Nurse practitioner

Nurse practitioner

Family Nurse Practitioner Lt. Cmdr. Michael Service cares for a young girl at the U.S. Naval Hospital (USNH) Yokosuka.
Occupation
Occupation type
 healthcare professional
Activity sectors
 healthcare, advanced practice registered nurse
Description
Education required
 Master's degree or doctorate. The American Association of Colleges of Nursing (AACN) recommends complete transition to the Doctor of Nursing Practice (DNP) by 2015.
Related jobs
 nurse midwife, nurse anesthetist, clinical nurse specialist

Nurse practitioners are advanced registered nurses educated and trained to provide health promotion and maintenance through the diagnosis and treatment of acute illness and chronic condition. According to the International Council of Nurses, an advanced practice registered nurse (APRN) is "a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master's degree is recommended for entry level."[1]

Overview

Nurse practitioners (NPs) manage acute and chronic medical conditions, both physical and mental, through history and physical exam and the ordering of diagnostic tests and medical treatments. NPs are qualified through state legislation to diagnose medical problems, order treatments, perform some procedures, prescribe medications,[2] and make referrals for a wide range of acute and chronic medical conditions within their scope of practice which is loosely defined depending on the state, as long as there is a supervising physician overseeing their work closely. Nurse Practitioners have become an integral part of the medical and health care system, due to the combination of experience and expertise they bring with them. Work experience as a nurse gives them a special approach in providing patient care, while their advanced studies provide the expertise and capability to carry on tasks otherwise assigned to administrators, as they take intense courses on leadership, health care policy, and lobbying.[3] NPs work in hospitals, private offices, clinics, and nursing homes/long term care facilities. Some nurse practitioners contract out their services for private duty, though fore safety they still require the expertise of a supervising physician.


In the United States, depending upon the state in which they work, nurse practitioners may or may not be required to practice under the supervision of a physician which is felt to be dangerous by many. In consideration of the shortage of primary care/internal medicine physicians, many states are eliminating "collaborative practice" agreements because of the persistent nurse lobby and nurse practitioners are able to function independently through legislation rather than through education. NPs—particularly in the area of primary care/internal medicine—fulfill a vital need for patient healthcare services, and the nurse practitioner should work with physicians, medical/surgical specialists, pharmacists, physical therapists, social workers, occupational therapists, and other healthcare professionals to achieve the best outcomes for patients.

NPs may serve as a patient's primary healthcare provider with a supervising physician, and they may treat patients of all ages depending upon their specialty. With commensurate education and experience, NPs may specialize in areas such as cardiology, dermatology, oncology, pain management, surgical services, orthopedics, women's health, and other specialties. There are no special board examinations NPs take to claim to be specialists in such areas, and they can move from specialty to specialty in this current system without appropriate formal education in them. Physicians require closely supervised fellowship training for years and pass 9-hour board to prove mastery of the specialty before they are allowed to practice in that specialty. Similar to all healthcare professions, the core philosophy of the nurse practitioner role is individualized care that focuses on a patient's medical issues as well as the effects of illness on the life of a patient and his or her family. NPs tend to concentrate on a holistic approach to patient care, and they emphasize health promotion, patient education/counseling, and disease prevention, as their scholastic curriculum is devoid of significant courses in pathophysiology, pharmacology, physiology, or biochemistry. The main classifications of nurse practitioners are: adult (ANP); acute care (ACNP); gerontological (GNP); family (FNP); pediatric (PNP); neonatal (NNP); and psychiatric-mental health (PMHNP). Adult-gerontology primary care nurse practitioner (AGPCNP) is a classification that has recently evolved.

In addition to providing a wide range of healthcare services, nurse practitioners may conduct research or teach, and they are often very active in legislative lobbying for expanded scope of practice and development of healthcare policy at local, state, and national levels.

History

The advanced practice nursing role began to take shape in the mid-20th century United States. Nurse anesthetists and nurse midwives were established in the 1940s, followed by psychiatric nursing in 1954. The present day concept of the APRN as a primary care provider was created in the mid-1960s, spurred on by a national shortage of medical doctors. The first formal graduate certificate program for nurse practitioners was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965, with a vision to help balance rising healthcare costs, increase the number of healthcare providers, and correct the inefficient distribution of health resources. In 1971, The U.S. Secretary of Health, Education and Welfare, Elliot Richardson, made a formal recommendation in expanding the scope of the nursing practice and qualifying them to be able to serve as primary care providers.[4] During the mid 1970s to early 1980s, the completion of a master's degree became required in order to become a certified nurse practitioner. In 2012, discussions have risen between accreditation agencies, national certifying bodies, and state boards of nursing about the possibility of making the DNP as the new minimum of education for NP certification and licensure by 2015.[5]

Scope of practice

United States

In the United States, because the profession is state-regulated, care provided by NPs varies and is limited to their education and credentials. Many NPs seek to work independently of physicians despite not having the years of formal training required of physicians, while in some states a supervisory agreement with a physician is required for practice.[6][7] The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, pharmacologic recommendations, etc. again varies widely amongst states of licensure/certification.[8][9][10]

The "Pearson Report" provides a state-by-state breakdown of the specific duties an NP may perform in the state.[11] A nurse practitioner's role may include the following:

Nurse practitioners can legally examine patients, diagnose illnesses, prescribe medication, and provide treatments. These are responsibilities similar to those of physicians, but NPs do not have the same authority in all 50 states, nor do they have the same education as physicians. Just under half of the country permits NPs the authority to practice on their own. In fact, 22 states (plus D.C.) give full practice authority to NPs. Thirty-eight states require NPs to have a written agreement with a physician in order to provide care. Even with the formal agreement between physician and NPs, their practice is restricted in at least one domain (e.g., prescribing, treatment). Twelve of those states appropriately restrict NPs even more. In order for NP's to provide care to patients, they are required to be supervised or delegated by a physician.[12] The states in the Pacific Northwest, the Mountain states, and in upper New England generally permit more freedom to NPs. Many states in the South are the most restrictive states.

Canada

In Canada, an NP is a registered nurse with a graduate degree in nursing. Canada recognizes them in the following specialties: primary healthcare NPs (PHCNP) and acute care NPs (ACNP). NPs diagnose illnesses, prescribe pharmaceuticals, order and interpret diagnostic tests, and perform procedures in their scope of practice. PHCNPs work in places like community healthcare centers, primary healthcare settings and long term care institutions. The main focus of PHCNPs includes health promotion, preventative care, treatment and diagnosis of acute illnesses and injuries, and overseeing and managing chronic diseases. ANCNPs are specialized NPs who serve a specific population of patients. They administer care to individuals who are acutely, critically or chronically ill patients. ANCNPs generally work in in-patient facilities that include neonatology, nephrology, and cardiology units.[13]

Education, licensing, and board certification

United States

The path to becoming a nurse practitioner in the United States begins by earning a Bachelor of Science in Nursing (BSN) or other undergraduate degree, and requires licensure as a registered nurse (RN) and experience in the generalist RN role. Then, one must graduate from an accredited graduate (MSN) or doctoral (DNP) program. The typical curriculum for a nurse practitioner program includes courses in epidemiology; health promotion; basic pathophysiology; physical assessment and diagnostic reasoning; basicpharmacology; laboratory/radiography diagnostics; statistics and research methods; health policy; role development and leadership; minor acute and chronic disease management (e.g., adults, children, women's health, geriatrics, etc.); and clinical rotations, which varies widely depending on the program and population focus. Clinical rotations for NPs do not involve direct patient management, formal didactics, or an appropriate hospital setting. Rotation hours can also include "independent study" which can consume the required hours, depending on the online school. Doctor of Nursing Practice (DNP) programs include additional, basic biostatistics; research methods; clinical outcome measures; general care of special populations; organizational management; informatics; and healthcare policy and economics. DNP programs also require completion of a research project. There is no residency for NPs as there are required of newly-minted physicians before being allowed to practice. Some nurse practitioners, as well as other APRN roles, may choose to pursue the Doctor of Philosophy (PhD) as a terminal degree. The PhD in nursing focuses on nursing research and nursing education, while the DNP focuses more on clinical practice.

There is an initiative to require the DNP as the entry level degree for all APRN roles, including the nurse practitioner, nurse anesthetist, clinical nurse specialist, and nurse midwife. Those who have a MSN but are currently practicing in an APRN role would be grandfathered into this change without having any extra education. Many universities have started to phase out MSN programs in lieu of this expected change and have devised BSN-DNP programs. NPs may elect to complete a postgraduate residency or fellowship, but they do not exist as there is no formal graduate medical education body for NPs that is required to govern such training. The majority of such programs focus on primary care; however, specialized programs (e.g., acute care, emergency medicine, cardiology, general surgery, etc.) also exist but are not required.

After completing the required education, the NP must pass a national board certifying exam in a specific population focus: acute care, family practice, women's health, pediatrics, adult-gerontology, neonatal, or psychiatric-mental health, which coincides with the type of program from which he or she graduated. After achieving board certification, the nurse practitioners must apply for additional credentials (e.g., APRN license, prescriptive authority, DEA registration number, etc.) at the state and federal level. The nurse practitioner must achieve a certain amount of continuing medical education (CME) credits and clinical practice hours in order to maintain certification and licensure. NPs are licensed through state boards of nursing.

Australia

In Australia, NPs are required to be registered by the Australian Health Practitioner Regulation Agency.[14] The Australian professional organisation is the Australian College of Nurse Practitioners (ACNP).[15]

Canada

In Canada, the educational standard is a graduate degree in nursing. The Canadian Nursing Association (CNA) notes that advanced practice nurses must have a combination of a graduate level education and the clinical experience that prepare them to practice at an advanced level. Their education alone does not give them the ability to practice at an advanced level. Two national frameworks have been developed in order to provide further guidance for the development of educational courses and requirements, research concepts, and government position statements regarding APRNs: The CNA's Advanced Nursing Practice: A National Framework and the Canadian Nurse Practitioner Core Competency Framework. All educational programs for NPs must achieve formal approval by provincial and territorial regulating nurse agencies due to the fact that the NP is considered a legislated role in Canada. As such, it is common to see differences among approved educational programs between territories and provinces. Specifically, inconsistencies can be found in core graduate courses, clinical experiences, and length of programs. Canada does not have a national curriculum or consistent standards regarding advanced practice nurses so all APRNs must meet individual requirements set by the provincial or territorial regulatory nursing body where they are practicing. In conclusion, the completion of a graduate education, a passing of an exam through the CNA Nurse Practitioner Exam Program, and a successful registration within the appropriate territory or province is required in order to practice as a nurse practitioner in Canada.[13]

Other countries

There are nurse practitioners in over fifty countries worldwide. Although credentials vary by country, most NPs hold at least a master's degree worldwide.

As of November 2013, NPs were recognized legally in Israel. The law passed on November 21, 2013.[16] Although in the early stages, the Israeli Ministry of Health has already graduated two NP classes - in palliative care and geriatrics. The law was passed in response to a growing physician shortage in specific health care fields, similar to trends occurring worldwide.

Nurse practitioner titles were in the past bestowed on some advanced practice registered nurses in the Netherlands. The title has now changed to that of Nursing Specialist. The idea is still the same: a master's-degree-level independently licensed nurse capable of setting indications for treatment independent of an MD.

Salary

The salary of a nurse practitioner depends on the area of specialization, location, years of experience, level of education, and size of company. In 2015 the American Association of Nurse Practitioners (AANP) conducted its 4th annual nurse practitioner salary survey. The results revealed the salary range of a NP to be between $98,760 to $108,643 reported income among full-time NPs. According to the U.S. Bureau of Labor Statistics, nurse practitioners in the top 10% earned an average salary of $135,800. The median salary was $98,190. According to a report published by Merritt Hawkins, starting salaries for NPs increased in dramatic fashion between 2015 and 2016. The highest average starting salary reached $197,000 in 2016. The primary factor in the dramatic increase in starting salaries is skyrocketing demand for NPs, recognizing them as the 5th most highly sought after advanced health professional in 2016. [17] Oddly enough, the average starting physician salary for those who just graduated medical school and passed the appropriate national exams is around $45,000, and they are expected to work around 80 hours per week.

Increasing need in US

Employment of registered nurses and nurse practitioners is expected to increase immensely in the next ten years through legislation and the idea of short-term savings. Much of the growth is expected to come as a result of legislation and proliferation of online schools, leading to the idea of better health care and a greater variety of solutions for health problems which have not been proven through appropriate research. Also, life expectancy is getting longer; therefore more patients are living longer and living more active lives. It is further anticipated that the need for NPs will increase because of the passage of the Patient Protection and Affordable Care Act (PPACA).[18][19][20]

Growth is also expected to be much faster in outpatient centers, where the patients do not stay overnight. Moreover, the increasing number of procedures that were once only available in hospitals are now in physicians' offices. The need for NPs is expected to be greatest in places where people have long-term illnesses such as dementia or head trauma patients that are in need of extensive rehabilitation.

"Nurse practitioners really are becoming a growing presence, particularly in primary care," said David I. Auerbach, PhD, the author and a health economist at RAND Corp. In addition, this site says that nurse practitioners are expected to double by 2025. Auerbach also told American Medical News, "There’s a lot of experimentation going on looking at different ways of working together, and there’s a lot of interest in collaborative team-based models. The new care models, such as the patient-centered medical home and accountable care organizations, really depend on nurse practitioners and physician assistants."[21]

As a result of the PPACA, hospitals and medical care facilities are forced to rethink the demand for nurses and non-physician providers. This is mainly because this new Act drew millions of people the opportunity at medical attention that did not have it before, and because there are so many new people in need of medical attention, the need for medical professionals also grows. With the combination of this new Act, and the aging Baby Boomer population, there is expected to be a large increase in the need for medical staff, especially physicians. Unfortunately, the Act did not account for the need for increased physician residency expansion thus creating an artificial shortage of physicians in an already-overloaded system. According to a study published in American Medical News (an online publication that no longer exists), nurse practitioners' jobs are expected to grow up to 130 percent from 86,000 in 2008 to 198,000 in 2025 through aggressive lobbying. Though there is some skepticism to these vast figures, they are backed up by many studies and the opinions of very well known medical professionals.[22] As a result of this extreme need for NPs, they are also expected to receive more autonomy through lobbying for legislation, meaning that nurse practitioners would be able to fill the traditional primary care role like a physician would despite not having had to train like one. For an example, a nurse practitioner would be able to prescribe medication without the oversight of a doctor, which would be dangerous without appropriate pharmacology courses and examinations. Many states are passing laws that allow for independent practice of nurse practitioners due to the aggressive nurse lobby. "Currently there are 12 states with active legislation looking at utilizing nurse practitioners at the top of their education to meet patient care needs," said Dr. Tayin Kopanos with the American Association of Nurse Practitioners. Many nurses and other leaders in healthcare are advocating for overturning laws that require physicians to look over the work of NPs.[23]

See also

References

  1. ↑ "Definition and Characteristics of the Role". International Council of Nurses (ICN) International Nurse Practitioner/Advanced Practice Nursing Network. International Council of Nurses (ICN). Retrieved 25 November 2015.
  2. 1 2 Stokowski, RN, MS, Laura A. "APRN Prescribing Law: A State-by-State Summary". Medscape. Retrieved 25 November 2015.
  3. ↑ "Nurse Practitioner Career Guide". nurse.org. Retrieved 2017-05-15.
  4. ↑ "Historical Perspectives on an Expanded Role for Nursing". www.nursingworld.org. Retrieved 2017-05-10.
  5. ↑ "The History of Nurse Practitioners". www.graduatenursingedu.org. Retrieved 2017-05-10.
  6. ↑ "Defining Nurse Practitioner Scope of Practice: Expanding Primary Care Services". ISPUB. 2001-06-09. Archived from the original on 2011-09-28. Retrieved 2011-08-31.
  7. ↑ Hancock, Jay (2010-04-14). "Jay Hancock's blog: Md. should make nurse practitioners independent". Weblogs.baltimoresun.com. Retrieved 2011-08-31.
  8. ↑ Flanagan, Lyndia (October 1998). "Nurse Practitioners: Growing Competition for Family Physicians?". Family Practice Management. 5 (9): 34–43. PMID 10187057.
  9. ↑ Brown, Deonne J. (October 2007). "Consumer perspectives on nurse practitioners and independent practice". Journal of the American Academy of Nurse Practitioners. 19 (10): 523–9. PMID 17897116. doi:10.1111/j.1745-7599.2007.00261.x.
  10. ↑ Kaplan, Louise; Brown, Marie-Annette (March 2004). "Prescriptive Authority and Barriers to NP Practice". Nurse Practitioner. 29 (3): 28–35. PMID 15021500. INIST:15566634.
  11. ↑ "Pearson Report" www.pearsonreport.com
  12. ↑ "Nurse Practitioner State Practice Environment". American Association of Nurse Practitioners. February 2017. Retrieved 2017-06-06.
  13. 1 2 "How to Become an Advanced Practice Nurse in Canada". www.graduatenursingedu.org. Retrieved 2017-05-16.
  14. ↑ Website - Australian Health Practitioner Regulation Agency
  15. ↑ Website - Australian College of
  16. ↑ Israeli Ministry of Health - Legislation Library
  17. ↑ "Nurse Practitioner Salary | Certified Nurse Midwife | Anesthetist Salaries". www.graduatenursingedu.org. Retrieved 2017-05-16.
  18. ↑ Hofer, Adam N; Abraham, Jean Marie; Moscovice, Ira (March 2011). "Expansion of Coverage under the Patient Protection and Affordable Care Act and Primary Care Utilization". The Milbank Quarterly. 89 (1): 69–89. JSTOR 23036196. PMC 3160595 Freely accessible. PMID 21418313. doi:10.1111/j.1468-0009.2011.00620.x. INIST:24090631.
  19. ↑ Hoyt, K. Sue; Proehl, Jean A. (2012). "Affordable Care Act: implications for APRNs". Advanced Emergency Nursing Journal. 34 (4): 287–9. PMID 23111302. doi:10.1097/TME.0b013e3182729830.
  20. ↑ Newhouse, Robin P.; Weiner, Jonathan P.; Stanik-Hutt, Julie; White, Kathleen M.; Johantgen, Meg; Steinwachs, Don; Zangaro, George; Aldebron, Jillian; Bass, Eric B. (2012). "Policy implications for optimizing advanced practice registered nurse use nationally". Policy, Politics, & Nursing Practice. 13 (2): 81–9. PMID 22941772. doi:10.1177/1527154412456299.
  21. ↑ ADMIN. "High Demand for Nurse Practitioners." Health Care Medical Articles HealthCareerWebcom RSS. N.p., 17 July 2013. Web. 18 Nov. 2013.
  22. ↑ Occupational Outlook Handbook."Summary." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, 29 Mar. 2012. Web. 18 Nov. 2013.
  23. ↑ Fairman, Julie A.; Rowe, John W.; Hassmiller, Susan; Shalala, Donna E. (2011). "Broadening the Scope of Nursing Practice". The New England Journal of Medicine. 364 (3): 193–6. PMID 21158652. doi:10.1056/NEJMp1012121.
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