Jan 2010

State-Mandated Collaboration for Nurse Practitioners

Susan Schrand, MSN, CRNP
Virtual Mentor. 2010;12(1):52-54. doi: 10.1001/virtualmentor.2010.12.1.oped2-1001.


Consider the following: a registered nurse with a decade of experience excels in a nurse practitioner graduate program and, after becoming board-certified by a national credentialing body, decides to establish a practice in a medically underserved rural area where it is common for health care professionals of all stripes—nurses, physical therapists, dieticians, pharmacists, dentists, physicians—to consult with each other regularly in order to provide the best care possible.

This informal arrangement benefits patients and professionals alike, and a growing number of states allow nurse practitioners (NPs) to practice without physician involvement as licensed independent providers. Many states, however, still impose some pharmacy restriction or limit on prescribing authority and mandate some form of collaboration with or supervision by physicians. (The 2009 Pearson Report lays out a state-by-state analysis of requirements for nurse practitioner independent practice [1].) In some states, this supervision is required to take the form of a written collaborative agreement.

For a rural NP, meeting this requirement may be difficult due to the shortage of physicians in the area, and, if the physician collaborators require a fee, the agreement may present financial obstacles to establishing the practice and keeping costs low for patients. Furthermore, the formality of the relationship, the limited choice in collaborators, and the fact that the agreement is mandated can inhibit truly collaborative work.

The other professionals in the community are free to practice within their own professional jurisdiction, based upon their own licensure, and are not required by statute or regulation to have a professional from another domain contract with them to practice. Why should a professional with advanced graduate education, certification, and expertise, who collaborates regularly with other health care professionals, be held to a different standard than they are?

This requirement is already a hardship for rural NPs, and if the collaboration requirement continues, soon there will not be enough physicians to collaborate with all the practicing NPs. Nurse practitioners are the fastest growing segment of primary caregivers in the United States. In fact, the number of primary care NPs is increasing at a rate of 9.44 percent per capita, compared to 1.17 percent per capita increase for physicians [2]. If the covert intent of this legislation is to minimize the number of nurse practitioners who are licensed to practice, then it will succeed.

As of this writing, the literature fails to document whether legally mandated collaboration between nurse practitioners and physicians (1) increases collaboration between the two professions or (2) promotes patient safety or positive public outcomes. Nurse practitioners do not need a legally mandated tie to physicians to continue to work jointly with their colleagues in all disciplines; patients are best served by voluntary and willing collaborations, regardless of the background and educational domain of the person being consulted. Discussing cases and gathering other perspectives on treatment and care plans occurs daily in every setting of health care, both within and across professional disciplines. When necessary, formal consultation occurs.

The exchange of knowledge, expertise and judgment is a vital part of the process any practitioner, whether nurse or physician, must use to render excellent patient care. All primary caregivers should collaborate when addressing questions beyond their scope of practice or current level of expertise. To do otherwise, is, for all intents and purposes, medical malpractice, with or without a legislative mandate. Mandated legal affiliations can erode the spirit of collaboration (when, for example, physicians must approve prescriptions written for patients they have never met), continue to marginalize the nurse practitioner profession, and undermine the goal of increasing access to care. In addition, a system of paid collaboration cannot help but lead to higher medical costs, as this obligation increases NP practices’ business expenses.

According to a comprehensive review of the literature, all studies of NP care have concluded that NPs provide safe and effective care, even when practicing independently from physicians [3]. Since 1965, there have been no documented findings of poor patient outcomes when a NP is designated as a licensed independent practitioner. Moreover, the increase in the number of medical malpractice claims against nurse practitioners is no greater than the corresponding increase in claims against physicians [4]. Nurse practitioners practice safely and effectively in states that do not legislate physician involvement. The role of nurse practitioners is distinctive, in that we are trained to deliver care that blends the sciences and philosophies of both medicine and nursing, and the end result has been holistic, high-quality, and evidence-based care that has satisfied patients across the country [5]. It is a goal of the National Council of State Boards of Nursing to license Advanced Practice Registered Nurses (APRN), a category that includes NPs, as independent practitioners with no regulatory requirements for collaboration, direction or supervision [6].

Just as we excel in counseling and educating our patients, nurse practitioners and our professional organizations are committed to demonstrating to the public, lawmakers, and our colleagues in other areas of health care that we are a viable and trusted profession that has proven itself over many decades. By doing so, we can remove these persistent barriers that prevent us from practicing to the full extent of our education and clinical expertise.


  1. Pearson L. The Pearson Report 2009.  Am J Nurse Pract. 2009;13(2). Accessed December 16, 2009.

  2. U.S. Government Accountability Office (GAO). Primary care professionals: recent supply, trends, projections and valuation of service. Accessed December 16, 2009.

  3. Laurant M, Reeves D, Hermens R, et al. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005;(2):CD001271.

  4. Miller K. Malpractice trends: viewing the data and avoiding the hot seat of litigation. J Nurse Pract. 2009;5(9):662-665.
  5. American Academy of Nurse Practitioners. Documentation of quality of nurse practitioner practice. Accessed December 16, 2009.

  6. National Council of State Boards of Nursing. APRN model act: rules and regulations. Accessed December 15, 2009.


Virtual Mentor. 2010;12(1):52-54.



The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.