1. Kaplan, Louise PhD, ARNP
  2. Brown, Marie-Annette PhD, ARNP, FAAN

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Despite legislative gains in scope of practice, the majority of nurse practitioners (NPs) in the United States are not fully autonomous.1


It is easy to lose sight of the factors that constitute full autonomy. Even in states where NPs have legal authority for full autonomy, there are practice barriers that subvert this autonomy. Barriers range from receiving a lower rate of reimbursement than physicians to seemingly small acts of exclusion, such as not being able to authorize disability parking permits.


Full Autonomy = Full Control

Autonomy is considered the basis of a profession.2 Professional autonomy is defined as "socially granted and legally defined freedom to make practice decisions without technical evaluation from sources outside the profession."3 True autonomy will occur only when NPs have full control of their profession. The ability to attain this control is limited by factors such as the position taken by organized medicine: physicians have the authority to supervise and direct other healthcare professionals.


Each of us must assume responsibility to create a national environment in which each NP is fully autonomous.


According to Safriet, physicians have "[horizontal ellipsis]a monopoly on authority, if not ability. All others, including both long-standing and emerging professions, must constantly choose between two unattractive alternatives: foregoing the safe practice of what they have been educated and trained to do, or risking legal sanction for stepping outside the boundaries of their legislatively defined, static, circumscribed, and outdated scopes of practice."4


For over a decade, NPs in Washington state lobbied intensively for fully autonomous II-IV prescriptive authority and worked to defuse opposition from organized medicine. Why, then, did NPs compromise in 2000 and accept a II-IV prescribing law requiring indirect physician involvement? Over the years, many NPs had stepped outside the boundaries of their scope of practice using quasi-legal strategies to provide controlled substances to patients. Leaders in the NP field made the strategic decision that the Joint Practice Agreement (JPA) requirement served as an interim step toward fully autonomous prescribing. They planned to lobby for the elimination of the JPA after NPs demonstrated competence and established credibility prescribing II-IV drugs. In March 2005, the governor of Washington signed a law removing the JPA requirement. Washington NPs now have fully autonomous practice including prescribing for legend and controlled substances.


Surviving the Proving Ground

As our research revealed, (see The Nurse Practitioner. 2006;31(1):57-63) the law passed in 2000 created additional barriers for some NPs, such as maintaining a prescribing log or taking an examination to demonstrate knowledge. These additional requirements were a burden, made the NP vulnerable to physician demands, and were another way the profession was diminished. Nurse practitioners are still 'surviving the proving ground' much the way our esteemed pioneers did 40 years ago.5 Any barrier, no matter how small, constrains NP autonomous practice and limits access to comprehensive care for millions of patients.


In all 50 states, NPs individually and collectively work to eliminate barriers that restrict practice and prevent full autonomy. Each of us must assume responsibility and participate in a grass roots effort to remove external barriers and create a national practice environment in which each NP is fully autonomous. Concurrently, we must create a paradigm shift in the way we think about ourselves. We are competent, highly skilled professionals who are essential to our nation's health. It is not just in action but in thought that we create our autonomy.



References available upon request.