State laws and career satisfaction

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Both NPs and PAs are more likely to work in states that authorize them to practice to the full extent of their education and experience. Like the professions themselves, the best states for PAs and NPs to work, vary based state regulations.

The American Academy of Physician Assistants (AAPA) has studied PA practice and state law, and identified six optimal conditions that are essential to efficient practice for physician-PA teams. Called the "Six Key Elements of a Modern Physician Assistant Practice Act," and include:

  • Use of the regulatory term “licensure” when describing the role of PAs, and not “certify” or “register.” This is important because many state and national laws use the broad term “licensed health professional” when granting certain privileges, such as participating in loan repayment programs and caring for individuals in the event of a natural disaster.
  • Full prescriptive authority. On average PAs receive 75 hours of formal pharmacology training. Working in a state that allows you to prescribe will enable a more efficient relationship with your supervising physician.
  • Scope of practice determined on site.
  • Adaptable supervision requirements. This enables PA-physician teams match supervision mechanisms to the practice and providers.
  • Determing chart cosignature requirements at the practice site
  • No restriction on the number of PAs a physician may supervise.

According to these criteria, North Dakota and Rhode Island rank high on the best places for PAs to work — meeting all six key elements. Alaska, Maine, Michigan, Minnesota, New Mexico, North Carolina, South Dakota and Wyoming are not far behind — these states meet five criteria each.

Several other state-based variables may also factor into your decision. One such measure is “ease of practice,” or the number of steps and the amount of paperwork it takes to start working or to change jobs as PA. In many states, a licensed PA may begin practice with a licensed physician upon completing a document that is kept on file at the practice and requires no approval or notification by a state regulatory agency. These states include Arizona, California, Connecticut, Delaware, Michigan, Nebraska, New York and Rhode Island.

Best states for NPs

Choosing the best state to practice as an NP is driven more by goals and interests, according to Julie Stanik-Hutt, PhD, ACNP-BC, FAAN, director of the School of Nursing Master's Program at Johns Hopkins University, in Baltimore. For example, she suggested that NPs who would like to practice in geriatric medicine consider states that have large populations of older adult citizens such as Florida, Arizona or Iowa.

It is important to pay attention to rules and regulations for NPs. Like NP regulations, these can vary across state lines. “What we have is a crazy quilt patchwork across this country of different regulations and requirements in all 50 states and the District of Columbia,” Stanik-Hutt said. “When a nurse practitioner contemplates moving from the state they're in to another state, he or she might have to go through a huge rigmarole or the state may just require a copy of the applicant's nurse certification and a licensing fee.”

To avoid this, many nurses have started looking into independent practice, a regulatory structure that gives nurse practitioners more autonomy. This structure has been adopted by 14 states including: Alaska, Arizona, Colorado, Hawaii, Idaho, Iowa, Maine, Montana, New Hampshire, New Mexico, Oregon, Rhode Island, Washington and Wyoming. The District of Columbia also permits independent practice. District of Columbia.

“Several more states plan to introduce legislation to update the regulation of nurse practitioners in 2011,” said Tay Kopanos, DNP, NP, director of health policy and state government affairs for the American Academy of Nurse Practitioners.

To meet the AANP's definition of independent/autonomous practice NPs must be regulated by the state's board of nursing, have no formal added regulatory links to other health professions (such as physicians) or to the board of medicine for practice in the following five practice areas:

  • Patient evaluation and assessment,
  • Ordering and interpreting diagnostic testing,
  • Diagnosis,
  • Treatment initiation,
  • Medication prescription.

Independent practice is currently a growing trend. “Enacting these updates will be critical for states to meet their current healthcare needs and to recruit the workforce to address the healthcare demands of the future,” Kopanos said.

Susan Schooleman is a freelance medical writer living in the greater Denver area.

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