State Practice Agreements

In 2015, Maryland became the 21st state in the union to allow nurse practitioners to practice independently of a physician. Gov. Larry Hogan signed the Nurse Practitioner Full Practice Authority Act and this new development allows nurse practitioners to prescribe certain drugs without having an “attestation agreement” with physicians (Medscape, 2015). This caused great controversy for many, with some siding for the new act and others against this gain of independence for nurse practitioners.

Physician Collaboration Issues

Nurse practitioner’s unlike Physicians Assistants who are also midlevel providers do not have to work under a physician nor do they have to collaborate with a physician to practice medicine in Maryland. In addition to being free of collaborative agreements, a nurse practitioner in Maryland has the authority to open up their own practice. Some nurse practitioners have to make payments to doctors to form collaborative agreements in other states. In Maryland, before commencing practice in the past, a nurse practitioner was mandated to complete a board- approved written attestation that  clearly defines the follows: the NP has an agreement for collaborating and consulting with a physician, states the name and license number of the physician, explained that the NP shall refer and consult with physicians and other healthcare providers as needed, shall practice in accordance with the standards of practice in regards to the American Academy of Nurse Practitioners (AANP) or any other nationally certifying NP body recognized by the board (Buppert, 2015).

When Governor Larry Hoagn initial proposed the Nurse Practitioner Full Practice Authority Act in Maryland, a state medical society known as Med Chi asked that legislators amend the initial bill to require that less-experienced practitioners should enter a collaborative agreement, similar to how others states, including New York, handle the situation. The doctors also wanted the law to allow for the discipline of nurse practitioners who fail to refer to or consult a physician when necessary. Those two amendments were added and this Med Chi no longer refuted the bill. Some physician professional organizations, including the American Medical Association, believe that because physicians have longer and more rigorous training than NPs, nurse practitioners are incapable of providing quality, safe care at the same level as physicians (Medscape, 2014). If the NP changed or terminated the agreement to collaborate with a physician, a new written attestation stating the name of the new physician should have been written and submitted immediately by mail or facsimile to the Board (Buppert, 2015).

According to the Maryland Board of Nursing, the requirement for NP attestation as a condition of practice in Maryland was been repealed and Attestations are no longer required after October 1, 2015 (MBON, 2106). In place of the attestation agreement there is a new bill which requires each new applicant who has never been certified as a CRNP in this or any other state to name a mentor on their application for certification who is either a certified Maryland CRNP or Licensed Maryland Physician (MBON, 2016). There is no burden for the mentor and there is no record keeping for this bill as the NP’s application and submission of their mentor serve as proof of compliance with this bill (MBON, 2016). The mentor is required for 18 months starting with the day the NP submits their application to the Board of Nursing will only apply to CRNPs who have never been certified in this or any other State (MBON, 2016).

Barriers to NP Independent Practice

States that give nurse practitioners more authority are improving access to healthcare as a result. Full practice authority is also referred to autonomous practice or independent practice and under such authority, NPs are required by their licensing state to meet educational and practice requirements for licensure, maintain national certification, consult and refer to other healthcare providers per patient/family needs, and be accountable to the public and state board of nursing for meeting the standards of care in practice and professional conduct (AANP, 2014). One barrier to practicing as an NP in Maryland will take place if the NP is unable to find a mentor for the first 18 months of practice, as this is part of the application process. Nurse practitioners hold prescriptive privileges in 50 states with the ability to prescribe controlled substances in 49, which has allowed NPs to prescribe medications for patients in need (Brassard and Smolenski, 2011). Despite having prescriptive privileges, barriers may exist preventing NPs from following their patients when they are admitted to acute care facilities which ultimately may impact patient outcomes. Continuity of care is an important aspect of providing the best care for patients and this is lacking when patients enter the acute care setting as only NP’s trained in an acute care have authority in this setting. At a time when care coordination has drawn national attention, obtaining admitting privileges to a hospital poses a significant obstacle to continuity of care (Brassard & Smolenski, 2011). Another barrier is the need to be credentialed by all payors before providing care as many NPs report that payer polices have a significant impact on their ability to practice to the fullest extent of their licensure and training (Yee, Boukus, Cross, & Samuel 2011).

A Plan to address NP Practice Issues in Maryland

In Maryland, there are limited barrier to practicing as an NP and I am grateful for this. A plan that I will utilize to address NP practice issues in my state will be to find a dedicated mentor to assist me in the beginning year and a half of practice. I also have no desire to practice independently until a gain enough experience to do so. I will work with other experienced providers so that they can guide me through how to provide safe and efficient care to patients in my current state. I will also try to hold an open line of communication with the acute care facilities in my practice area so that they ensure patient records are delivered to me in a time sensitive manner for the patients that I am caring for if I am working in a primary care of specialty setting. Setting up a meeting with the acute care facility representative will assist with adding me as a provider in the area and familiarize them with my ability to practice and interest in making a difference in their community.

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