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Nurse Practitioners

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Nurse Practitioners

A nurse practitioner (NP) is an advanced practice registered nurse (APRN) who has completed advanced didactic and clinical education beyond that required of the registered nurse (RN) role.

Overview

Nurse practitioners manage acute and chronic medical conditions (both physical and mental) through comprehensive history taking, physical exam, and the ordering of diagnostic tests and treatments. NPs (within their scope of practice) are qualified to diagnose medical problems, order treatments, prescribe medications, and make referrals for a wide range of acute and chronic medical conditions. NPs can serve as a patient's primary health care provider and they can see patients of all ages depending on their specialty (e.g., family, adult, pediatrics, geriatrics, etc.). NPs can also specialize (with commensurate training and experience) in other areas of medicine (e.g., cardiology, dermatology, oncology, pain management, orthopedics, OB/GYN, etc.). Similar to all medical professions, the core philosophy of the nurse practitioner role is individualized care that focuses on the patient's medical issues as well as the effects of illness on the life of the patient and his or her family. Like all health care providers, NPs make prevention, wellness, and patient education their priority. Since they are nurses, NPs tend to focus more on holistic care (i.e., treating the mind, body, soul), and they spend more time counseling and educating patients. In addition to providing health care services, NPs may conduct research, teach, and are often active in patient advocacy activities and in the development of health care policy at the local, state, and national level. To become licensed to practice, nurse practitioners must first graduate from an accredited graduate/doctoral level program. After completing the required education (MSN or DNP), the nurse practitioner must pass a national board certifying exam in a specific area (e.g., family medicine, women's health, pediatrics, adult medicine, acute care, etc.), which coincides with the type of program from which they graduated. After achieving board certification, the NP must apply for additional credentials (e.g., APRN license, prescriptive authority, DEA registration number, etc.) at the state and federal level. Nurse practitioners must have a certain amount of continuing education credits in order to maintain certification and licensure. NPs are licensed through State Boards of Nursing, found through the National Council of State Boards of Nursing. NPs must function within their scope of practice, which is set by State Boards of Nursing. NPs may or may not be required to practice under the supervision of a physician (either directly or via a collaborative practice agreement). In many states, NPs can practice independently without physician supervision. Additionally, in many states, NPs can operate their own offices, clinics, etc. and directly bill insurance companies and Medicare for their services.

According to the International Council of Nurses, an NP/advanced practice nurse is "a registered nurse who has acquired the knowledge base, decision-making skills, and clinical competencies for expanded practice beyond that of an RN, the characteristics of which would be determined by the context in which he or she is credentialed to practice."[1]

In addition to the nurse practitioner role, the three other advanced practice registered nurse (APRN) roles include the certified registered nurse anesthetist (CRNA), Certified Nurse Midwife (CNM), and Clinical Nurse Specialist (CNS). Each APRN role is distinct and involves different educational and certification requirements, but the scope of practice for all APRN roles is mandated by State Boards of Nursing.

Nurse practitioners can be educated and certified in areas of family health (FNP), pediatrics, including pediatric acute/chronic care, pediatric critical care, pediatric oncology and general pediatrics (PNP), neonatology (NNP), gerontology (GNP), women's health (WHNP), psychiatry & mental health (PMHNP), acute care (ACNP), adult health (ANP), oncology (FNP, ACNP, ANP, PNP or ANP) emergency (as FNP or ACNP), occupational health (as ANP or FNP), etc. In Canada, NPs are licensed by the province or territory in which they practice.

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 APN as a primary care provider was created in the mid-1960s, spurred on by a shortage of medical doctors. The first official training for nurse practitioners was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965, with a vision to help balance rising health care costs, increase the number of health care providers, and correct the inefficient distribution of health resources. There was some confusion about the varying titles and abilities of advanced practice nurses as the role was developed, which has persisted as the authority and responsibilities of the NP have evolved over time.

Scope of practice

In the United States, because the profession is state-regulated, care provided by NPs varies widely and is limited to their education and knowledge content. Some nurse practitioners seek to work independently of physicians while, in other states, a collaborative agreement with a physician is required for practice.[2][3] The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, pharmacologic recommendations, etc. again varies widely amongst states of licensure/certification.[4][5][6] practice.[7][8][9][10]

The scope of practice for NPs is limited outside the United States and varies even more widely than the state-by-state discrepancies. The International Council of Nurses outlines the following general characteristics of advanced practice nursing: · Integrates research, education, practice and management · Politically seeks a high level of professional autonomy and even independent practice · Case management/personal case load · Advanced health assessment skills, decision-making skills and nursing diagnostic reasoning skills · Recognized advanced nursing clinical competencies · Provision to acquire consulting services from other more highly trained medical providers · Plans, implements and evaluates programs · Recognized first point of contact for clients

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

  • Medical diagnoses, treatment, evaluation, and management of acute and chronic illness and disease (e.g., hypertension, diabetes, dyslipidemia, anemia, asthma, depression, anxiety, obesity, osteoarthritis, smoking cessation, thyroid disorders, wound care, musculoskeletal disorders, etc.)
  • Obtaining medical histories and conducting physical examinations
  • Ordering and performing diagnostic studies (e.g., lab tests, x-rays and EKGs)
  • Requesting physical therapy, occupational therapy, and other rehabilitation treatments
  • Prescribing drugs for acute and chronic illness (extent of prescriptive authority varies by state regulations)
  • Providing prenatal care and family planning services
  • Providing well-child care, including screening and immunizations
  • Providing primary and specialty care services, health-maintenance care for adults, including annual physicals
  • Providing care for patients in acute and critical care settings
  • Performing or assisting in minor surgeries and procedures (with additional training and/or under physician supervision in states where mandated; e.g. dermatological biopsies, suturing, casting)
  • Counseling and educating patients on health behaviors, self-care skills, and treatment options in coordination with occupational therapists and other healthcare providers.

Practice settings

NPs practice in all U.S. states, Canadian provinces and territories and in all Australian states and territories. The institutions in which they work may include:

Education, licensing, and board certification in the United States

Education to become a nurse practitioner (NP) requires advanced coursework and clinical rotations beyond that required of the RN. In addition to maintaining the "nursing model," NPs are introduced to the "medical model" and learn to focus primarily on disease and medical diagnosis. Nurses practitioners do not use nursing diagnosis; they are taught to use differential diagnosis and medical treatments. However, NPs retain their nursing skills (i.e., the nursing model) and approach the patient in a holistic manner while employing the medical model to diagnose and treat disease. Curriculum for NP programs includes, but is not limited to, courses in epidemiology; health promotion; pathophysiology; physical assessment; pharmacology; differential diagnosis and laboratory/radiography diagnostics; statistics and research methods; health policy; role development and leadership; acute and chronic disease management (e.g., adults, children, women's health, geriatrics, etc.); and, clinical rotations, which varies depending on the program. MSN programs also require a thesis or clinical research project. There are a variety of paths to becoming a nurse practitioner in the United States. Typically, the process begins with obtaining a Bachelor of Science in Nursing (BSN, 4 years), followed by a Masters of Science in Nursing (MSN, usually 3 years).[12] DNP programs usually require an additional 2–3 years of study beyond the MSN. Doctor of Nursing Practice (DNP) programs require advanced coursework in biostatistics; research methods; quality improvement and outcome measures; care of special populations; evidence based practice; informatics; organizational management; and, a project/dissertation and practicum. There is currently an initiative to require the DNP as the entry level practice degree for nurse practitioners. Admission to a MSN program is competitive and requires an undergraduate degree (usually the BSN), licensure as a RN, and completion of the Graduate Record Exam (GRE). Admission to a DNP program requires a graduate degree (usually the MSN) and licensure as a RN. There are programs that eliminate the need for a MSN and allow the student to progress from a BSN directly to a DNP. Some APRNs (e.g., nurse practitioners) may choose to pursue the Doctor of Philosophy (PhD) as a terminal degree. The PhD in nursing focuses more on research and teaching, while the DNP focuses more on clinical practice.

Registered nurses initially trained at the associate degree or diploma level must first complete a Bachelor of Science in Nursing (BSN) or enter a program offering an ADN-to-MN/MSN bridge program. Some of these bridge programs may award a Bachelor's degree while the candidate continues to complete the elements of their Master's or Doctorate degree.

United States

In the United States, nursing is largely degree based. While not every state includes specific language requiring a master's degree for NPs, the majority of states now require a master's degree for practice. Further, the current nurse practitioner programs offered by all universities and colleges are at the master's degree level or higher. Although controversial in academic circles, the nursing profession defends that masters degrees in nursing are rigorious and represents a masters level knowledge in the nursing profession. Many Universities and colleges contend that their academic institutions are at the mercy of accrediting bodies and nursing degrees are inflated and politically motivated and lack the rigor of more traditional graduate programs. The current proposal is that all advanced practice registered nurse programs will require a Doctor of Nursing Practice (DNP) degree by 2015, thus effectively eliminating the MN or the MSN as an entry to practice degree. However, all State Boards of Nursing will be required to revise their current Practice Acts in order for this to become mandatory. Also heavily scrutinized, there are numerous certifying bodies for nurse practitioners. All U.S. states require national board certification for nurse practitioners before they are permitted to practice. The two biggest certifying bodies are the American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners (AANP).

The variety of educational paths for NPs is a result of the history of the field.[13] The first Nurse Practitioner program was created by a nurse educator, Loretta Ford, EdD, RN, PNP, and a physician, Henry Silver, MD, in 1965 at the University of Colorado as a non-degree certificate program. This program trained experienced Registered Nurses for their new advanced nursing roles as Pediatric Nurse Practitioners. In the late 1960s into the 1970s, continued predictions of a primary-care physician shortage increased funding and attendance in various certificate-based nurse practitioner programs. Then, during the 1980s Nurse Practitioner educational requirements were transitioned into graduate-level master's degree programs. Subsequently the national certifying organizations and state licensing boards began to require a master's degree for NP practice. However, already established NPs with certificate-based education were grandfathered in. Once again there are changes presently in the field, and by 2015 all new NPs will need to be trained at the doctorate level as a Doctor of Nursing Practice. Once again already established NPs with lesser education will be grandfathered in.

After completing the education program, the candidate must be licensed by the state in which he or she plans to practice. The State Boards of Nursing regulate nurse practitioners and each state has its own licensing and certification criteria. In general, the criteria include completion of a graduate degree in nursing and board certification by an accrediting body (ANCC, AANP). The license period varies by state; some require biennial relicensing, others require triennial.

Australia

In Australia, Nurse Practitioners 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]

Global expansion

Role in healthcare

The role of Nurse Practitioners is very diverse.[16][17][18][19] Nurse Practitioners are educated under the nursing model which is designed to provide holistic and preventive care engaging the individual as the primary leader in their own care and well-being.[20] Nurse Practitioners bring the nursing history of patient advocacy to partner with the individual for mutually agreed upon treatments and optimal health outcomes. Nurse Practitioners often view the health and wellness of individuals within the family or community system and attempt to incorporate cultural relativism within their treatments and recommendations. NPs are advanced practice nurses who provide high-quality healthcare services in primary care settings and are able to diagnose and treat a range of health problems.[21][22][23]

Specialties

  • Acute care nurse practitioner
  • Adult nurse practitioner
  • Family practice nurse practitioner
  • Psychiatric nurse practitioner
  • Geriatric nurse practitioner
  • Pediatric nurse practitioner
  • Obstetric nurse practitioner
  • Neonatal nurse practitioner
  • Emergency nurse practitioner
  • Hepatology nurse practitioner
  • "-C" and "-BC" indicate "certified" and "board certified" by a national certifying organization such as the American Nurses Credentialing Center, American Academy of Nurse Practitioners, or the National Certification Corporation (e.g., FNP-BC, NNP-BC, ANP-C, NP-C, WHNP-BC, etc.).

Post-nominal credentials and initials

Post-nominal initials NPs may use are regulated by the state in which they are licensed and include:

  • ACNP-BC (Acute Care Nurse Practitioner - Board Certified; if certified by the ANCC)
  • ACNPC (Acute Care Nurse Practitioner Certified)[24]
  • AGACNP-BC (Adult-Gerontology Acute Care Nurse Practitioner - Board Certified; if certified by the ANCC)
  • AGPCNP-BC (Adult-Gerontology Primary Care Nurse Practitioner - Board Certified; if certified by the ANCC)
  • ANP-BC (Adult Nurse Practitioner - Board Certified; if certified by the ANCC)
  • APN (Advanced Practice Nurse)
  • APRN-BC (Advanced Practice Registered Nurse - Board Certified; no longer awarded, replaced with specialty-specific credentials by the ANCC [25])
  • ARNP (Advanced Registered Nurse Practitioner)
  • CAS (Certificate of Advanced Study)
  • CNP (Certified Nurse Practitioner)
  • CPNP (Certified Pediatric Nurse Practitioner; if certified by the Pediatric Nursing Certification Board PNCB)
  • CPNP-AC (Certified Pediatric Nurse Practitioner - Acute Care; if certified by the PNCB [26])
  • CPNP-PC (Certified Pediatric Nurse Practitioner - Primary Care; if certified by the PNCB [27])
  • CRNP (Certified Registered Nurse Practitioner; used primarily in Pennsylvania [28] and Alabama [29])
  • DNP (Doctor of Nursing Practice; the terminal practice degree for NPs)
  • DNSc (Doctor of Nursing Science; equivalent to Ph.D., most D.N.Sc. programs now converted to PhD programs)
  • ENP-BC (Emergency Nurse Practitioner - Board Certified; if certified by the ANCC)
  • FAAN (Fellow of the American Academy of Nursing AAN)
  • FAANP (Fellow of the American Academy of Nurse Practitioners AANP)
  • FAEN (Fellow of the Academy of Emergency Nursing AEN)
  • FNP-BC (Family Nurse Practitioner - Board Certified; if certified by the ANCC)
  • GNP-BC (Gerontology Nurse Practitioner - Board Certified; if certified by the ANCC)
  • MA (Master of Arts in Nursing)
  • MN (Master of Nursing)
  • MS (Master of Science with a major in Nursing)
  • MSN (Master of Science in Nursing)
  • NP-C (Nurse Practitioner - Certified; if certified by the AANP)
  • PMHNP-BC (Adult or Family Psychiatric–Mental Health Nurse Practitioner-Board Certified; if certified by the ANCC)
  • PMC (Post-Master's Certificate)
  • PNP-BC (Pediatric Nurse Practitioner - Board Certified; if certified by the ANCC)
  • RN (Registered Nurse)
  • RN(EP) or NP (Registered Nurse - Extended Practice; Manitoba, Canada)
  • RN(NP) (Registered Nurse - Nurse Practitioner; Saskatchewan, Canada)
  • SNP-BC (School Nurse Practitioner - Board Certified; no longer awarded by the ANCC)
  • WHNP-BC (Women's Health Nurse Practitioner - Board Certified; if certified by the NCC)

See also

Nursing portal

References

External links

  • AANP Standards for NP practice in retail based clinics
  • CNS and NP Practice in Canada
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