Research · 8 min read
What a Nurse Practitioner Needs Before Prescribing Without a Physician Agreement
One state converts a written agreement into an independent license after a stated amount of experience and an attestation from the physician who signed it. Another keeps the agreement in place and caps how many practitioners one physician may cover.
Key takeaways
- Virginia's default under Code section 54.1-2957 is a written or electronic practice agreement with at least one patient care team physician, and the exception is recorded as a designation on the license itself.
- Virginia's route out requires the equivalent of at least three years of full-time clinical experience plus an attestation with stated contents from the physician or a qualifying nurse practitioner.
- Independence in Virginia is bounded: practice within training and knowledge, consult and collaborate based on clinical conditions, and maintain a referral plan for complex cases and emergencies.
- Virginia's prescriptive authority section makes it unlawful to prescribe controlled substances unless authorized by the practice agreement or by the independent-practice designation.
- The numerical caps differ: Virginia allows a physician six advanced practice registered nurses, or ten in the psychiatric-mental health category; California allows a physician and surgeon four nurse practitioners.
- California's section 2836.1 defines supervision as excluding physical presence but including collaboration on and approval of the standardized procedure and availability by telephonic contact at the time of patient examination.
Answer first: the default is a written agreement, and one state has an exit from it
Virginia Code section 54.1-2957 states the default in plain terms. Every nurse practitioner who does not meet the requirements of a later subsection shall maintain appropriate collaboration and consultation, as evidenced in a written or electronic practice agreement, with at least one patient care team physician. A nurse practitioner who meets the requirements of that subsection may practice without a written or electronic practice agreement.
The section also requires the license itself to be joint. The Board of Medicine and the Board of Nursing shall jointly prescribe the regulations governing the licensure of advanced practice registered nurses, and it is unlawful for a person to practice as an advanced practice registered nurse in the Commonwealth unless he holds such a joint license.
So in Virginia there are two states of affairs, not one, and which one a given clinician is in is recorded on the license rather than inferred from a job title. That is a fact a consumer-facing page rarely conveys, and the phrase nurse practitioner does not carry it.
California's structure is different. Business and Professions Code section 2836.1 provides that nothing in the nursing chapter or any other provision of law shall be construed to prohibit a nurse practitioner from furnishing or ordering drugs or devices when a list of conditions all apply, and the first of those conditions is that the drugs or devices are furnished or ordered in accordance with standardized procedures or protocols developed by the nurse practitioner and the supervising physician and surgeon.
What Virginia's practice agreement has to contain
Virginia does not leave the content of the agreement to the parties. Section 54.1-2957 directs the Boards of Medicine and Nursing to jointly promulgate regulations specifying collaboration and consultation among physicians and advanced practice registered nurses working as part of patient care teams, and then names what those regulations must include.
They must include the development of, and periodic review and revision of, a written or electronic practice agreement; guidelines for availability and ongoing communications that define consultation among the collaborating parties and the patient; and periodic joint evaluation of the services delivered.
The statute then states two provisions that practice agreements themselves shall include: periodic review of health records, which may include visits to the site where health care is delivered, in the manner and at the frequency determined by the advanced practice registered nurse and the patient care team physician; and input from appropriate health care providers in complex clinical cases and patient emergencies, and for referrals.
Evidence of a practice agreement shall be maintained by the advanced practice registered nurse and provided to the Boards upon request. For those providing care within a hospital or health care system, the practice agreement may be included as part of documents delineating clinical privileges or the written or electronic delineation of duties and responsibilities in collaboration and consultation with a patient care team physician.
The statute also allows the collaboration itself to happen remotely. Collaboration and consultation among advanced practice registered nurses and patient care team physicians may be provided through telemedicine as described in the cited insurance section.
One further provision deals with the failure case. Where a patient care team physician dies, becomes disabled, retires from active practice, surrenders or loses a license, relocates, or is otherwise unable to serve, and the nurse cannot enter into a new agreement, the nurse may continue to practice upon notification to the Boards' designee for an initial period not to exceed sixty days, provided the nurse continues to prescribe only those drugs previously authorized by the agreement and continues to have access to appropriate input from health care providers in complex cases, emergencies, and for referrals.
Virginia's route out is an experience threshold plus an attestation
Section 54.1-2957 sets out what a nurse practitioner must have accumulated before the agreement requirement falls away, and the mechanism is an attestation from the person who was supervising.
A nurse practitioner who has completed the equivalent of at least three years of full-time clinical experience, as determined by the Boards, may practice in the practice category in which he is certified and licensed without a written or electronic practice agreement, upon receipt of an attestation from either the patient care team physician or an attesting nurse practitioner who has met the same requirements for at least three years.
The attestation has stated contents. It must state that the attesting physician or nurse practitioner served on a patient care team with the nurse practitioner pursuant to a practice agreement meeting the section's requirements; that while a party to that agreement, the attesting person routinely practiced with a patient population and in a practice area included within the category for which the nurse practitioner was certified and licensed; and the period of time for which they practiced together under that agreement.
The section defines the experience it is counting. Clinical experience means the postgraduate delivery of health care directly to patients pursuant to a practice agreement with a patient care team physician.
On receipt of the attestation, a fee, and verification, the Boards shall issue a new license that includes a designation indicating that the nurse practitioner is authorized to practice without a practice agreement. Where a nurse practitioner cannot obtain the attestation, the Boards may accept other evidence under regulations they adopt.
The independence that follows is bounded by three duties written into the same subsection. A nurse practitioner authorized to practice without a practice agreement shall only practice within the scope of his clinical and professional training and the limits of his knowledge and experience and consistent with the applicable standards of care; shall consult and collaborate with other health care providers based on the clinical conditions of the patient; and shall establish a plan for referral of complex medical cases and emergencies to physicians or other appropriate health care providers.
California keeps the standardized procedure, and defines supervision by what it does not require
California's section 2836.1 lists conditions that must all apply before a nurse practitioner may furnish or order drugs or devices, and reading them together shows how differently the state has structured the same problem.
The nurse practitioner must be functioning pursuant to a standardized procedure, as defined in the cited section, or a protocol, developed and approved by the supervising physician and surgeon, the nurse practitioner, and the facility administrator or the designee. The standardized procedure covering the furnishing of drugs or devices shall specify which nurse practitioners may furnish or order drugs or devices, which drugs or devices may be furnished or ordered, under what circumstances, the extent of physician and surgeon supervision, the method of periodic review of the nurse practitioner's competence including peer review, and review of the provisions of the standardized procedure.
Supervision is then defined by what it does and does not demand. The furnishing or ordering of drugs or devices by a nurse practitioner occurs under physician and surgeon supervision. Physician and surgeon supervision shall not be construed to require the physical presence of the physician, but does include collaboration on the development of the standardized procedure, approval of the standardized procedure, and availability by telephonic contact at the time of patient examination by the nurse practitioner.
Availability by telephonic contact at the time of patient examination is the operative content of that supervision. It is not presence, and it is not review afterward.
California states its own numerical cap in one sentence: for purposes of the section, no physician and surgeon shall supervise more than four nurse practitioners at one time. Virginia's cap for a patient care team physician is six, or ten in the psychiatric-mental health category. Same concept, different numbers, different states.
The scheduled drugs carry extra conditions in California. Drugs or devices furnished or ordered may include Schedule II through Schedule V controlled substances under the state's controlled substances act, limited to those agreed upon by the nurse practitioner and physician and specified in the standardized procedure. Where Schedule II or III controlled substances are furnished or ordered, they shall be furnished or ordered in accordance with a patient-specific protocol approved by the treating or supervising physician, and a copy of the relevant section of the standardized procedure shall be provided on request to any licensed pharmacist who dispenses, where there is uncertainty about the nurse practitioner's order. For Schedule II protocols specifically, the provision for furnishing shall address the diagnosis of the illness, injury, or condition for which the substance is to be furnished.
California also requires a pharmacology qualification: the board must have certified under the cited section that the nurse practitioner has satisfactorily completed a course in pharmacology covering the drugs or devices to be furnished or ordered.
Behind all of this sits section 2836, which directs the California board to establish categories of nurse practitioners and standards for nurses to hold themselves out as nurse practitioners in each category, taking into account the advanced levels of nursing practice performed and the clinical and didactic education outlined in the referenced national core competencies, or a successor approved by the board. The categories are set by the board, which is why the answer to what a given nurse practitioner may do is found on a license and in a standardized procedure rather than in a job title.
Sources
- Code of Virginia section 54.1-2957 — Licensure and practice of advanced practice registered nursesThe definition of clinical experience; the joint licensure requirement and the unlawfulness of practicing without a joint license; the default practice agreement requirement and the alternative for those meeting the independence requirements; the contents the Boards' regulations and the practice agreements themselves must include; the maintenance and production of evidence of an agreement; the permission for collaboration and consultation through telemedicine; the sixty-day continuation provision when a patient care team physician can no longer serve; and the three-year experience threshold, the attestation and its stated contents, the issuance of a license with an independence designation, and the three duties bounding practice without an agreement.
- Code of Virginia section 54.1-2957.01 — Prescription of certain controlled substances and devices by licensed advanced practice registered nursesThe grant of authority to prescribe Schedule II through Schedule VI controlled substances and devices; the requirement that a nurse who has not met the independence requirements prescribe only as authorized by a written or electronic practice agreement stating the prescriptive practices and the substances authorized or not authorized; the signature or naming requirement for the patient care team physician; the statement that prescribing outside those conditions is unlawful; the disclosure to the patient at the initial encounter and the disclosure of the patient care team physician's name and contact information on request; and the caps of six advanced practice registered nurses, or ten in the psychiatric-mental health category.
- California Business and Professions Code section 2836.1 — furnishing or ordering drugs or devices by a nurse practitionerThe conditions that must all apply before a nurse practitioner may furnish or order drugs or devices; the requirement of standardized procedures or protocols developed and approved by the supervising physician and surgeon, the nurse practitioner and the facility administrator or designee; the stated contents of the standardized procedure covering furnishing; the definition of physician and surgeon supervision as not requiring physical presence but including collaboration on and approval of the standardized procedure and availability by telephonic contact at the time of patient examination; the cap of four nurse practitioners per supervising physician and surgeon; the Schedule II through V limits, the patient-specific protocol requirement for Schedule II and III, the Schedule II diagnosis requirement, and the pharmacist copy provision; and the board pharmacology certification requirement.
- California Business and Professions Code section 2836 — nurse practitioner categories and standardsThe direction to the board to establish categories of nurse practitioners and standards for holding oneself out as a nurse practitioner in each category, taking into account advanced levels of nursing practice and the clinical and didactic education outlined in the referenced national core competencies or a board-approved successor.
Frequently asked questions
Does a nurse practitioner always need a physician agreement to prescribe?
It depends on the state and on the individual license. Virginia Code section 54.1-2957 requires a written or electronic practice agreement with at least one patient care team physician unless the nurse practitioner meets the requirements for practicing without one, in which case the Boards issue a license carrying a designation to that effect. California's section 2836.1 permits furnishing or ordering drugs only where a list of conditions applies, including a standardized procedure developed and approved with a supervising physician and surgeon.
How does a Virginia nurse practitioner become able to practice without an agreement?
Section 54.1-2957 requires the equivalent of at least three years of full-time clinical experience as determined by the Boards, plus an attestation from the patient care team physician or a qualifying attesting nurse practitioner stating that they served on a patient care team under a compliant practice agreement, that they routinely practiced with a patient population and in a practice area within the nurse practitioner's certified category, and the period of time they practiced together. A fee accompanies the attestation, and the Boards then issue a license with the corresponding designation.
How many nurse practitioners may one physician cover?
The two states set different numbers. Virginia Code section 54.1-2957.01 provides that a physician shall not serve as a patient care team physician on a patient care team or enter into a practice agreement with more than six advanced practice registered nurses at any one time, except up to ten in the psychiatric-mental health category. California Business and Professions Code section 2836.1 provides that no physician and surgeon shall supervise more than four nurse practitioners at one time.
What does supervision actually require in California?
Section 2836.1 states that physician and surgeon supervision shall not be construed to require the physical presence of the physician, but does include collaboration on the development of the standardized procedure, approval of the standardized procedure, and availability by telephonic contact at the time of patient examination by the nurse practitioner.
Does a Virginia patient get told who the physician is?
Section 54.1-2957.01 imposes two disclosure duties. The advanced practice registered nurse shall disclose to the patient at the initial encounter that he is a licensed advanced practice registered nurse. And any party to a practice agreement shall disclose, upon request of a patient or the patient's legal representative, the name of the patient care team physician and information regarding how to contact that physician.
What happens in Virginia if the collaborating physician leaves?
Section 54.1-2957 permits the nurse practitioner to continue treating patients without a patient care team physician for an initial period not to exceed sixty days, upon notification to the Boards' designee or alternate and receipt of that notification, provided the nurse continues to prescribe only drugs previously authorized by the agreement and continues to have access to appropriate input from health care providers in complex clinical cases and patient emergencies and for referrals.