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Группа авторов. The Advanced Practice Registered Nurse as a Prescriber
Table of Contents
List of Tables
List of Illustrations
Guide
Pages
The Advanced Practice Registered Nurse as a Prescriber
Contributors
Preface
1 What Do APRN Prescribers Need to Understand?
THE JOURNEY OF APRN PRESCRIPTIVE AUTHORITY
Washington State as an exemplar
OVERVIEW OF CHAPTERS
CONCLUSION
REFERENCES
2 Embracing the PrescriberRole as an APRN
DEVELOPMENT OF THE APRN ROLE
DEVELOPMENT OF THE APRN ROLE AND PRESCRIPTIVE AUTHORITY. Prescriptive authority
ADAPTING TO THE APRN’S ROLE AS PRESCRIBER. Transition to the prescribing role
Prescriptive authority and responsibility
Professional relationships
Strategies for success as a prescriber
BARRIERS TO TRANSITIONING TO THE PRESCRIBER ROLE
A FRAMEWORK FOR PRESCRIBING. Rational prescribing
Knowledge of the patient
Knowledge of the disease and standard management
Patient education and shared decision making
Box 2.1 Strategies for improving rational prescribing
Maintaining a trust relationship with the patient
SPECIAL CONSIDERATIONS FOR PRESCRIBING. Overview
Prescribing for specific populations
Other special considerations
THE FUTURE OF THE APRN PRESCRIBING ROLE
REFERENCES
3 Creating a Practice Environmentfor Full Prescriptive Authority
EXTERNAL BARRIERS TO PRESCRIBING. Federal laws and policies
State laws and rules
Box 3.1 Georgia Board of Nursing selected rules on APRN prescriptive authority
Box 3.2 Georgia Composite Board of Medicine rules on APRN prescriptive authority
Other barriers
INTERNAL BARRIERS TO PRESCRIBING
STRATEGIES TO ADDRESS PRESCRIBING BARRIERS
ELIMINATING EXTERNAL BARRIERS TO PRESCRIBING. Legislative activities
Box 3.3 Recommendation: educate policymakers about the benefits of APRN practice
Box 3.4 Influencing legislative change. Know how the process works
Make yourself the expert
Get to know your legislators
Get to know legislative staff
Network with other citizens
Regulatory changes
Advocacy
Developing political competence for effective advocacy
Box 3.5 Barriers to political competence. Using force versus power
Box 3.6 Recommendation: prepare APRNs for a new scope of practice before legislation actually passes
ELIMINATING INTERNAL BARRIERS TO PRESCRIBING
Role development in APRN programs
Professional development for the experienced APRN
IMPLICATIONS
REFERENCES
4 Regulation of PrescriptiveAuthority
A MODEL FOR APRN FULL PRACTICE AUTHORITY
Box 4.1 Washington law: autonomous prescribing
CONSENSUS MODEL FOR APRN REGULATION. LACE
Licensing
Accreditation
Certification
Education
HISTORY OF APRN PRESCRIBING REGULATION
AUTONOMOUS PRESCRIPTIVE AUTHORITY
Box 4.2 Virginia law: joint jurisdiction
Collaboration
The National Provider Identifier
OTHER REGULATORY REQUIREMENTS
PRESCRIPTIVE AUTHORITY LIMITATIONS
Box 4.3 Utah Controlled Substances Act Rules (2019): applies to all prescribers
Medication samples
Formularies
Dispensing
Box 4.4 Oregon law: dispensing limits
Quantity limitations
Co‐signatures
Mail order/prescribing across state lines
CONCLUSION
REFERENCES
Notes
5 Global Prescribing
DEFINING THE ADVANCED PRACTICE NURSE GLOBALLY
Midwifery
Nurses as anesthesia providers
Clinical nurse specialists
Nurse practitioners
COUNTRIES WITH ADVANCED PRACTICE ROLES
TASK SHARING
NURSE PRESCRIBING
United Kingdom
Poland
Ireland
Canada
OUTCOMES OF NURSE PRESCRIBING
APRN PRESCRIBING
Australia
Canada
New Zealand
United Kingdom
United States
CONCLUSION
REFERENCES
6 Managing Difficult andComplex Patient Interactions
KNOWLEDGE OF SELF AS THE FOUNDATION FOR PROFESSIONAL GROWTH
Box 6.1 Developing mindfulness in everyday practice
Box 6.2 Framework to guide reflective practice
Box 6.3 Case example of miscommunication
MOTIVATIONAL INTERVIEWING AS THE FOUNDATION FOR COUNSELING ABOUT CHANGE
ETHICAL CONSIDERATIONS WHEN DEALING WITH DIFFICULT AND COMPLEX PATIENT INTERACTIONS
Box 6.4 OARS
ENGAGING PATIENTS WITH SUBSTANCE‐RELATED CONCERNS
Box 6.5 Five major steps to intervention (the “5 As”)
THE OPIOID EPIDEMIC AS A PROMPT FOR DIFFICULT CONVERSATIONS
Box 6.6 Recovery Research Institute “Addictionary” – stigma alert
MANAGING INTERACTIONS THAT CAN LEAD TO BOUNDARY VIOLATIONS
Box 6.7 Case example: expectations
Box 6.8 Red flag behaviors
ENGAGING PATIENTS WITH BEHAVIORAL HEALTH ISSUES
Borderline personality disorder
SOMATIC SYMPTOMS AND RELATED DISORDERS. Patients with extreme health anxiety
Recognition of somatic symptoms
Management of somatic symptoms
Box 6.9 Practice management strategies for somatic symptoms
RESPONDING TO A REQUEST FOR INAPPROPRIATE TREATMENT
Box 6.10 Strategies to say no
PATIENT ISSUES ABOUT THEIR TREATMENT RECOMMENDATIONS
The Choice Triad as an approach to address differences
Box 6.11 The Choice Triad
Box 6.12 Case example: patient‐centered care
CONCLUSION
REFERENCES
7 Practical Considerations when Prescribing Controlled Substances
DEFINITIONS RELATED TO CONTROLLED SUBSTANCES
Box 7.1 Controlled substance schedules
Box 7.2 Definitions related to controlled substances
THE OPIOID EPIDEMIC
The historical cycle of treating pain in the United States: a swinging pendulum
The opioid overdose epidemic
BEST PRACTICES WHEN PRESCRIBING CONTROLLED SUBSTANCES
A universal approach
Box 7.3 Universal precautions in pain medicine
Risk stratification and referral
CLINICAL GUIDELINES AND CONSENSUS STATEMENTS
Opioid guidelines
CDC opioid prescribing guideline
Box 7.4 Risk factors for adverse outcomes or overdose from opioid therapy
Box 7.5 Centers for Disease Control and Prevention (CDC) recommendations for prescribing opioids for chronic pain outside of active cancer, palliative, and end‐of‐life care. (Note: Bold highlights by the author.)
Veterans Health Administration and Department of Defense opioid therapy clinical practice guidelines
Washington State opioid guideline
CLINICAL GUIDANCE FOR BENZODIAZEPINES AND OTHER CONTROLLED SUBSTANCES
Benzodiazepines and benzodiazepine receptor agonists
Stimulants
ASSESSMENT OF PATIENTS PRIOR TO INITIATING A CONTROLLED SUBSTANCE
Patient history
Box 7.6 Screening and monitoring tools for controlled substance prescribing
Physical examination
Diagnostic testing
State Prescription Drug Monitoring Programs
Urine drug testing
Box 7.7 Urine drug testing assays
Box 7.8 Urine drug screen interpretation: selected opioid metabolites
Consultation
Diagnosis
INITIATING CONTROLLED SUBSTANCE PRESCRIPTIONS
Managing patient expectations
Treatment agreements
Initial dosing
Box 7.9 Examples of content that may be included in opioid or controlled substance treatment agreements
Therapeutic trial
Approach to new patients who are currently taking controlled substances
New patients
The “inherited patient”
Coverage for colleagues
Options for future therapy
Naloxone for management of opioid overdose
DEA “X” license
MONITORING OF PATIENTS RECEIVING CONTROLLED SUBSTANCE PRESCRIPTIONS
Frequency of visits
Writing renewal prescriptions
Documentation
STRATEGIES FOR TAPER AND DISCONTINUATION OF CONTROLLED SUBSTANCES
Standing firm in decision
Self‐care
Tapering controlled substances
Misapplication of guidelines when tapering opioids
Benzodiazepine taper
Opioid use disorder and substance use disorder
CONCLUSION
Box 7.10 Criteria for diagnosis of opioid use disorder
REFERENCES
8 Legal Aspects of Prescribing
WHAT DO ADVANCED PRACTICE REGISTERED NURSE (APRN) PRESCRIBERS NEED TO KNOW ABOUT THE LAW?
CASES INVOLVING BOARDS OF NURSING
Box 8.1 Terminology
NP prescribing inconsistent with standard of care
Lessons learned
NP failed to respond to the effect of prescribed medications
Lesson learned
NP prescribed for self or family
Lesson learned
NP prescribed outside of legal authority
Lesson learned
CASES INVOLVING CONSULTATION WITH ATTORNEYS
NP prescribed without legal authority and appropriate monitoring
Lesson learned
CASES INVOLVING THE DEA
NP prescribed without DEA registration
Lesson learned
CASES INVOLVING GOVERNMENT AUDITORS
NP failed to document a verbal order
Lesson learned
SUMMARY
PUBLIC ACCESS TO LICENSURE STATUS, AND BOARD AND CIVIL ACTIONS
FEDERAL PRESCRIBING LAWS
Who may prescribe controlled substances?
Purpose of a controlled substance prescription
Form of prescription
Electronic prescribing
Restrictions on amounts prescribed
Special rules for Schedule II substances
Box 8.2 Ten advantages of EPCS
Schedule III–V substances
Delivery of a controlled substance to persons outside the United States
How to avoid problems as a prescriber of controlled substances
Record‐keeping requirements
Disposal of controlled substances
Requirements regarding prescription pads
Prescribing off‐label
STATE LAWS ON PRESCRIBING. Authority to prescribe
Physician involvement
Prescribing for self or family members
Box 8.3 Example of state law authorizing APRN prescribing in Pennsylvania
Box 8.4 Kentucky advisory opinion on prescribing for self, family and others in a personal relationship
Formularies
Standard of care and risk management recommendations of prescribing
Box 8.5 Alabama CRNP/CNM formulary of drug classifications
Standard Legend Drugs
Specialty Legend Drugs
LIABILITY INSURANCE
Types of insurance
CONCLUSION
DISCLAIMER
REFERENCES
9 Medical Marijuana and the APRN
DEFINITIONS
PHARMACOLOGY
LEGALIZATION
People who use marijuana
Support for marijuana legalization
US federal law
US state laws
AUTHORIZATIONS. Requirements to provide authorization
Requirements about the patient–provider relationship
Qualifying conditions
Screening prior to authorization
Providing authorization
Patient evaluation
Informed and shared decision making
Treatment
Documentation
Box 9.1 Appendix 1 Medicinal Cannabis Agreement
Patient education
Sample guidelines
Legal issues
Box 9.2 Authorization practice guidelines from Washington State
SECTION 1: PATIENT EVALUATION
SECTION 2: TREATMENT PLAN
SECTION 3: ONGOING TREATMENT
SECTION 4: TREATING MINOR PATIENTS OR PATIENTS WITHOUT DECISION MAKING CAPACITY
SECTION 5: MAINTENANCE
SECTION 6: CONTINUING EDUCATION
Reasons why clinicians do not provide authorization
THE EVIDENCE BASE FOR MEDICAL MARIJUANA
Sources of evidence
What is the evidence?
Guidelines for APRN practice and education
Box 9.3 Selected findings of The Health Effects of Cannabis and Cannabinoids report (pp. 13–14)
Box 9.4 NCSBN recommendations for APRN student education
Box 9.5 NCSBN recommendations for APRN practice
CONCLUSION
REFERENCES
Index
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