Introduction
Health care functioning and the performance of particular stakeholders in the overall health care system are subject to national and state legislative rules. The regulations of the performance of Advanced Practice Nurses (APN) are imposed by the State Boards of Nursing, which generate and disseminate the requirements for APNs’ licensure, certification, qualifications, and other issues related to organizational and educational spheres. Given the allocation of the regulatory responsibilities to each state separately, there are significant differences between states’ regulations, which predetermine the specific features for APN practice based on their location. In particular, the present paper aims at comparing and contrasting APN practice regulations of the State of New Jersey and the State of Hawaii. While both states’ APN regulations have similar application requirements and certification, the terms of prescription authority, collaboration agreement requirements, nursing compact, and some practical implications. The paper is designed to present an issue-by-issue comparison of the features applicable to APN practice regulations in the two states to identify the most significant differences and similarities.
Background Comparison: Definitions, Educational Requirements, and Licensure
The definitions of APN in the regulatory documents of both states pertain to the same characteristics. Both states define APNs as individuals performing nursing practice according to the state licensure and certification (Hawaii Board of Nursing, n. d.; New Jersey Board of Nursing Law, 2020). The nursing practice, in its turn, is also similarly defined by both regulatory documents, with the same categorization of practice as registered nurse and practice as licensed practical nurse.
A difference in definitions is the title that is used for the identification of APNs. Indeed, the Hawaiian regulatory document refers to these individuals as Advanced Practice Registered Nurses, while in New Jersey they are titled Advanced Practice Nurses (Hawaii Board of Nursing, n. d.; New Jersey Board of Nursing Law, 2020). Moreover, the New Jersey Board of Nursing Law (2020) specifically states that “whenever the titles or designations “nurse practitioner,” “clinical nurse specialist” or “nurse practitioner/clinical nurse specialist” occur …, the same shall be deemed to mean or refer to the title or designation “advanced practice nurse” (p. 22). Therefore, the New Jersey State regulations are more transparent as per the professional titles implied in the designation APN.
The educational requirements that are necessary for a nurse to be recognized as an APN are similar in both compared states. The minimum requirements related to the level of educational degree are that the individual is expected to have “completed an accredited graduate-level education program” (Hawaii Board of Nursing, n. d., p. 7). However, only the Hawaiian regulatory body exemplifies a Master’s degree or a program that leads to a Master’s degree as a requirement. The New Jersey regulations imply that the applicants for APNs must have graduate educational degrees.
In terms of certification, in Hawaii, the document regulating APN practice clearly lists “registered nurse anesthetist, a nurse-midwife, a clinical nurse specialist, or a nurse practitioner” certifications as options for becoming an APN (Hawaii Board of Nursing, n. d., p. 7). New Jersey, it requires different certifications, necessitating nurses to be “certified as a nurse practitioner, clinical nurse specialist or advanced practice nurse by a national accrediting organization” that is approved by the board (New Jersey Board of Nursing Law, 2020, p. 23). At the same time, the New Jersey regulatory document separately demands the completion of a pharmacological course. On the other hand, the Hawaii State Board of Nursing (n. d.) addresses the necessity of successful recertification for maintaining advanced clinical knowledge and competencies. Nonetheless, both states necessitate current national certification that validates successful examination passing.
Similar to the requirements for certification, the licensure and qualification expectations in Hawaii and New Jersey are predominantly similar. In particular, in both states, an APN applicant must possess an active, unencumbered license proving their competence to perform as a registered nurse in a given state (Hawaii Board of Nursing, n. d.; New Jersey Board of Nursing Law, 2020). As for the qualifications and responsibilities, they are similar for both states. In particular, APNs in both Hawaii and New Jersey are entitled to initiate laboratory tests and diagnoses and prescribe or order medications and treatments. However, these generalized duties are further elaborated on in the consecutive sections that specifically address the authority to prescribe medications.
Prescriptive Authority, Collaborative Agreements, and Joint Protocols
As the analysis of prescriptive authority of APNs in Hawaii and New Jersey demonstrates, this is the area in which the two states’ regulations differ most significantly. As stated by Martin and Alexander (2019), “currently, 21 states grant all APRN roles full practice authority, which means a written Collaborative Practice Agreement (CPA), supervision, and conditions on practice are not required” (p. 22). Hawaii is one of the states where APNs are not subject to CPA. However, New Jersey is included in the list of states where CPA is required for medication prescription by APNs (Martin & Alexander, 2019). In general, the Hawaiian legislature authorizes APNs for free prescription of medications as long as it is aligned with the provisions of a specifically created committee (Hawaii Board of Nursing, n. d.). The New Jersey regulations, on the other hand, significantly restrict free medication prescription and necessitate APNs to collaborate with physicians within the provisions of joint protocols (New Jersey Board of Nursing Law, 2020). These differences require more accurate and detailed analysis with proper attention paid to each state.
The State of Hawaii allows APNs to prescribe medications to patients freely under the appropriate certification and licensure implied by the board. In particular, no DEA or CDS registration is required and is not mentioned in the document. The only licensure that allows APNs to prescribe medication is APRN licensure (Hawaii Board of Nursing, n. d.). However, the possession of APRN licensure is not completely sufficient for an APRN to prescribe drugs. As outlined by the legislature, a joint formulary advisory committee should be established with the participation of the representative of the department of commerce and consumer affairs (Hawaii Board of Nursing, n. d.). The board should be comprised of two licensed APRNs assigned by the board, two individuals licensed by the Hawaii medical board, three licensed pharmacists, one representative of the University of Hawaii, and one representative of the school of nursing. This qualified committee is eligible to recognize APRNs as eligible for granted prescriptive authority. The committee then establishes the formulary and recommends “the applicable formulary for persons recognized” eligible according to licensure and competence requirements (Hawaii Board of Nursing, n. d., p. 9).
The free authority to prescription is granted under the provision of several terms. According to the legal document, “only qualified advanced practice registered nurses authorized to diagnose, prescribe, and institute therapy” within their specialization may be authorized to prescribe drugs (Hawaii Board of Nursing, n. d., p. 9). The array of medications that an APN is eligible to prescribe includes over-the-counter drugs, controlled substances, and uncontrolled legend drugs. These medications might be prescribed to APRN patients in accordance with the practice guidelines as recommended by the joint formulary advisory committee. No other regulatory issues such as collaborative practice agreements or joint protocols are applicable to APN practice in the State of Hawaii.
Unlike the State of Hawaii, the State of New Jersey does not grant APNs full and unrestricted prescription authority. On the contrary, the New Jersey Board of Nursing necessitates APNs to collaborate with physicians to adjust their judgment concerning the prescribed medication with the responsible professional. According to Martin and Alexander (2019), physicians commonly “require APRNs to pay them for signing on to a CPA and often entail patient medical record reviews, shared billing procedures, regular in-person or electronic communication, and patient referral pathways” (p. 22). In particular, in New Jersey, an APN and a collaborating professional are expected to address in the joint protocol whether a consultation is needed to initiate an order to prescribe a dangerous controlled substance.
Furthermore, the initiated order must be written by the collaborating physician, authorized, and signed by the APN with the indication of his or her certification number and full name (New Jersey Board of Nursing Law, 2020). The physician should be available for communication and consultations as well as is eligible to review patient records. At least once a year, the joint protocols must be reviewed, updated, and signed by the two involved parties. In addition, several requirements are necessary to be followed by the APRN to be authorized for medication prescription. Namely, an APN must complete “six contact hours of continuing professional education in pharmacology related to controlled substances, including pharmacologic therapy, addiction prevention and management, and issues concerning prescription opioid drugs” (New Jersey Board of Nursing Law, 2020, p. 24). These six hours should exclude the pharmacology education within the context of initial certification, according to the New Jersey Board of Nursing.
A slightly different type of regulation related to medication prescription authority is applicable to nurses employed by home care agencies. In particular, such APNs are granted to transport and administer a concise list of medications that are approved by state nursing authorities. They include: “sterile saline solution, sterile water, adrenalin/epinephrine, diphenhydramine hydrochloride, heparin flush solution and any other non-controlled drug approved by the New Jersey Board of Nursing” (New Jersey Board of Nursing Law, 2020, p. 25). Therefore, the outlined specification of prescription duties and authority of APNs in New Jersey demonstrate a significant dependence of the APNs on collaborative practice agreements and joint protocols, which are not applicable to Hawaii-based APRNs who have free prescription authority.
Practice-Related Particularities
Some of the practice-related features of state regulations have differences and similarities. As for the hospital privileges, neither document explicitly addresses what is necessary to obtain them. The Hawaiian legislation does not impose restrictions on nurses and ensures their independent practice. This implies that an APRN in Hawaii can open one’s business. As for the New Jersey regulations, the nurses are dependent on collaborative practice agreements, which restrict their fully independent performance. Another important difference between the two analyzed states’ laws concerns the provision of end-of-life or palliative care. In Hawaii, APRNs are eligible to provide end-of-life care to patients under their licensure. However, the New Jersey regulations require specific additional certification in order for an APN to perform as a palliative care nurse. Indeed, the continued certification requirements regarding this issue necessitate APNs to “complete two credits of educational programs or topics related to end-of-life care as part of the total number of continuing education credits required by the board” (New Jersey Board of Nursing Law, 2020, p. 22). Therefore, APNs in Hawaii have more opportunities and independence in their practice.
Similar to palliative care, the provision of physical therapy and home health care services also differ in these two states. According to Hawaiian regulations, APRNS can “plan and initiate a therapeutic regimen that includes nutritional, diagnostic, and supportive services including home health care, hospice, and physical and occupational therapy” (Hawaii Board of Nursing, n. d., p. 9). However, New Jersey regulations differentiate between APNs and homemaker-home health aides who are eligible to provide home health care and must obtain specific qualifications and certification (New Jersey Board of Nursing Law, 2020). As for the nurse licensure compact that allows nurses to obtain multistate licensure, Hawaii is not included in the list of such states, while New Jersey is partially subject to these provisions (Puente, 2017). In such a manner, the New Jersey Board of Nursing is more inclined to the differentiation between different duties and responsibilities of APNs depending on the spheres of nursing practice. However, the Hawaii Board of Nursing takes a more generalized approach allowing for more independence and universality of responsibilities and duties.
Conclusions and Summary of Key Points
While the national legislature in the USA regulates nursing practice on a general scale, state Boards of Nursing are responsible for designing state-specific requirements that guide the practice of nurses locally. The conducted comparative analysis of the state regulations related to APN practice in New Jersey and Hawaii provides a solid background for making conclusions about the identified similarities and differences. While both states’ regulatory boards define key concepts related to nursing similarly, the Hawaiian approach prioritizes APRN as a title of the position, while the New Jersey board refers to this profession as APN. The similarities that have been identified between the states’ regulations relate to the strict rules requiring nationally approved certification, a license of a registered nurse of a given state, and the educational degree of a graduate level or higher. The similarities are predominantly applicable to the immediate duties of APNs related to patient care provision, initiation of laboratory tests and diagnostic procedures, as well as ordering or prescribing medication and treatment.
However, the most significant difference between the state of Hawaii and the State of New Jersey’s regulations of APN practice is related to prescription authority. Indeed, the Hawaii Board of Nursing provides APNs with free prescription authority under APRN licensure as long as the actions of APNs in relation to drug prescription align with a specifically created committee’s recommendations. APRNs can prescribe controlled drugs, legend drugs, and over-the-counter medications in Hawaii. On the contrary, in New Jersey, APNs are bound by collaborative practice agreements with collaborative physicians, which necessitate ordering prescriptions from physicians within the framework of joint protocols. Similarly, end-of-life and palliative care provision, physical therapy, and home health care are the services that APNs in New Jersey have to be specifically certified for, unlike APNs in Hawaii. In such a manner, APNs in New Jersey have less independence in terms of practice and medication prescription in comparison to Hawaii.
References
Hawaii Board of Nursing. (n. d.). Hawaii Revised Statutes Chapter 457 – Nursing [PDF document].
Martin, B., & Alexander, M. (2019). The economic burden and practice restrictions associated with collaborative practice agreements: A national survey of advanced practice registered nurses. Journal of Nursing Regulation, 9(4), 22-30.
New Jersey Board of Nursing Law. (2020). New Jersey Board of Nursing Statutes [PDF document].
Puente, J., & MJ, C. (2017). The enhanced nurse licensure compact. American Nurse Today, 12(10), 50-53.