UP FRONT
Advanced Practice Perspectives
states mandate that the APRN have a
documented formal relationship with a
physician and that this relationship be
renewed annually, although institutions
can delineate the extent of physician
involvement.
• Seven states are restrictive in practice
authority, requiring the APRN to have more
direct physician oversight in patient care.
• The remaining three states – Nebraska,
New York, and Connecticut – are currently
in various stages of allowing APRNs the
autonomy to practice without physician
supervision.
Because of the heterogeneity
of each state, it is best to refer
to the American Association
of Nurse Practitioner’s State
Regulatory Map to learn
more about state-specific
regulations. Scan the QR code, or visit www.
aanp.org/legislation-regulation.
The Scope of Practice for PAs
Similar to APRN practice, state laws and
regulations also guide PA practice. According to
the American Academy of Physician Assistants,
all states require PAs to practice under a
physician’s supervision, but as with APRNs, the
FIGURE 2.
extent of the relationship varies from state to
state (FIGURE 2). Six key elements are mandated
to be part of every state PA practice act:
1. Licensure:
How does a state authorize PAs to practice?
2. Scope of practice determined at the
practice site:
State laws determine the extent of the PA’s
autonomy or need for supervision.
3. Adaptable supervision requirements:
PAs, similar to most APRNs, must have
a supervising physician available. Some
states require on-site supervision, while
others allow telecommunication in certain
circumstances.
4. Full prescriptive authority:
All PAs are required to complete extensive
training in pharmacology, but some states
allow physicians to delegate prescriptive
authority (for example, PAs may even
prescribe chemotherapy and controlled
substances in some cases).
5. Chart co-signature requirements
determined at the practice:
Some physician-PA teams use co-signature
to ensure that the supervising physician is
providing oversight, but this may or may not
be required depending on the practice site.
Number of Key Elements Included in State PA Law
THE COMPLEXITIES OF
WHAT AN APRN CAN
DO VARY GREATLY
FROM STATE TO STATE.
6. Number of PAs a physician may supervise
determined at the practice level:
The supervising physician may decide the
appropriate number of PAs to supervise,
depending on the specialty and clinical
setting.
To learn more about the six
key elements of PA practice
and specifics of your state,
scan the QR code or visit
www.aapa.org.
So, What Can We Do?
As you can see, the complexities of what an APRN
can do vary greatly from state to state, and by
institution. Astute APPs and physicians will learn
the state- and institution-specific regulations and
work together to the full extent of the law.
So, when my patient asked me if I, as an
APRN and PhD, could replace his medical
oncologist as an “official doctor,”
there were many factors to take into
consideration. I had to respond:
“I appreciate your confidence
and the trust you have in me as
your provider. And, frankly, I am
honored that you want me to be
in charge of your care. However,
although I have been well-trained
as a hematology/oncology
practitioner, I do not have a medical
doctorate but a research doctorate.
I am not a medical doctor. We –
the treatment team – all play an
important role in your care. Your
medical oncologist, the other team
members, and I will continue to
work together as we have all these
years, to provide you with the best
care we can.”
“That sounds good,” he replied.
“I’m just glad you aren’t leaving the
hospital.” ●
references
1. American Association of Nurse Practitioners. “State Practice Environment.” Accessed
from www.aanp.org/legislation-regulation/
state-legislation-regulation/state-practiceenvironment.
Reprinted with permission from the American Academy of Physician Assistants (AAPA)
14
ASH Clinical News
2. American Academy of Physician Assistants.
“Six Key Elements.” Accessed from www.aapa.
org/threecolumnlanding.aspx?id=303.
January 2015