Tennessee NPs: The Fight for Full Practice Authority

Nurse practitioner holding up a stethoscope
Nurse practitioner holding up a stethoscope

Primary care is the foundation of the U.S. health care system and a patient’s entry point to care delivery. Primary patient care helps improve quality, outcomes and the patient experience, while containing costs, reducing unnecessary utilization, and promoting efficient use of health care resources.

By earning a Master of Science in Nursing - Family Nurse Practitioner (MSN-FNP) degree and becoming a nurse practitioner, you can help fulfill the growing need for primary care providers. Carson-Newman's CCNE-accredited online MSN-FNP program prepares graduates with the skills necessary to define their own future as a holistic and confident family nurse practitioner.

Scope of Practice

A health care provider’s scope of practice outlines the procedures, actions and processes that he or she is permitted to undertake in keeping with the terms of his or her professional license. Scope of practice for nurse practitioners (NPs) includes practice authority, prescriptive authority, and primary care provider status. Practice authority is an NP’s ability to practice independently without physician oversight. Prescriptive authority refers to an NP’s authority to prescribe medications. Some states expressly identify a nurse practitioner as a primary care provider.

Not all states define NP scope of practice in the same way. Because laws differ significantly, the ability of NPs to deliver care to patients varies depending on where they practice. Presently, 23 states have scope of practice policies that give full practice authority to NPs, allowing practice of primary care to the full extent of graduate education, advanced clinical training, and national certification. 

In these states, all NPs are permitted to evaluate and diagnose patients, order and interpret diagnostic tests, and execute treatment such as prescribing medications and controlled substances. This clinical ability is permitted under the exclusive licensure authority of the state board of nursing. The National Academy of Medicine recommends this practice model.

Twenty-eight states limit or prevent NPs from practicing primary care independent of physicians. Sixteen states reduce the ability of NPs to engage in at least one element of practice. This includes restrictions placed around the ability to prescribe medications, requiring a physician to be present for a portion of the NP’s office hours. Eleven states give NPs limited practice authority, requiring a career-long regulated collaborative agreement with a physician so the NP can provide patient care.

Tennessee Nurse Practitioner Scope of Practice

NPs in many states have full practice authority and enjoy relative autonomy in treating patients, working to the full extent of their training and credentialing. In the state of Tennessee, NPs continue to work under restricted practice conditions and may be treated as mid-level providers who require physician supervision throughout their careers. 

Tennessee NPs are required to have supervising physicians visit their clinical sites every 30 days. This can be a challenge for health care clinics in more rural regions of the state. According to the American Association of Nurse Practitioners, Tennessee’s practice and licensure laws restrict the ability for NPs to engage in at least one element of NP practice:

  • Practice Authority: Physician supervision is required. The physician has control and responsibility for prescriptive services rendered by the NP. Tenn. Code Ann. §63-7-123
  • Prescriptive Authority: NPs may prescribe Schedules II-V controlled substances upon receiving a certificate of fitness from the State Board of Nursing and adoption of physician supervisory rules. Schedules II-IV may only be prescribed after consultation with the physician. Tenn. Code Ann. §63-7-123
  • Nurse Practitioner as a Primary Care Provider: NPs are recognized in state policy as primary care providers. Primary care providers are health care professionals capable of providing a wide variety of basic health services. Tenn. Admin. Code §1200-13-13.01(98)

The Physician Shortage

It is expected that demand for primary care will increase significantly in the coming years as the U.S. health care system serves a growing aging population. The supply of primary care physicians (PCPs) is insufficient to meet current and future demand. The estimated shortage could grow from 18,000 in 2018 to 49,000 in 2030. 

At this time, 13% of U.S. residents (44 million) live in a county with a PCP shortage, defined as less than one PCP per 2,000 people. Rural residents are nearly five times as likely to live in a county with a PCP shortage compared to urban and suburban residents (38% vs. 8%).

Tennessee will not be immune to this PCP shortage. The U.S. Department of Health and Human Services estimates a 19.2% shortfall in the number of PCPs needed by 2025. A 2016 study from Avalere Health found 18% of people in 111 different regions in Tennessee lack access to enough doctors. 

A recent study by the Tennessee Rural Partnership examined the total number of PCPs in each county of East Tennessee. The study found 10 counties in East Tennessee that had 10 PCPs or fewer. Researchers estimated approximately 77% of the total physicians in East Tennessee were located in just two counties, Hamilton County and Knox County.

The nation’s ongoing battle against opioids and methamphetamine could worsen the shortfall. Half of all U.S. counties do not have a federally approved physician available to write prescriptions for buprenorphine, a substance used in treating opioid addiction. Tennessee is one of three states that does not allow NPs to write these prescriptions while the opioid crisis continues to ravage communities across the country. 

Implications for Nursing

Graduates of MSN-FNP programs are prepared to help address this looming problem, especially in underserved rural areas. 78% of NPs in the U.S. practice primary care, whereas only 33% of physicians do. NPs are also more likely than primary care physicians to practice in underserved communities and to accept new patients. 

Advanced Practice Clinicians, such as NPs, help expand primary care capacity and increase access to care. This can be achieved by practicing independently or as part of multidisciplinary care teams that help primary care practices deliver care to more patients.

NPs are qualified to independently deliver high-quality primary care. State laws and regulations that restrict the scope of practice for NPs can compromise patients’ health by exacerbating primary care shortages. In Tennessee, existing laws limit the ability of NPs to close the gap in primary care access. NPs should be permitted to practice to the full extent of their education and training. 

If all states were to grant NPs full practice authority, the number of Americans living in a county with a primary care shortage would decline from 44 million to fewer than 13 million – a 70% reduction. The number of rural residents living in a county with a primary care shortage would decline from 23 million to 8 million – a 65% reduction.

NursePractitionerSchools.com has interviewed more than 50 NP (and other APRN) professors, and the vast majority are in favor of implementing nationwide full practice authority. NPs are not in competition with physicians. They must strive to create a practice model that best addresses the health care needs of all Americans. 

Until the Tennessee Nurse Practitioner Scope of Practice allows for full practice authority, talented NPs may be tempted to relocate to other states and residents of rural regions in restricted practice areas may see their only health care clinic shuttered if a supervising physician retires.

For more information please see What is the Salary of a Nurse Practitioner in Tennessee and 7 Things You Should Know About Nurse Practitioners.

Sources:

American Association of Nurse Practitioners (n.d.). Tennessee: Information and resources for Tennessee NPs. Retrieved on November 7, 2018 from the AANP website at https://www.aanp.org/advocacy/tennessee

Blore, J. (n.d.). Tennessee NPs: The fight for full practice authority. Retrieved on November 7, 2018 from the Nurse Practitioner schools website at https://www.nursepractitionerschools.com/blog/tennessee-np-practice-authority

National Conference of State Legislatures (n.d.). Tennessee scope of practice policy: State profile. Retrieved on November 7, 2018 from the Scope of Practice Policy website at http://scopeofpracticepolicy.org/states/tn/

UnitedHealth Group (2018). Addressing the nation’s primary care shortage: Advanced practice clinicians and innovative care delivery models. Retrieved from https://www.unitedhealthgroup.com/content/dam/UHG/PDF/2018/UHG-Primary-Care-Report-2018.pdf

Vance, J. (2016, March 5). Study: Tennessee experiencing shortage of primary care physicians. Retrieved from the Johnson City Press website at https://www.johnsoncitypress.com/Health-Care/2016/03/05/Study-Tennessee-facing-large-shortage-of-primary-care-physicians