what I am as a future NP (god willing). I will do my best to apply myself, knowledge, and know when to recognize when my abilities or the ability to treat a patient requires physician treatment / collaboration or referral. I think when you take a step out of your “titles” or “ego” for that fact,you can see that WE ARE ALL HUMAN, WE ARE ALL INTERCONNECTED and OUR KNOWLEGDE, SKILLS and EXPERIENCES ARE UNIQUE and when we can put the best talents out there to better serve our patients then that is what truly matters. Practice with competence, evidence, humility and compassion. MD’s stop bashing our NP’s they are here to take care of patients to provide a service to our community. Learn to appreciate them and know that the knowledge of the MD is not with any competition as we learn from you, grow with you as a fundamental TEAM. I decided to advance my role not try to take over yours and it’s not as simple as “well you should have just gone to medical school then”. I went to nursing school because you (MD) believe it or not I wouldn’t have had it any other way!

  33. marylou buttocks

    To all you Physicians out there. You are full of shit!! I was a FT floor (IMC/ICU) RN for over 25 years before becoming a NP. After graduation, I was hired by a dirtbag MD, who had 35-40 patients scheduled a day-for me to see, while he would go off on golf trips, cruises and traveled around the world. He never gave a crap about his patients, who were mostly poor and uneducated, and non English speaking. He was not always accessible by phone. I had to go on Uptodate, or call physician friends, if I had any concerns. I probably made the office over $3000.00 a day, as I also did Derm & advanced wound care. My pay was $375.00 a day after taxes. THIS IS WHY YOU SHs REFUSE TO GIVE AUTONOMY TO NPs IN CALIFORNIA. You don’t want to give up your cozy, little money train. DISGUSTING!!! Can’t wait to leave Commiefornia!!!!! and the 3rd Reich AMA.

    1. I’m a Doctor, my wife is becoming an NP, soon, Feb. 2021, then off to DNP. When I was studying for my “USMLE”, Step I & II, she knew a lot & learned it with ease!! It stuck in her head better then it did with me, because she’s practiced Nursing for over 10 yrs. This is because many NP programs wont let you into the program w/out having a minimum Nursing practice for 5 yrs. can say, she knows more then any resident I’ve trained and more than many Dr.’s I knew !! NP’s are JUST AS GOOD AS WE, Dr.’s are. Make NP’s full pledged Medical Providers, w/out physicians collaboration, as most Patient’s care is clinical. Nurses & NP’s have many years of training behind them & that is sufficient enough to take of care family medicine since it’s the same routine over and over!! STOP THE IMPORTATION OF FOREIGN DOCTORS as Americans are sick of it. Make NP’s FULL PLEDGED MEDICAL CARE PROVIDER, N O W !!!

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  36. Awesome stuff. Please keep writing more things like this. I really like the fact you went so in depth on this and really explored the topic as much as you did. I read a lot of blogs but usually, it’s pretty shallow content. Thanks for upping the game here!

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