Full vs Reduced vs Restricted Scope of Practice- Do you feel it?

[Myec]

Hi all,

I hope you all had/ are having a safe and restful holiday break.

This question was on my mind for a while as a NP student— how does each state’s various scope of practice affect daily clinical practice among NPs? (https://campaignforaction.org/resource/state-practice-environment-nurse-practitioners/). 

My answer I gathered from a couple of NP friends in outpatient setting was pretty generic so far — besides experiences, it depends on where you work and whom you work with, not just on the scope of practice defined by each state board of nursing. To get broader real-world perspectives from NPs in different states, I would like to ask you to share your thoughts on this question: 

For those who work in the state with “Restricted/ Reduced practice”, do you feel the scope of practice limits building your career or just add extra administrative tasks( e.g., getting cosignatures from attending physicians on miscellaneous orders)? 
 

For those who work in the state with “Full practice”, how does working in full autonomy look and feel like? Have you felt feeling asking for guidance/advice from MD colleagues was somewhat limited due to the scope of practice? 
 

It would be helpful to know what settings you work in and its impact on different stage of your career (a new grad vs after some experiences) to gauge your perspective better. 

Thank you very much for sharing in advance! 
 

- A primary care NP student-

 

[djmatte, ADN, MSN, RN, NP]

I technically work in a restricted state (Michigan).  For the majority of my work, I am autonomous in my daily tasks and patient interaction.  In actuality my collaborator isn't even in my specific clinic (we have 4) and likely only "reviews" charts with the push of a button.  I do however share patients with other MDs in our clinic and I do utilize them for input; especially for patients they see more regularly.  But this comes more in the form of colleague information sharing and "brain picking" more than a more paternal relationship.  Many of those same MDs come to me for patients they see less of to gauge my plans or intentions as well.  Nobody at the end of the day is going to over-ride my clinical decisions because there is no realistic way of doing that.

On that note, I do WANT more independent practice in this state for my own simple ambitions.  I see areas where I can go out on my own to provide care to communities that might benefit in ways that are less traditional (note private pay situations).  I think I can manage the types of patients I see that minimize my risk as a clinician.  Even setting this idea up on the side as a part-time endeavor is an impossibility in our current environment.  We do prescribe non-scheduled drugs under our license in the state, but the collaborative agreement falls under that still.  So if I wanted to go it alone in say a personal tele-health situation, I would still need either my current collaborator or a second one to work in some supervisory capacity.

[verene, MSN]

I work in a full practice state. While legally I could do something crazy like open my own private practice out the gate after boards, I intentionally chose to work inpatient because of the resources available to me.

A little surreal to be an attending NP right out the gate, but my co-attending is an NP with about 20 years of experience. We are actually the only unit in the hospital that has both Attendings as NPs and not a physician/NP combo.

The major differences between what I can do and what a physician can do in my setting are:

1) Medical management - I work psych and while our psychiatrists can write for some of the medical orders, PMHNPs are really limited by our scope. That said, we have an in-house medical team, so it's usually not a big deal (and most of the psychiatrists will defer to medical as well for anything other than the most routine stuff) and the internist assigned to my unit is AWESOME and super collaborative.

2) Call duties - NPs don't take call at all, physicans take voluntary call. Should I be upset that I don't have work work nights and/or holidays? (Not really!).

3) I work with forensic population and patients with the most serious crimes/charges are not assigned to PMHNPs. This is more due to the fact that these cases are more likely to end up in federal court in the future, and the Judges there much prefer to hear from psychiatrists.  So this means I'll never have to testify in federal court related to an aggravated murder case. (Again, is this something I should feel really upset by? No, not particularly.)

My practice setting is SUPER collaborative, so there really isn't any issue with going to either NP or physician (or other specialty) colleagues for a case consult. Consultation is just part of the culture - you pick the brain of whoever is around and/or subject matter experts depending on case.

My supervisor is an MD which is mostly happenstance (we also have supervising NPs), and is Pro-NP practice (as is our Chief of Psychiatry and our CMO). I feel that they really have my back when I need it. (Like super complicated case I had recently which required a rather non-standard plan of care where both my supervisor and Chief came and assessed patient with me and threw notes into the patient chart that they agreed with the plan of care to really back up that this was a very collaborative, thoughtful and intentional decision which was in the patient's best interests - so that should anyone throw a fit down the road, I'm not left holding all the liability myself).

 

[PaulL]

On 12/28/2020 at 12:01 PM, djmatte said:

On that note, I do WANT more independent practice in this state for my own simple ambitions.  I see areas where I can go out on my own to provide care to communities that might benefit in ways that are less traditional (note private pay situations).

Super interesting that you want to do something like this. I feel extending care into medically underserved areas/populations is one of the primary benefits of allowing independent practice for NPs.

[FullGlass, BSN, MSN, NP]

I am in California, and have never received any meaningful MD supervision.  So it is just absurd to hang on to this.  I am practicing independently in every sense of the word, except for the legal.  If I move to another state, I will only move to a state with IPA.

[myoglobin, ASN, BSN, MSN]

I work in Washington state and have been completely IP since graduation. I would not have it any other way.