Sooner or later, most people will need a prescription medication. For example, patients may need prescription antibiotics to avoid infection after surgery. They may also need prescriptions to help manage their diabetes symptoms, to control their blood pressure, or simply to cope with the effects of seasonal allergies.
A common question about nurse practitioners is whether they have the authority to prescribe medications or need approval from a supervising physician. The issue of whether nurse practitioners can prescribe is closely related to other questions about scope of practice that aspiring advanced practice nurses often ask.
The American Nurses Association defines scope of practice as the services that a qualified health professional is capable of competently performing, in keeping with the terms of their professional license. Addressing questions about scope of practice is an important step for nurses who are interested in advanced practice roles, including those who are studying in a BSN to DNP program.
1. What Are the Levels of Scope of Practice?
For nurse practitioners, scope of practice involves much more than just the ability to prescribe medications. Scope of practice defines the duties and responsibilities they are legally allowed to carry out, based on their license in their state of practice. As a general rule, advanced practice nurses, including nurse practitioners, enjoy a broader scope of practice than registered nurses but a more limited scope of practice compared with physicians.
In any particular state, a nurse practitioner may be given one of three scope of practice levels by the nursing board:
- Full practice
- Reduced practice
- Restricted practice
Differences between levels can be substantial and affect a nurse practitioner’s permission to perform certain medical procedures.
Full Practice
Full practice denotes the broadest, most permissive scope of practice for nurse practitioners. Nurse practitioners who are allowed full practice have the authority to:
- Evaluate and assess patients
- Make diagnoses
- Order and interpret diagnostic tests
Can nurse practitioners prescribe medications when they have full scope of practice? Yes, depending on the state: States that allow full practice authority for nurse practitioners permit these health care professionals to prescribe medication as needed.
Reduced Practice
In a reduced practice environment, nurse practitioners are permitted by the nursing board to perform at least one of the duties outlined under full practice. For example, in some states, a reduced practice nurse practitioner may either prescribe medications or interpret diagnostic tests — or, in some cases, do both.
Primary distinctions between reduced practice and full practice is that in a reduced practice, nurse practitioners must enter into a regulative, collaborative agreement with a physician in order to administer patient care. This does not mean that the physician must micromanage or sign off on every decision the nurse practitioner makes, but the relationship has a supervisory component.
Restricted Practice
The third scope of practice level for nurse practitioners is restricted practice, and the level of oversight required can be quite different. Specifically, nurses in a restricted practice must work in a collaborative and supervisory relationship with a physician throughout their careers in order to provide patient care.
Additionally, nurse practitioners who work in a restricted practice are expressly prohibited from engaging in at least one of the duties allowed by full practice; often, this means that nurse practitioners are not allowed to prescribe medications to their patients.
Dictating Scope of Practice
The specifics of scope of practice can vary from one state to the next, as they are set and outlined by each state’s nursing board. The best way to learn more about scope of practice in a specific state is to consult the corresponding nursing board.
2. Who May Write a Prescription?
Prescription medications can be vital for patient health. Improper dosage, or prescription without taking into account interactions between different medications, can be highly dangerous, even life-threatening. Because of these risks, substantial education is required in order to be allowed to prescribe medication.
Registered nurses (RNs) don’t have authority to write prescriptions, and neither do licensed practical nurses (LPNs). In fact, an advanced practice registered nurse (APRN) is the only nursing level qualified to prescribe and administer prescription medication, and even this can vary from one state to the next, depending on how that state’s nursing board defines scope of practice.
Nurses and Prescription Writing
Clearly, the term nurse may denote a number of levels of practice. However, when the average patient uses the term nurse, what they really have in mind is an RN.
RNs have completed a nursing degree at either the associate or bachelor’s level, and in some cases, they may even have a Master of Science of Nursing (MSN). In addition, they have passed a licensing exam administered by their state’s nursing board to hold a valid nursing license.
RNs typically practice as part of a broader clinical care team and may have duties that include checking vital signs, educating patients, updating patient records, and providing wound care. RNs may also administer medications as prescribed by the attending physician, but no state permits them to write prescriptions.
Nurse Practitioners and Prescription Writing
Nurse practitioners have at least an MSN and often have advanced certifications. For example, they may earn certifications denoting specialized experience in mental health care, pediatric care, or trauma care. They also have additional years of clinical experience, and their licenses allow them to offer higher levels of patient care.
As such, nurse practitioners often work more independently and autonomously than RNs. They can perform all the functions that an RN can, but depending on the state, they may also be able to order X-rays and other diagnostic tests, counsel patients, and even write prescriptions.
Why Nurse Practitioners Can Prescribe
A nurse practitioner's authority to prescribe medications is directly connected to their advanced level of training, which involves learning how to:
- Diagnose patient conditions
- Assess symptoms
- Recommend appropriate prescriptions
As part of their advanced training, nurse practitioners participate in clinical simulations where they learn more about pharmacology and the ways medications interact with each other. Advanced practice nursing students also receive training in overseeing the safe use of medications, enabling them to assess patient risk factors and make informed decisions about dosages.
This level of education is more sophisticated than what undergraduate nursing students receive, and it is the basis for a nurse practitioner’s prescriptive authority.
3. Can a Nurse Prescribe Antibiotics?
Antibiotics rank among the most commonly prescribed pharmaceuticals. They are often recommended for patients who are battling infections, but they are also used in preventive care. For instance, antibiotics are often prescribed for patients before and after surgery, significantly minimizing the risk of an infection that could complicate recovery.
Nursing students may wonder about their autonomy to prescribe antibiotics to patients in need. Registered nurses are not allowed to prescribe antibiotics because they do not have the training to do so safely. Overprescribing antibiotics can have dangerous effects for a patient’s immune system, digestive health, and more.
Advanced practice nurses, including nurse practitioners, may or may not have authority to prescribe antibiotics, either with or without the supervision of a collaborating physician. Again, this authority is tied to the nurse practitioner’s scope of practice in their state.
4. How Does Scope of Practice Vary by State?
People who want to become advanced practice nurses should bear in mind that the scope of practice granted to them can vary widely from one state to the next — with some states proving quite stricter, while others are more permissive. Variations in scope of practice can impact a nurse practitioner’s career in a number of ways, not least their prescription power.
As an example, Florida does not permit nurse practitioners to diagnose or to treat patients unless a physician is present to supervise. By contrast, Washington state permits nurse practitioners to diagnose, treat, and even prescribe medications, including medical marijuana.
Case Study: Scope of Practice in Washington State
Washington is a good example of how scope of practice can be precisely defined within a given state, with different medical and nursing licenses affording varying levels of prescription autonomy. For example, in Washington:
- Nurse practitioners enjoy a full scope of practice, meaning they can prescribe medications without any restrictions.
- Osteopathic physician assistants, or OAs, can prescribe medications but only when they have approval from the Board of Osteopathic Medicine and Surgery.
- A certified registered nurse anesthetist can prescribe only from a specific list of pharmaceuticals, namely those that are used in the sedation or anesthesia process.
- Dentists face no restrictions or limitations on their prescribing power.
- Optometrists can prescribe certain types of medications but have limitations on what types of drugs they may prescribe; for example, they are not permitted to prescribe oral steroids.
- A physician assistant can prescribe medications, pending approval from the Washington Medical Commission.
- Veterinarians can prescribe for animals only — never for humans.
These details highlight how the scope of practice can vary by license, even within a single state. To complicate matters even further, other types of health care professionals may provide patients with medications under the guidance of a physician.
For example, a dental hygienist may administer certain topical or local anesthetics when authorized to do so by a dentist. Advanced practice nurses may delegate drug administration power to home care aides — but only in certain scenarios, including home-based or community-based care.
States That Allow Nurse Practitioners to Prescribe Medications
Nurses and nursing students interested in advanced practice nursing benefit from knowing about how the scope of practice, and specifically prescriptive authority, varies by state. As of March 2022, all 50 states allow nurse practitioners prescriptive authority. The question is whether nurse practitioners can prescribe with full autonomy or require supervision from a collaborating physician.
In most states, nurse practitioners do not need a physician’s supervision to prescribe pharmaceuticals. The states in which nurse practitioners do require supervision from a physician in order to prescribe are:
- Arkansas
- California
- Indiana
- Kentucky
- Maryland
- Massachusetts
- Michigan
- New Jersey
- Oklahoma
- Texas
- West Virginia
In some other states, registered nurses have authority to dispense particular medications, usually contraceptives or treatments for sexually transmitted infections; typically, this is allowed only in the context of a public health clinic. As of March 2022, 16 states allow RNs limited power to dispense these types of medications.
5. Can Nurses Prescribe Controlled Substances?
For nursing professionals, prescription power may be further understood in terms of different categories of narcotics. For example, some medicines are considered to be "controlled substances," which may be further broken down into five categories, or schedules. Thus, controlled substances can all be categorized as Schedule I through Schedule V drugs.
Substances that fall into Schedule I are considered to be the most dangerous in terms of their risk of abuse and addiction. They are considered to be so risky, in fact, that the Drug Enforcement Administration (DEA) does not consider Schedule I drugs to be suitable for medical use in any context.
By contrast, Schedule V drugs encompass medications such as codeine for coughs and phenylephrine for congestion. While these substances have some level of risk for abuse or addiction, that risk is not considered to be severe. And, in many cases, the medical benefits of Schedule V drugs may outweigh the minimal risks. As such, these medications may sometimes be prescribed in medical contexts.
Nurse Practitioner Scope of Practice and Controlled Substances
Controlled substances are drugs that have some proven medicinal qualities but also some addictive properties and are thus carefully regulated by the government. In most states, a nurse practitioner’s scope of practice authorizes them to prescribe some types of controlled substances. The only exceptions are Alabama and Florida, which currently do not allow nurse practitioners to prescribe them in any context.
In states that do allow nurse practitioners to prescribe controlled substances, the specifics can vary quite a bit. For example, some states may allow nurse practitioners to prescribe a Schedule II medication, such as Adderall, to a patient who presents symptoms of ADHD. In another state, the nurse practitioner may need a supervising physician to sign off on this prescription.
As with all other facets of scope of practice, individuals who wish to become advanced practice nurses will want to study the guidelines issued by their state of practice.
Accelerate Your Career With a Quality Nursing Education
Prescription medications play an important role in patient care. Nurses who wish to prescribe medications as part of patient care will need to obtain formal clinical training.
The online BSN to DNP program from Hawai‘i Pacific University allows BSN-credentialed nurses to build on their current skills and competencies as they earn their Doctor of Nursing Practice, helping to prepare them to achieve their professional goals.
Hawai‘i Pacific University’s program, which can be completed in as little as 34 months, offers many courses directly related to prescribing medication, including Advanced Pathophysiology and Advanced Pharmacology. Discover how you can advance your nursing career while helping people who need it most.
Recommended Reading:
Patient Rights and the Essential Role of Nurses
10 Effective Nursing Communication Skills for Nurse Leaders
The Importance of a Nurse’s Role in Patient Safety
Sources:
American Nurses Association, "Scope of Practice"
Guttmacher Institute, "Nurses’ Authority to Prescribe or Dispense"
Incredible Health, "Nurse Practitioner Scope of Practice by State for 2022"