Las Vegas — Protocols related to physician oversight, inability to order home health services and regulations on prescribing controlled substances are among the top concerns of NPs who practice independently, according to researchers at the American Association of Nurse Practitioners (AANP) 2013 National Conference.

NPs are expected to help fill in gaps in primary healthcare needs as the Affordable Care Act takes effect, creating additional opportunities for NP entrepreneurship. But unfavorable legislation, restrictions in federal and state health programs and economic inconsistencies continue to pose challenges to independent NP practice, Janet DuBois, DNP, ARNP, FNP-BC, FAANP, of the University of Arizona College of Nursing in Tucson, reported during a poster session.

She and colleagues surveyed a random sample of independent ARPNs from 20 states, who were listed on the AANP website, via email. The survey consisted of 38 questions related to marketing and business practices, demographics, barriers to practice, financial information, physician supervision and NP satisfaction.

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Physician contracts (69%), protocols for physician oversight (36%), inability to order home health (29%), and inability to prescribe controlled substances (24%) were among barriers to practice most often reported, Dubois and colleagues found.

Other barriers included inability to order hospice care (20%), supervision for initial prescriptive authority (17%), lack of reimbursement from third party payers (17%) and inability to sign death certificates (13%).

In terms of business and finance the majority of NPs had no business or marketing training (56%) or customer service training (61%). Only 20% reported using social media, and most indicated they relied on word of mouth for advertising.

“There is a lack of formal business and marketing training and education,” Dubois said. “Newer marketing strategies such as using social media and the internet are underutilized.”

Despite these factors, the majority of independent NP practices reported being profitable in less than 2 years.

“The greatest challenges to practice management were increases in management time, billing and collection issues and overhead costs,”  Dubois said.

Most participants were aged 50 to 60 years (70%), held a Master’s degree (76%) and had been in practice for more than 10 years (72%). NPs from three states – Florida, Alabama and Kentucky — comprised the bulk of study participants (60%).

Most reported having no prescriptive authority for controlled substances (58%). However, about one-quarter (24%) were able to prescribe controlled substances in Schedules II through V.

Study limitations included a large proportion of participants practicing in Florida, a state that does not allow NPs to prescribe controlled substances or hold a Drug Enforcement Administration License, due to limited access to NP groups and difficulty identifying NP owned independent practices.

Areas for further study include determining better ways to identify independent practice owners for future research and developing strategies to address barriers to practice and lack of business/marketing knowledge.


Dubois J, Green R, Aertker J. Poster #303. “Characteristics and Barriers of Nurse Practitioners in Independent Practice.” Presented at: American Association of Nurse Practitioners 2013 National Conference. June 19-23, 2013; Las Vegas.