Scope of Practice

Where CNSs Can Practice and Prescribe Without Physician Supervision

A review of state laws and regulations reveals that since 2010, eight states have granted clinical nurse specialists (CNSs) the authority to practice without a physician’s supervision and six have given CNSs independent authority to prescribe drugs and durable medical equipment. These represent 32 percent and 40 percent increases, respectively, in the number of states that grant such authority; CNSs can now practice independently in 28 states and prescribe independently in 19.

In addition to the 28 states in which CNSs have independent practice authority, 13 recognize CNSs as Advanced Practice Registered Nurses but require them to have a collaborative practice agreement with a physician.  There are also 19 states that require a CNS to have an agreement with a physician to prescribe drugs and durable medical equipment.

In its landmark report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine  recommended that nurses be able to practice to the full extent of their education and skills. The National Association of Clinical Nurse Specialists commissioned the review to determine how much progress has been made since the publication of that report.  The work was done in consultation with the National Council of State Boards of Nursing.

CNS Scope of Practice and Prescriptive Authority (PDF)

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Full Scope of Practice: States have no requirement for a written collaborative agreement, no supervision, no conditions for practice and CNSs are allowed to practice to the full scope of their education and training.

Collaboration Required: States have a written agreement specifying scope of practice and medical acts allowed with or without a general supervision requirement by a MD, DO, DDS or podiatrist; or direct supervision required in the presence of a licensed, MD, DO, DDS or podiatrist with or without a written practice agreement.

Limited Scope of Practice: CNSs have no advanced practice authority.
*Note: Maryland has granted independent practice authority only to psychiatric and mental health CNSs.

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Independent Authority: States have no requirement for a written collaborative agreement, no supervision, no conditions for practice.

Supervision Required: States have a written agreement specifying scope of practice and medical acts allowed with or without a general supervision requirement by a MD, DO, DDS or podiatrist; or direct supervision required in the presence of a licensed, MD, DO, DDS or podiatrist with or without a written practice agreement.

No Prescribing Authority: An APRN is not authorized to prescribe pharmacologic and non-pharmacologic therapies beyond the perioperative and periprocedural periods.