Scope of Practice and the Nurse Practitioner: Regulation, Competency, Expansion, and Evolution Tracy A. Klein, MS, WHCNP, FNP Topics in Advanced Practice Nursing eJournal 5(2):, 2005. © 2005 Medscape Reprinted with permission from Topics in Advanced Practice Nursing eJournal 5(2):,2005. Available at: http://www.medscape.com/viewarticle/506277 . ©2005 Medscape. Nurse Practitioners: Defining Scope of Practice Nurse practitioners (NPs) are one of the few healthcare providers mandated by their role and practice to carry what amounts to 2 licenses to practice. All NPs must first be trained and recognized by their state of practice with the registered nurse (RN) license. They are then additionally state- and/or nationally certified in their advanced practice specialty and role. As an NP, your scope depends upon basic education as a nurse combined with additional specialized training. This entitles you to practice in areas beyond the scope of the RN, such as diagnosing and prescribing. An NP may be held to many standards, and therein lies the confusion. Who do you turn to when you have a question regarding your scope of practice: your employer, professional association, collaborating physician, nurse practice act, Medicare provider, or insurance carrier? All can and do play a role in defining the scope of healthcare in terms of permitting what you may do. But what about what you are able to do, or what your patient wants you to do? How each state handles scope-of-practice questions varies, although general principles cross all lines of practice. The purpose of this article is to evaluate current mechanisms for credentialing and recognizing scope of practice for NPs. Each NP, whether governed by state regulations providing for independent, supervised, collaborative, or other practice requirements, is independently responsible for his/her patient care. This article will help you sort out some of the ethical and practical questions you should ask yourself when faced with a scope-of-practice decision. What Influences Scope of Practice? What is scope of practice? Scope can be defined as the activities that an individual healthcare practitioner is permitted to perform within a specific profession. However, as noted by the Federation of State Medical Boards, even the wide scope of the physician is pressured by "factors including: fluctuations in the health care workforce and specific health care specialties; geographic and economic disparities in access to health care services; economic incentives for physician and non-physician providers, and consumer demand." [1] The Institute of Medicine (IOM), in its report titled Health Professions Education: A Bridge to Quality, [2] calls for competency-based education and interdisciplinary practice models for the future. Some advanced practice nursing specialties, such as midwifery and nurse anesthesia, have decades-long histories of uniform accreditation and competency-based education. Physician assistant education has also developed under a single accrediting body, core curriculum, and board certification mechanism since the 1970s. The NP role, however, evolved in a more fragmented fashion, and curriculum standardization and accreditation standards followed, rather than directed, education. The development in 2002-2004 of the National Organization of Nurse Practitioner Faculties core competencies for several NP specialties offers a framework for specialty education as an adult, family, gerontological, pediatric, women's health, or psychiatric mental health NP. All NPs should be familiar with these important documents. However, these competencies, although they are useful, address the entry-level NP. What about the evolution of practice as the NP expands his or her competency within his or her scope? Experience and environment can and will stretch the NP's knowledge and competency beyond that of the basic education level. Scope of Practice: Why NPs Should Be Concerned Scope of practice determines who you can see, who you can treat, and under what circumstance or guidance you can provide this care. Scope of practice also determines the limits and privileges of your licensure and certification as an advanced practice nurse. In the United States, scope of practice determines your ability to bill and be paid for what you do, as well as your ability to be covered by malpractice insurance. Significant liability issues are created when NPs practice outside of their scope. According to Nurses Service Organization (NSO) claims data in 2004, [3] practicing beyond scope accounted for 6% of all claims filed. Scope also determines the "minimum standard" of competency for a provider with like knowledge and training in a given specialty; 32% of NSO claims in the same report pertained to "failure to meet minimum standards." If you are the only NP practicing in cardiology in your state, you may have some opportunity, by virtue of your unique status, to shape the minimum standard for your specialty. More concerning, however, is the potential for physicians and physician-controlled groups to set the standards for your practice. At best, these standards may mandate physician supervision to assure and determine your competency and credentialing