HomeFeaturesAsk a Professor: The NP Practice Environment in Oklahoma

The Oklahoma NP Practice Environment

“Advocacy is part of our role as professionals. If you hate politics, too bad. You’re in it whether you like it or not.”

Dr. Cene’ Livingston, Professor and Chair of Advanced Practice Programs at Oklahoma City University Kramer School of Nursing

America needs more highly trained healthcare providers. As the Baby Boomers enter into old age, medical schools can’t graduate enough physicians fast enough to meet that demographic’s increasingly complex healthcare needs. A 2024 report from the Association of American Medical Colleges (AAMC) forecast a shortage of as many as 86,000 primary care physicians by 2036. That only captures a portion of the wider picture, as Americans are more than just Baby Boomers, and their healthcare needs stretch well beyond primary care.

Some states, like Oklahoma, are already feeling the effects of this growing healthcare gap. According to the Kaiser Family Foundation, Oklahoma has 190 Healthcare Professional Shortage Areas that are home to a collective 1.2 million people, which amounts to more than a quarter of the state’s population. Historically underserved populations within those areas have it even worse.

Increasing access to quality care is a major issue for Oklahoma, and the state’s nurse practitioners (NPs) could be a critical resource towards that end. But first, Oklahoma’s laws around prescriptive authority for NPs will have to catch up with some of their neighbors.

Meet the Expert: Cene’ Livingston, DNP, APRN, FNP-BC, PMHNP-BC, CNE

Dr. Cene’ Livingston is professor and lead faculty of the PMHNP track at Oklahoma City University’s Kramer School of Nursing. She has served as full‑time faculty since 2012 and brings over 25 years of nursing expertise and 15 years as a nurse practitioner to her role. Dr. Livingston is dual-certified as both a Family Nurse Practitioner and Psychiatric Mental Health Nurse Practitioner and also holds certification as a Nurse Educator.

Dr. Livingston’s teaching interests span psychiatric and primary care, transcultural care, and translational research, while her research focuses on nurse education, cultural humility and diversity in healthcare, and psychiatric topics such as addiction, trauma, and resilience.

Dr. Livingston was first interviewed for this feature in June 2022 and again in July 2024.

Meet the Expert: Michelle Johnston, DNP, APRN, CNP, FNP-BC, AGACNP-BC, CNE

Dr. Michelle Johnston is the lead faculty for the BSN-to-DNP FNP track at Oklahoma City University’s Kramer School of Nursing. She is also president-elect of the Association of Oklahoma Nurse Practitioners (AONP).

Dr. Johnston’s teaching focuses on primary care across the lifespan, including pediatrics, women’s health, and pharmacology. Her scholarly interests include screening for adverse childhood experiences in adults with type 2 diabetes.

A registered nurse since 1995 and a certified family nurse practitioner since 2007, Dr. Johnston brings decades of clinical experience with a focus on children and adolescents in primary care. Since joining the Oklahoma City University full-time faculty in 2018, she has earned her DNP and become a certified nurse educator.

Dr. Johnston was interviewed for an update to this article in August 2025.

The Value of Oklahoma’s NPs

Oklahoma is one of the most unhealthy states in the nation. Approximately 18 percent of Oklahomans don’t have health insurance. The state is particularly deficient in caring for people with obesity, heart disease, and substance abuse disorders—and all these problems are exacerbated in rural areas, which make up a significant portion of Oklahoma’s total area.

NPs are ideally suited to meet Oklahoma’s health challenges. On average, NPs are more likely to work in rural and underserved areas than their physician colleagues are. Most NPs specialize in primary care and are particularly adept at managing chronic conditions. And a foundational aspect of NP practice is a holistic approach that takes all the social determinants of health into consideration, which is a value-add in a state with high wage inequality and restrictive legislation around women’s health.

On paper, NPs are exactly what Oklahoma needs to help fight its biggest health challenges. Unfortunately, the state has decades-old legislation restricting NPs from doing precisely what they’ve been trained to do.

The Burdens of Restricted Practice in Oklahoma

In Oklahoma, NPs are permitted to practice independently. However, they are not allowed to prescribe medications and treatments without first entering into a supervisory agreement with a physician. In most other states, this barrier to practice does not exist: NPs are extensively educated and trained in how to safely and effectively prescribe in the course of offering proper care to patients.

“The ability to prescribe is a fundamental tool to any NP,” Dr. Livingston says. “It’s a necessity, particularly when dealing with chronic conditions and mental health issues, which are two of the biggest health concerns in Oklahoma.”

Often, the ‘supervisory’ aspect of any practice agreement is little more than figurative. The supervising physician can be in a different city or even in a different state; they are not reviewing charts or authorizing courses of treatment. The supervisory misnomer is similar to that of the collaborative agreements in place in other states, which don’t foster collaboration but impede it.

“Any good NP understands that you’re just one part of the healthcare system working in collaboration with so many other entities, people, and professionals,” Dr. Livingston says. “You cannot provide adequate and effective care alone. But these rules restrict access to that care.”

If a physician refuses to sign an NP’s supervisory agreement, or if a supervising physician dies or retires, then an NP will need to find a new physician to sign for them, or else they can’t continue providing a large aspect of care: prescribing medications. That’s a big deal anywhere, but especially in rural areas, where patients don’t have easy access to an alternative provider.

“Rural areas are where we see the biggest negative impact of supervisory agreements,” Dr. Livingston says. “The NPs who work in rural areas are isolated, to a degree. If the NP doesn’t already know a physician who will sign the agreement, it can be very difficult, and/or expensive, to find a physician who will.”

Supervisory agreements aren’t creating a rigorous, systemized way of regulating NP practice. Experiences are uneven and, sometimes, unfair. Some physicians are amenable to the idea of NPs providing the care they’ve been trained to provide, while other physicians charge fees for signing an NP’s paperwork. And, in states like Oklahoma, the average physician’s understanding of the modern NP role is still potholed.

“Some physicians are reluctant to sign supervisory agreements because they fear that the NP will do something wrong and that they, as a physician, will somehow be implicated,” Dr. Livingston says. “But we have our own National Provider Identifier (NPI). We have our own Drug Enforcement Agency (DEA) number. We have our own insurance. If something goes awry, it’s not the physician who will be held accountable.”

NPs in Oklahoma deserve better, and so do their patients. Restrictive practice laws like those in Oklahoma were developed and enacted in the previous century, and, as a result, they regulate the type of nurse practitioner who existed in the previous century. But the modern NP is different.

Today, NP educational standards have matured, diversified, and specialized to the point of being incomparable to their condition at the time when these restrictive laws were created. Contemporary research has repeatedly shown that modern NPs provide high-quality, cost-effective care that improves patient outcomes. The only aspect of NP practice that hasn’t evolved is the type of law restricting it.

The Fight for Modern Legislation

“I’m still hopeful,” Dr. Livingston says. “One day, this state will come into the modern age and recognize that the world around it has evolved significantly, and we need to catch up. But you have to question the status quo. You have to ask yourself, why are we running on standards initiated eons ago?”

Dr. Livingston lives and works in Oklahoma, but she’s originally from Kansas, the most recent state to grant its NPs full practice authority. Full practice authority creates no new scope of practice for NPs, nor imbues NPs with any special rights—it simply allows NPs to practice to the full extent of their education and training, as they do in a majority of states.

NPs in Kansas are not more qualified than those in Oklahoma, either: they receive the same level of education and training, and both are overseen by a Board of Nursing. But some NPs in states like Oklahoma may consider moving to more progressive states like Kansas, where they can have more of a positive impact on patient outcomes.

“The idea of moving has crossed my mind once or twice,” Dr. Livingston says, with a laugh. “But no, I like it here. My family’s here. And I think I’m in a unique position to improve patient outcomes by helping NP students see a bigger picture. We’re not in competition with doctors. There are more than enough patients to go around! But we do want to contribute as much as we possibly can.”

The road to full practice authority is almost always built from smaller regulatory wins. So far, progress has been slow in Oklahoma. But the wider community is starting to realize the power of NPs utilizing telehealth for primary care services, particularly in rural areas. Continued collaboration between allied health professions will be a valuable resource.

“If we want healthcare to change, we have to do more,” Dr. Livingston says. “Over the last few years, a lot of blame has gone to our lobbyists. But in my opinion, we as NPs can be more well-versed on the legislative process and how to communicate with legislators. Advocacy is part of our role as professionals. If you hate politics, too bad. You’re in it whether you like it or not.”

Update 2025: Progressive Steps, Bright Future

In 2024, the Oklahoma House and Senate passed a bill that would’ve allowed NPs a pathway to full practice authority, but that bill was vetoed by the governor. Undeterred, Oklahoma’s NPs pushed a similar bill through in 2025, and this time the governor’s veto was overturned. HB 2298, which goes into effect on November 1, 2025, allows APRNs who have completed 6,240 clinical practice hours to apply for independent prescriptive authority.

Requiring a collaborative agreement with a physician to monitor prescriptive authority has, up until now, placed an unnecessary burden on NP practice in Oklahoma. Finding a physician to sign their prescriptive authority could be expensive, time-consuming, and sometimes simply not possible: many NPs chose to work with large health systems, where assistance in finding a collaborating physician was provided to them.

“This bill allows nurse practitioners more freedom to practice,” Dr. Johnston says. “NPs can now more easily move to more independent settings, and expand their practice into areas where there are people, but not providers.”

Rural care is important everywhere, but it’s particularly important in Oklahoma, where almost a third of the population lives in non-metropolitan areas (RHI 2024). Health disparities are worse in the rural parts of Oklahoma (OU 2020). And natural-cause mortality rates are much higher in rural areas than they are in metropolitan areas (USDA 2024). Introducing more highly qualified primary care providers would have a significantly positive effect. Fortunately, NPs are more likely than physicians to practice in rural and underserved areas. And now that there’s a pathway for independent practice in Oklahoma, more NPs can do exactly that.

“Next, we need to work on being able to prescribe schedule two substances,” Dr. Johnston says. “We have providers who need to prescribe ADHD medicine, for example, but can’t, because they’re not permitted to by law, still.”

There are other exceptions to what full prescriptive authority will mean for Oklahoma’s NPs. They’re still not allowed to prescribe diabetic shoes (the law on that is at the federal level). And while they can write follow-up or continuation orders for a patient who has been certified for home health care, they can’t independently initiate or certify eligibility for home health services.

“There are a lot of little things left to fight for that would help us better serve our patients,” Dr. Johnston says.

As HB 2298 comes into effect, Oklahoma’s NPs can focus their advocacy efforts on these areas. They can also expand into other areas, like educating patients on the efficacy of vaccines. Perplexing messaging at the federal level has coincided with fresh outbreaks of measles. Vaccination rates in Oklahoma kindergartens fell approximately 1 percent from 2023 to 2024 (CDC 2024).

NPs are being asked to do a lot in Oklahoma. But, under Medicare, they’re still reimbursed at 80 percent of the physician fee schedule when they bill independently, despite multiple studies showing they provide an equivalent quality of care as physicians do. Lower reimbursement rates mean an NP may need to see more patients in order to recoup the difference, putting stress on their already busy time: not only seeing patients, but performing chart reviews, prescription refills, and patient callbacks—all the elements that go into good quality care.

But Oklahoma’s NPs have many reasons to be optimistic. The state’s stance towards NP practice continues to trend in a progressive direction. More freedom to practice benefits all of Oklahoma’s patients.

“There’s a widening primary care gap, with fewer physicians going into primary care,” Dr. Johnston says. “NPs are well-suited to fill that gap. And as we move towards independent practice and being able to care for our patients to the full extent of our education, I think we will fill it.”

Matt Zbrog

Writer

Matt Zbrog is a writer and researcher from Southern California, and he believes nurse practitioners (NP) are an indispensable component of America’s current and future healthcare workforce. Since 2018, he’s written extensively about the work and advocacy of NPs, with a particular focus on the rapid growth of specialization programs, residencies, fellowships, and professional organizations. As part of an ongoing series on state practice authority, he’s worked with NP leaders, educators, and advocates from across the country to elevate policy discussions that empower NPs. His articles have featured interviews with the leadership of the American Association of Nurse Practitioners (AANP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and many other professional nursing associations.