You statement that "Most" states require a written collaborative agreement may be misleading. It is much more complicated than that. Personally, I would emphasize the independent practice in 22 states.
Which states allow APRNs to independently deliver a broad range of services?
The scope of practice for APRNs varies widely by state and specialty. For example, in the case ofnurse practitioners (NPs), the most numerous of APRN roles, 22 states and DC allow NPs to diagnoseand treat without physician involvement: (AK, AZ, CO, HI, ID, IA, KY, ME, MI, MT, NH, NJ, NM, ND,OK, OR, TN, UT, WA, WV, and WY. In contrast, 24 states require a formal relationship, documentedin writing, between an NP and a physician: (AL, AR, CA, DE, FL, GA, IL, KS, LA, MD, MA, MS, MO, NE,NV, NY, NC, OH, SC, SD, TX, VT, VA, and WI.) This relationship requirement varies from state to stateand could call for supervision, delegation, authorization, or more general direction andcollaboration. The remaining 4 states also require some form of relationship between NPs andphysicians, but do not require documentation of such relationship: CT, IN, MN, and PA. When itcomes to prescriptive authority, only 13 of the 23 jurisdictions that allow autonomous practice byNPs allow them to prescribe medications for diagnosis and treatment without the involvement of aphysician: AK, AZ, DC, ID, IA, ME, MT, NH, NM, OR, RI, WA, and WY. The remaining 38 states allrequire documented physician involvement for NPs to be able to prescribe medications.
In the case of certified nurse-midwives, 18 jurisdictions allow CNMs to diagnose and treat withoutrequiring physician supervision or formal collaborative agreements; other states vary as torequirements for physician involvement. All states confer prescriptive authority to CNMs, although11 require physician involvement.
For certified registered nurse anesthetists (CRNA) the ability to provide anesthesia in hospitals andoutpatient settings without supervision is controlled by both state and federal regulations. Stateregulations have to allow CRNAs to practice in hospitals and outpatient settings without supervisionfrom physicians, and the state must also opt out of federal Medicare requirements for physician
supervision (otherwise hospitals will not be reimbursed for CRNAs’ services). Currently, 16 stateshave state laws that do not require CRNAs to be supervised and have opted out of the federalsupervision requirements; other states either do not allow CRNAs to practice without supervision bya physician or have not opted out of the federal Medicare requirement for physician supervision ofCRNAs.