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By Matt Zbrog Reviewed By Jocelyn Blore Updated March 20, 2023 Editorial Values“What I find most concerning is that many nurse practitioners don’t ever read their collaborative agreement. You have to read it, from start to finish, so you understand what’s in it and what it means to your practice.”
Dr. Surani Hayre-Kwan is Director of Professional Practice & Nursing Excellence, Sutter Health
If you are a nurse practitioner (NP) in one of the 23 states that do not have full practice authority, then you will need a collaborative agreement. These agreements, which can go by several different names, detail the working relationship between an NP and a supervising physician. The precise terms of a collaborative agreement will vary notably from state to state, specialty to specialty, and setting to setting.
New NPs can be intimidated by the prospect of procuring, reading, and signing this type of legal document. Template agreements may ease some of their concerns, but there is no substitute for a close and careful reading. Before entering into a collaborative agreement, new NPs should carefully consider their options and fully understand the rules by which they’ll need to abide. They should also consult with their student and professional networks to get a balanced take on what they’re about to sign.
Read on to learn more about the basics of collaborative agreements and what to look out for in collaborative agreement templates.
Dr. Surani Hayre-Kwan is the director of professional practice and nursing excellence at Sutter Health in Sacramento, California. She is responsible for advancing professional practice throughout system affiliates. She provides leadership in professional development, clinical education, and training for nursing and advanced practice clinicians. She was previously the executive director of operations for the Sutter Pacific Medical Foundation.
Dr. Kwan has been a California Association for Nurse Practitioners (CANP) member for nearly 20 years and served as the association’s president for two terms. She is also a certified family nurse practitioner and a Fellow of the American Association for Nurse Practitioners and the American College of Healthcare Executives.
A collaborative agreement template provides a general outline of responsibilities and procedures for an NP and a supervising physician to sign and follow. However, there is no universal standard: collaborative agreements need to be tailored to an NP’s specialty, practice setting, and geographic location. The quality of these collaborative agreement templates can also vary drastically, ranging from what’s freely available on the internet to what’s offered by a major health system.
“Collaborative agreement templates do exist in the workplace, and new NPs should absolutely network to find those resources,” Dr. Kwan says. “But I like NPs to review all the options out there before they make a decision.”
Many times, the template agreements offered by a hospital or health system are ideally suited to a newly employed NP. But this isn’t a place to cut corners: a collaborative agreement defines the boundaries of one’s practice, and these agreements aren’t easily shared between different settings and specialties. A few lines can make a big difference.
“What I find most concerning is that many nurse practitioners don’t even read their collaborative agreement,” Dr. Kwan says. “You have to read it, from start to finish, so you understand what’s in it and what it means to your practice.”
The legal language in a collaborative agreement can be off-putting, but it’s not as scary as it first appears. Generally speaking, collaborative agreements outline the specific ways in which an NP and physician will collaborate. And while new NPs may want to tap into their professional and legal networks before signing one, they’re likely still capable of identifying which parts of a template do or do not apply to them and their practice.
While every state, setting, and specialty can have different requirements around what should be in a collaborative agreement, there is also some overlap between them. Some common elements in an NP collaborative agreement can include:
Despite those common elements, collaborative agreements can still differ significantly. Some NPs will check in more frequently than others with their supervising physicians. In the strictest states, NPs will need to be within a certain geographical distance of their supervising physician to practice. And even within the same state or health system, the specifics of collaborative agreements will vary.
“There still isn’t a good universal resource for collaborative practice agreements,” Dr. Kwan says. “You will find people pocketed in different parts of organizations across the country that might have some expertise in writing them and in understanding how to put the appropriate information into them. But it’s a sad fact that there really isn’t a single source of truth.”
Once you have a collaborative agreement template, you will need a supervising physician to sign it. This isn’t as hard as it sounds: oftentimes, if you’re hired as an NP at a hospital or health system, you’ll be provided with a supervising physician. Sometimes the supervising physician won’t even be on-site and instead be the organization’s medical director.
For NPs who want to practice independently or in rural settings, finding a supervising physician and a relevant collaborative agreement may take more work.
“Before you actually begin a new job, ask who your supervising physician will be,” Dr. Kwan says. “You should reach out to them if they haven’t already reached out to you, and either have an interview or go get coffee with them, so you know who you’re working with. As a new graduate, it’s not safe to assume that something is in existence when it may not be.”
Regardless of their state, setting, or specialty, new and veteran NPs need to understand the rules that govern their practice. It’s healthy to have questions.
“For new NPs, I would direct them back to the faculty of the program they just graduated from,” Dr. Kwan says. “Those are your experts. That’s your village that helps you practice safely for your career. And you will become part of that village as more new graduates come after you. It’s an effective system, but you have to participate in it.”
No collaborative agreement is a substitute for clinical decision-making, nor can it possibly outline every clinical scenario. NPs, like all other healthcare professionals, will always collaborate with other practitioners, whether there is a physical agreement in place to do so or not.
But in some cases, collaborative agreements place limitations on an NP’s ability to practice to the full extent of their training and education. In the worst scenarios, they hinder patients’ ability to access care. Particularly in rural and underserved areas, which have a limited number of physicians, the death or retirement of an NP’s supervising physician may require the NP to stop practicing until a new one can be found.
“It’s a huge deal to close down a clinic, and to reopen a clinic is just as onerous,” Dr. Kwan says.
NPs in states that do not require collaborative agreements are more likely than their physician colleagues to work in rural and underserved areas (CHCF 2019). Research has repeatedly shown that NPs can provide high-quality, cost-effective care to patients (AANP 2022). But the logistical requirements in some collaborative agreements undercuts the ability of an NP to provide that care where it’s needed most.
As of 2023, 29 states and territories have implemented full practice authority and done away with collaborative agreements. In each of those states and territories, NPs have been the driving force of advocacy that’s pushed for more progressive legislation. More states should follow in their footsteps soon.
“The most important thing I can share with new and aspiring NPs is that you have to get involved in advocacy and legislation,” Dr. Kwan says. “There isn’t going to be somebody else who’s going to do this work. It has to be you.”
Matt Zbrog is a writer and researcher from Southern California. Since 2018, he’s written extensively about the modern nursing workforce, conducting hundreds of interviews with nurse leaders, nurse educators, and nurse advocates to explore the issues that matter to them most. His Advocates to Know series focuses on nurse practitioners (NPs) who go above and beyond in changing policy and practice in important areas like veteran’s care, human trafficking prevention, and telehealth access. He regularly collaborates with subject matter experts from the American Nurses Association (ANA) and the National Association of Pediatric Nurse Practitioners (NAPNAP) to elevate issues that empower nurses everywhere.
