Impact of Structural Autonomy Accorded Through State Regulatory Policies on Nurses' Prescribing Practices

Summary The manifest function of regulations that implement nurse practice acts is to protect the safety and to promote the welfare of citizens of the state in relation to their needs for health care as provided by registered nurses. Regulations governing prescriptive authority of NPs in the five states of this study were highly comparable for NP minimum educational preparation and certification in a specialty area of practice. Additional requirements–an M.D. supervisor of a prescribing NP and limiting NPs' prescribing to a drug formulary–were viewed in this study as structural constraints on NPs' performance of the prescribing act. Rather than noting qualifications (expert knowledge) an NP would bring to the prescribing act, they set limits on the NP's discretionary and binding decisions and actions. Such limits suggest that the authority to prescribe derives from a societal status position of nursing. The limited-based authority states have placed NP prescribing directly as an extension of M.D. authority. The broad-based authority states that were the focus of this study have placed NP prescribing in the context of an NP's nursing license, but have varied in the level of autonomy that accompanies the authority. If the structural constraints on the prescribing act of NPs function to protect the safety and promote the welfare of those served, then differences in prescribing practices could be expected under variable application of those constraints. With the exception of the finding of a relatively higher incidence of prescribing generically in the higher autonomy conditions, the prescribing practices analyzed in this study were not influenced by those constraints. The data reported here do not examine the quality of the prescribing act. For that reason, and in the absence of other normative data on NP prescribing, the practices of these NPs were compared with those reported for M.D.s. They were quite comparable, whether or not a formulary or M.D. supervision was a structural requirement. Given the fact that M.D.s serve as preceptors in NP educational programs and may in other domains of nurselphysician relationships be role models in client assessment, diagnosis, and treatment, this finding is not surprising. If the requirement of M.D. supervision is to heighten the involvement of a more experienced prescriber (an M.D.) with NP client services, then one might expect to find a higher proportion of consultation where that requirement exists. By contrast, the findings show that both the highest (Condition 1) and the lowest (Condition 2) proportion of consultations prior to prescribing occurred under this requirement. The higher proportions of combined consultation and referral also occurred in the least and the highest autonomy conditions. It is questionable that the colleagial act of consultation/referral can be mandated; rather, use of it would seem to derive from the prudent judgement of a profess sional, an aspect of discretionary decision making. Use of such judgement would depend less on mandate than on the qualifications of a prescriber. If the requirement that prescribing be limited to a formulary is to constrain the range of drugs prescribed, then one might expect the NP drug repertoire to be least under that requirement. By contrast, the autonomy conditions that did not mandate a formulary revealed both the smallest (Condition 2) and the largest (Condition 4) legend drug product repertoire. The finding that 85.4% of all prescriptions were independent of M.D. involvement is consistent with the estimate by Record (1979) that a high proportion of people seeking primary care could be managed by NPs alone. The cost implications are significant in that only a small proportion of clients seen by NPs with prescriptive authority would need to bear the additional fee for M.D. services for obtaining a prescription. Further, only a relatively small proportion of an NPs clients would have to wait on the day of appointment to obtain confirmation of diagnosis and prescription or to make an appointment on a separate date when an M.D. is available. For wage earners, such savings of time is also a cost factor since wages often are reduced for time away from work. The finding that 56.2% of the total prescriptions could have been filled generically also has cost implications. Generally, generic products cost less than trade name products. However, allowing substitution for a trade name product is insufficient to require a pharmacist to fill the prescription with the least costly product; it only permits this to be done: If cost containment is an NPs goal when allowing drug product substitution, that goal is more likely to be achieved through use of a drug's generic name. In summary, expanded practice in nursing is requiring states to develop nursing practice regulations on acts that traditionally have been considered the domain of the M.D. This study, through finding that the act of prescribing was not influenced systematically by the level of autonomy represented through regulatory policy, points to the need for systematic appraisal of such policies in relation to the functions they serve. If the goals of public health, safety, and welfare are to be served by nursing regulatory policies, those policies must have the capability of serving those goals.