Alliances of cooperation: negotiating New Hampshire nurse practitioners' prescribing practice.

Abstract. Nurse practitioner legislation varies among states, particularly in relation to practice without physician oversight, altering the legal environment within which nurse practitioners can use knowledge and skills to meet patient needs. Using New Hampshire as a case study, this historical analysis of nurse practitioners' negotiations over time for independent practice, defined in state practice acts, illuminates the complex social and economic factors affecting nurses' struggle to gain legal rights over their own professional practice without supervision and intervention from another profession. In New Hampshire, not only did organized medicine oppose nurses' rights to practice, but pharmacists demanded the right to control all aspects of medication management, including who could prescribe and under what circumstances prescribing could occur. Shifting social and political terrain as well as changes in legislative and state professional board leadership affected the environment and negotiations of a small group of nurses who were ultimately successful in obtaining the right to define their own professional practice. In 1973, the New Hampshire Board of Nursing recognized a new category of nurses called "advanced registered nurse practitioners" when the legislature passed an addendum to the nursing practice act formally recognizing this emerging group of nurses. 1 Following a growing national trend, these nurse practitioners had obtained additional education that enabled them to diagnose disease, order diagnostic tests, and prescribe and dispense medications to patients, activities that had been traditionally designated as only within the realm of medicine. For the next four years, New Hampshire nurse practitioners worked in this expanded role diagnosing disease, dispensing contraceptives and drug samples, and prescribing medications by using physician presigned prescriptions or under physician auspices by telephoning prescriptions to community pharmacies under a physician's name. Most often the nurse practitioners were making their own clinical decisions about the drug, prescribing or dispensing without directly consulting doctors. Physicians, who were not always on premises when nurse practitioners examined patients, diagnosed illness, and prescribed or dispensed drugs (and may not even have worked in the same practice as the nurse practitioner), were fully aware and sanctioned this practice. 2 The nurse practitioners reasoned that since the New Hampshire Nurse Practice Act was broadly written and allowed nurses to practice consistent with their education, they were fully within their rights to diagnose and prescribe in the manner that they were doing, even though the practice act did not specifically address diagnosis or prescribing. The nurse practitioners, after all, were educated to perform these functions, and they were bound by state nursing statutes rather than by pharmacy or medical practice acts. The physicians supported these nurse practitioners' actions because, they believed, the Medical Practice Act allowed them to "delegate" with impunity any function they wished to another health care provider, and the physicians with whom the nurse practitioners worked were fully supportive of the practices. Both groups believed they were meeting patient needs without breaking the law. 3 This practice had been going on for several years without question from any state regulatory office. Community pharmacists, another party to the discussion, occasionally complained to the Commission on Pharmacy, but these rare complaints brought forth no action other than an occasional brief notation in Commission on Pharmacy Board meeting minutes. 4 Both physicians and nurse practitioners were unaware that they were breaking a state pharmacy law that permitted only physicians, dentists, and veterinarians to prescribe and dispense. For almost five years, neither physicians, pharmacists, nor any other professional group seemed interested in ending the nurse practitioners' practices, despite state pharmacy law to the contrary. …