The evolution of the usual of look after autonomous nurse practitioners

October 4, 2023 – In line with the American Affiliation of Nurse Practitioners (AANP), nurse practitioners ship “prime quality well being care in additional than 1 billion affected person visits every year,” and as of April 2022, there have been greater than 350,000 licensed nurse practitioners in the US. Enlarging the well being care position of nurse practitioners even additional, many states have lately handed legal guidelines allowing nurse practitioners to observe autonomously, with greater than half of the nation adopting such allowances.

This trending shift in well being care brings advantages and issues alike and magnifies a necessity for authorized readability on the implications of such a shift the place there may be nonetheless a whole lot of gray matter.

Nurse practitioners who can observe autonomously can legally carry out the skilled actions historically reserved for physicians, together with evaluation of a affected person’s situation, ordering diagnostic assessments, decoding outcomes and making diagnoses, prescribing treatment and ordering therapies impartial of a supervising doctor.

The advantage of these legal guidelines is the elevated availability of suppliers, notably within the areas of major care and household drugs, which in flip can result in extra inexpensive choices and fewer delays in remedy. Nonetheless, a priority with these legal guidelines is that in broadening the scope of observe for nurse practitioners, some states are successfully eradicating the “security web” of a supervising doctor, which can result in elevated malpractice actions, particularly actions primarily based on failures to diagnose or misdiagnosis.

As many states solely lately handed autonomous nurse practitioner legal guidelines inside the previous couple of years, there may be not sufficient empirical information to find out whether or not these legal guidelines have been correlated with any enhance in malpractice actions. It needs to be famous that even prior to those autonomous observe legal guidelines going into impact, nurse practitioners have been uncovered to malpractice legal responsibility.

Nonetheless, allowing nurse practitioners to observe impartial of physicians has created questions on what normal of care is relevant to autonomous nurse practitioners. Particularly:

(1) Is the usual of care increased or in any other case completely different for an autonomous nurse practitioner in comparison with a standard nurse practitioner “supervised” by a doctor?

(2) In that case, is the usual of look after an autonomous nurse practitioner equal to that of a doctor training in the identical subject or specialty?

(3) Can physicians nonetheless testify to ascertain the relevant normal of look after an autonomous nurse practitioner?

The precise normal of care in a selected malpractice motion is determined by a mess of things. An evaluation of malpractice actions towards nurse practitioners in two states that handed autonomous nurse practitioner laws (Florida and New York) means that the autonomous standing of a nurse practitioner will not be a consider establishing the relevant normal of care.


In 2020, the Florida Legislature handed laws to permit eligible Superior Observe Registered Nurses (APRNs) to carry the standing of impartial practitioner. Below this regulation, APRNs who meet sure standards to observe major care or midwifery with out doctor supervision or a protocol are given the standing of impartial practitioner.

In 2021, the Florida Board of Nursing established a preliminary definition of “requirements of observe” for autonomous nurse practitioners, which states:

Superior observe registered nurses who’re registered pursuant to Part 464.0123, F.S., shall have interaction in autonomous observe solely in a way that meets the Normal Commonplace of Observe. The Normal Commonplace of Observe shall be that normal of observe, care, talent, and remedy which, in gentle of all related surrounding circumstances, is acknowledged as acceptable and applicable by fairly prudent equally located well being care suppliers. (Emphasis added.)

Nonetheless, this new definition of “normal of care” was unaccompanied by any new laws to ascertain who could present knowledgeable testimony in regards to the relevant normal of look after an autonomous nurse practitioner.Fla. Stat.§ 766.102(6) (2023) offers, “a doctor … could give knowledgeable testimony in a medical negligence motion with respect to the usual of care of such medical assist employees,” together with “nurse practitioners” if the doctor is licensed, qualifies as an knowledgeable beneath subsection (5), and, “by purpose of energetic scientific observe or instruction of scholars, has data of the relevant normal of look after … nurse practitioners.”

As Florida’s autonomous observe act is new, there may be restricted case regulation differentiating the usual of look after a supervised nurse practitioner versus an autonomous nurse practitioner. Nonetheless, a minimum of one Florida courtroom permitted a doctor to supply knowledgeable testimony about the usual of look after an autonomous nurse practitioner pursuant to the present necessities of § 766.102(6) (Univ. of Fla. Bd. of Trustees v. Carmody, Florida Supreme Courtroom, July 2023). Presently, it seems that a Florida nurse practitioner’s autonomous standing doesn’t inherently disqualify a doctor from testifying concerning the relevant normal of care.

New York

In 2022, New York enacted laws permitting for autonomous nurse practitioners. With full observe authority, nurse practitioners in New York can consider, check, diagnose, handle remedy and prescribe drugs for sufferers with out having to signal a contract settlement with a supervising doctor.

N.Y. Comp. Codes R. & Regs. tit. 8 § 64.5(b) offers:

A nurse practitioner who has greater than three thousand 600 hours of expertise training as a licensed or licensed nurse practitioner pursuant to the legal guidelines of New York or every other state or as a nurse practitioner whereas employed by the US Veterans Administration, the US Armed Forces or the US Public Well being Service shall not be required to observe in collaboration with a doctor certified within the specialty concerned and in accordance with a written observe settlement and written observe protocols as set forth in subdivision (a) of this part.

Nonetheless, not like Florida, New York’s Board of Nursing has not explicitly issued a revised definition of “normal of care” or “normal of observe” for autonomous nurse practitioners.

N.Y. Comp. Codes R. & Regs. tit. 10 § 85.43(b) merely states that “[n]urse practitioners shall be licensed to supply well being care providers to eligible medical help recipients which fall throughout the scope of observe for licensed nurse practitioners as decided by the Division of Training (see part 6902 of the Training Regulation and eight NYCRR sections 52.12, 64.5 and 64.6).”

Like Florida, New York has historically allowed physicians to supply knowledgeable testimony in regards to the relevant normal of look after nurse practitioners, though, nurse practitioners usually are not typically allowed to testify a couple of doctor’s normal of care. New York courts, similar to that in Michalko v. DeLuccia, have held that “[a] medical knowledgeable doesn’t need to be a specialist in the identical subject as a defendant physician” to render an opinion about correct remedy (New York Appellate Division, Third Division, 2020).

Additionally in Mills v. Moriarty, the courtroom held that “[t]he nurse-practitioner, who was not a medical physician, lacked the {qualifications} to render a medical opinion as to the related normal of care and whether or not the defendants had deviated from that normal,” (New York Appellate Division, Second Division, 2003).

As a result of New York solely lately permitted autonomous nurse practitioners, there’s a shortage of case regulation relating to malpractice actions towards them. Nonetheless, in reviewing current selections issued after the enlargement of a New York nurse practitioner’s scope of observe, it seems that New York courts nonetheless allow physicians to function knowledgeable witnesses to ascertain the usual of look after malpractice actions towards nurse practitioners. One instance is within the June 2023 case, Heinrich v. Serens, New York Appellate Division, Fourth Division.


The potential of legislatively creating autonomous nurse practitioners stays a subject of debate for a lot of states. Nonetheless, regardless of the nationwide development of increasing the scope of observe for nurse practitioners, it seems state courts haven’t but clearly differentiated the relevant requirements of observe for an autonomous nurse practitioner versus a nurse practitioner supervised by a doctor.

Moreover, each Florida and New York nonetheless allow, and provides nice weight to, the knowledgeable testimony of a doctor even when no doctor was concerned within the underlying malpractice motion towards a nurse practitioner. Due to this fact, whereas autonomous nurse practitioners in lots of states can now “step out of the shadow” of doctor supervision, the relevant normal of look after nurse practitioners remains to be very a lot “supervised” by the knowledgeable testimony of physicians.

Abbye E. Alexander and Christopher J. Tellner are common, joint contributing columnists on well being care litigation for Reuters Authorized Information and Westlaw Immediately.

Opinions expressed are these of the writer. They don’t mirror the views of Reuters Information, which, beneath the Belief Ideas, is dedicated to integrity, independence, and freedom from bias. Westlaw Immediately is owned by Thomson Reuters and operates independently of Reuters Information.