Does Working in an Independent Practice State Really Affect Your NP Job?

I’ve had several nurse practitioners tell me they will only work in independent practice states. That is, states whose scope of practice laws don’t require nurse practitioners to be supervised by or collaborate with a physician. While I understand the position of these NPs, they are capable of treating patients without oversight, I have to wonder – does working in an independent practice state actually change what a nurse practitioner’s day-to-day job looks like?

Scope of practice laws govern the way nurse practitioners work. They outline what services they’re allowed to provide and how NPs are allowed to prescribe. In most states, these regulations specify that a certain amount of physician oversight is required for an NP to practice, prescribe, or both. Until recently, for example, nurse practitioners in Florida were not permitted to prescribe certain controlled substances. In contrast, NPs practicing in states like New Mexico are allowed to work completely free of physician oversight. Most states fall somewhere between these scope of practice extremes. In Tennessee where I live and work, a physician must sign just 20 percent of my charts, to name one more moderate example. 

Given the breadth of scope of practice laws, you can see why nurse practitioners seek out states with independent practice provisions. Working under a host of regulations surrounding physician oversight seems limiting and cumbersome. In theory, these NPs’ concerns seem well founded. But, in practice do their hesitations about working in states with restrictions pan out? It depends. 

One major concept that nurse practitioners with scope of practice concerns often fail to consider is that the vast majority of employers maintain their own set of practice rules. In the hospital where I work, for example, institutional policy says that physicians must sign 100% of NP’s charts even though state law mandates that just 20% of charts be reviewed by an MD. Employer policies like these may be motivated by legal concerns or billing considerations. Whatever the reason, very few employers allow nurse practitioners to truly work independently. Even NPs who work autonomously in a clinical sense will still be managed by administrators and have a set of policies and procedures they’re required to follow. 

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Sure, adding state regulations to facility policy means two sets of hoops to jump through rather than one, however nurse practitioners fixated on independent practice are often idealistic in their views. In most cases independent practice law doesn’t translate to working free of oversight.

While overall I disagree that independent practice should be the ultimate consideration when it comes to practice location, I do agree that it affects an NP’s day-to-day in the most restrictive cases. Limitations on the type of medications NP may prescribe, for example, are inconvenient and require more work on the part of healthcare providers to accommodate. Restrictions requiring that a physician be present on site with the NP or practice within a certain distance do create real logistical challenges. But, once you reach a certain level of autonomy, state supervisory requirements go unnoticed by nurse practitioners in most settings. A requirement that the supervising physician review a few charts, for example, would likely be required by an employer regardless of state law. 

Finally, it is important to note that I’m referencing the day-to-day job description of nurse practitioners here. Scope of practice regulations impact NP salaries and the job market. However, I don’t see a major difference in the overall job description of NPs in the majority of states regardless of scope of practice laws. 

Do scope of practice laws affect your day-to-day as a nurse practitioner? Will you only work in independent practice states?


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