The Importance of a Practice Protocol for Nurse Practitioners

Virginia law governing the licensure and practice of nurse practitioners requires that they practice under the supervision of a physician.  Regulations promulgated and adopted by the Board of Nursing and the Board of Medicine further specify that the practice of a nurse practitioner must be “in collaboration with and under the medical direction and supervision of a licensed physician.”  The regulations detail what these terms entail:

"Collaboration" means the process by which a nurse practitioner, in association with a physician, delivers health care services within the scope of practice of the nurse practitioner's professional education and experience and with medical direction and supervision, consistent with this chapter.

"Medical direction and supervision" means participation in the development of a written protocol including provision for periodic review and revision; development of guidelines for availability and ongoing communications which provide for and define consultation among the collaborating parties and the patient; and periodic joint evaluation of services provided, e.g., chart review, case review, and review of patient care outcomes.  Guidelines for availability shall address at a minimum the availability of the collaborating physician proportionate to such factors as practice setting, acuity, and geography.

You will note first that the regulations require that health care services delivered by a nurse practitioner be within the scope of practice of the nurse practitioner’s professional education and experience.

Then you will note that a nurse practitioner is required to have a written protocol.  This written protocol is a practice protocol.  It is different from a clinical protocol that specifies every action to be taken for every set of circumstances you might encounter.  Rather, it is a general document that represents the agreements that the nurse practitioner and the supervising physician have with regard to the nurse practitioner’s practice.

The law requires that the written protocol have several elements:

• A provision for periodic review and revision of the written protocol.  This provision should be spelled out in the written protocol Guidelines for availability and ongoing communications which provide for and define consultation among the collaborating parties [the physician and the nurse practitioner] and the patient.  Note that the guidelines for availability shall address at a minimum the availability of the collaborating physician proportionate to such factors as practice setting, acuity, and geography.
• A provision for periodic joint evaluation of services provided, e.g., chart review, case review, and review of patient care outcomes   
• Authorization from the supervising physician to prescribe physical therapy.
• With the passage of HB-855 during the 2004 session of the General Assembly that authorizes nurse practitioners to sign and certify various documents and forms, the written protocol also must include “the nurse practitioner's authority for signatures, certifications, stamps, verifications, affidavits and endorsements provided it is:

i.           in accordance with the specialty license of the nurse practitioner and with the scope of practice of the supervising physician;

ii.          permitted by § 54.1-2957.02 or applicable sections of the Code of Virginia; and

iii.         not in conflict with federal law or regulation.”

VCNP frequently is asked to be more specific about how a written protocol should be worded.  For example, a nurse practitioner might ask how often should chart review be done, or how close a supervising physician must be.  These factors are not specified in the regulations because they are dependent on a number of factors including the type of practice, the practice setting, the experience of the nurse practitioner, the longevity of the nurse practitioner-physician relationship, the acuity of the patients, and a host of other variables.  It is up to the nurse practitioner and the supervising physician to determine what is reasonable given their specific practice to ensure good quality care.

Please notice that the written protocol is not the same as the practice agreement required for nurse practitioners with prescriptive authority.  A nurse practitioner with prescriptive authority must have both a written protocol and a practice agreement.  A nurse practitioner without prescriptive authority is required to have only a written protocol.

Thus, all nurse practitioners are required to have a written protocol that includes all of these elements to be practicing legally.  To practice without one, or without one that meets the requirements in this definition, risks disciplinary action against both the nurse practitioner and the supervising physician.