Scope of practice for the advanced practice nurse

• Perform acts of nursing diagnosis and nursing treatment of alterations of the health status.  
• Perform acts of medical diagnosis and treatment, prescription, and operation as authorized within the supervisory protocol.  
• Prescribe, dispense, administer, or order any drug; however, prescribing or dispensing controlled substances requires a master's or doctoral degree in a clinical nursing specialty area with training in specialized practitioner skills.
   
• Initiate appropriate therapies for certain conditions.  
• Order diagnostic tests and physical and occupational therapy.  
• Order any medication for administration to a patient in licensed healthcare facilities, notwithstanding pharmacy regulations.  
• Certified Nurse Practitioners can initiate, monitor, or adjust treatment for certain uncomplicated acute illnesses and monitor and manage patients with stable chronic diseases.  

California's Scope of Practice for APRNs:

California has been undergoing significant changes in its APRN scope of practice. As of January 1, 2023, Assembly Bill 890 (AB 890) created two new categories of Nurse Practitioners that can function within a defined scope of practice without standardized procedures under specific conditions:  

• 103 NPs: Can practice without standardized procedures within the population focus of their national certification in a group setting (clinic, hospital, or medical group) with at least one physician. They must hold national certification and have completed a transition to practice in California of at least three full-time equivalent years (4600 hours within 5 years).  
• 104 NPs: Can practice independently outside of a group setting, including owning their own practice, without standardized procedures within their national certification population focus. They must have worked as a 103 NP in good standing for at least three years.  

Key aspects of California's NP scope of practice include:

• Authority to evaluate patients, diagnose patient problems, order and interpret diagnostic tests, and initiate and manage treatments, including prescribing medications and controlled substances under their licensure authority.  
• Ability to establish primary and differential diagnoses.
• Authority to prescribe, administer, dispense, and furnish pharmacological agents, including controlled substances (with specific requirements for Schedule II).
• Ability to order durable medical equipment, medical devices, nutrition, blood and blood products, and diagnostic and supportive services, including home health care.  
• NPs can perform or interpret clinical laboratory procedures they are permitted to under state and federal regulations.
• NPs can sign disabled person placard forms and Physician Orders for Life-Sustaining Treatment (POLST) forms.  
• The California Board of Registered Nursing (BRN) expects NPs to gain full practice authority by 2026.

Comparison:

The key difference between Florida and California currently lies in the requirement for physician supervision.

• Florida mandates that APRNs practice within the framework of an established supervisory protocol with a physician, although the specifics of this protocol can vary.  
• California is moving towards greater autonomy for Nurse Practitioners. While the initial "transition to practice" for 103 NPs requires a group setting with physician presence, they do not operate under standardized procedures. The 104 NP category allows for fully independent practice for experienced NPs. This signifies a move away from mandatory physician supervision for a significant portion of NP practice in California.  

This difference reflects varying state approaches to regulating advanced nursing practice. California's recent changes align more closely with the recommendations of the Institute of Medicine (now the National Academy of Medicine) to allow APRNs to practice to the full extent of their education and training to improve access to care. Florida's model maintains a level of physician oversight, which proponents argue ensures patient safety and collaborative care. However, critics suggest it can create unnecessary barriers to NP practice and limit access to care, particularly in underserved areas.

As Kenya considers strengthening its healthcare workforce and potentially expanding the roles of advanced practice nurses, understanding the different models of APRN scope of practice in states like Florida and California can provide valuable insights into the potential benefits and considerations of various regulatory frameworks.