Ask a Professor: The NP Practice Environment in Oklahoma

“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, Associate Professor and Lead Faculty 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 2020 report from the Association of American Medical Colleges (AAMC) forecast a shortage of as many as 55,200 primary care physicians by 2023. 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 183 Healthcare Professional Shortage Areas that are home to a collective 1.4 million people, which amounts to more than a third of the state’s entire 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 interim chair of advanced practice programs, associate professor, and lead faculty at Oklahoma City University Kramer School of Nursing. She earned her BSN from the University of Central Oklahoma, her MSN from the University of Phoenix, and her DNP from Oklahoma City University. She also holds a post-master’s FNP certificate from Saint Louis University, and a post-master’s PMHNP certificate from the University of Tennessee, Knoxville. 

Dr. Livingston is dual-certified as a family nurse practitioner (FNP) and a psychiatric-mental health nurse practitioner (PMHNP) and teaches both tracks within the DNP program at Oklahoma City University. She is an active member of multiple nursing, advanced practice nursing, and civic organizations.

The Value of Oklahoma’s NPs

Oklahoma is one of the most unhealthy states in the nation. United Health Foundation ranks the Sooner State as fifth worst for socioeconomic factors impacting health, and third worst for access to care. Approximately 14.5 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 the privilege of 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, like the one in place in Oklahoma.

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, when we live in 2022, 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—t 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. And a recent bill by the state’s physical therapists included language that allowed for NPs to prescribe physical therapy. 

Continued collaboration between allied health professions will be a valuable resource. Going forward, Oklahoma’s NPs need to come together to raise awareness about the value of the state’s NPs and how restrictions on their ability to practice limit access to healthcare for Oklahomans. 

“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.”

Matt Zbrog

Matt Zbrog


Matt Zbrog is a writer and researcher from Southern California, and he believes a strong society demands a stronger healthcare system. Since early 2018, he’s written extensively about emerging topics in healthcare administration, healthcare research, and healthcare education. Drawing upon interviews with hospital CEOs, nurse practitioners, nursing professors, and advocacy groups, his writing and research are focused on learning from those who know the subject best.