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Nurse practitioner

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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
Professional
Activity sectors
Nursing
Description
Education required
Master of Science in Nursing

A nurse practitioner (NP) is an advanced practice registered nurse classified as a mid-level practitioner. A NP is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose illness and disease, prescribe medication and formulate treatment plans. NP training covers basic disease prevention, coordination of care, and health promotion, but does not provide the depth of expertise needed to recognize more complex conditions.[1][2] According to the American Association of Nurse Practitioners, a NP is educated at the graduate level to provide "primary, acute, chronic, and specialty care to patients of all ages" depending on their field of practice.[3] The scope of practice for a nurse practitioner is defined by jurisdiction.[4][5] NPs may or may not be required to practice under the supervision of a physician. In the U.S., NPs have been lobbying for full practice authority.[6]Arguments against full practice authority include that fact that NP education can consist of online coursework with few hours of actual patient contact.[7] While NP training includes 500 to 1,500 hours of patient contact, family physician training includes on average 15,000 to 16,000 patient contact hours.[1] Increased utilization of mid-level practitioners, such as NPs and physician assistants, is leading to increased cost of care through increased use of resources and unnecessary referrals.[8][9][10]

History

The advanced practice nursing role began to take shape in the mid-20th century in the United States.[citation needed] Nurse anesthetists and nurse midwives were established in the 1940s, followed by psychiatric nursing in 1954.[citation needed] The present day concept of advanced practice nursing as a primary care provider was created in the mid-1960s, spurred on by a national shortage of physicians.[citation needed] The first formal graduate certificate program for NPs was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965.[citation needed] In 1971, The U.S. Secretary of Health, Education and Welfare, Elliot Richardson, made a formal recommendation in expanding the scope of nursing practice to be able to serve as primary care providers.[11] During the mid 1970s to early 1980s, the completion of a master's degree became required in order to become a certified NP.[citation needed] In 2012, discussions have risen between accreditation agencies, national certifying bodies, and state boards of nursing about the possibility of making the Doctorate of Nursing Practice (DNP) as the new minimum standard of education for NP certification and licensure by 2015.[12]

Controversy in the United States

Limitations of education

The amount and quality of education required to be a NP has been the subject of controversy in U.S. Opponents of independent practice have argued that NP education can consist of online coursework with few hours of actual patient contact.[7] In Oklahoma, NPs experience patient care 5,000 hours compared with 20,000 hours for MDs.[7] To become an NP requires 1.5 to 3 years of post-baccalaureate training, compared to physicians who are required to complete a minimum of 7 years of post-baccalaureate training. A new nurse practitioner has between 500 and 1,500 hours of clinical training, compared with a family physician who would have more than 15,000 hours of clinical training by the time of certification.[1] The quality of education and of applicants for NP schools has been cited as a reason to not allow NPs to practice medicine autonomously. Some graduate nursing schools have 100% acceptance rates.[13]

Quality of care

Given the quality and quantity of training, experts have questioned the quality of care delivered by NPs. A self assessment of the practicing NPs showed that majority of the NPs feel that they are either somewhat or minimally prepared for practice after formal NP education.[14] Research has shown that “there is a tremendous need to enhance nurses’ skills."[15] Numerous studies have also raised multiple concerns associated with lack of appropriate training. For example, NPs are more likely to prescribe antibiotics when they are not indicated.[16] NPs are also more likely to make unnecessary referrals.[8] Referrals from NPs were also shown to be less clear, indicate poor understanding of pathophysiology, and lack adequate evaluation and documentation prior to generating the referral.[17] Mid-level practitioners, such as NPs and physician assistants, are also more likely to order unnecessary tests and procedures such as skin biopsies and imaging studies.[9][18] In emergency and critical care, utilization of NPs under physician supervision may improve access to care and improve outcomes.[19] Although some studies have claimed that NPs provide similar quality care when compared to physicians, these studies were shown to have a high potential for bias and insufficient strength of evidence.[20]

Scope of practice

United States

In the U.S., because the profession is state-regulated, the scope of practice varies by state. Some states allow NPs to have full practice authority. However, in other states, a written collaborative or supervisory agreement with a physician is legally required for practice.[21] Autonomous practice was introduced in the 1980s, mostly in states facing a physician shortage or that struggled to find enough healthcare providers to work in rural areas.[22] The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, and pharmacologic recommendations again varies widely between states.[23][24][25]

NPs can legally examine patients, diagnose some illnesses, prescribe some medications, and provide some treatments. In 2017, 22 states gave 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 such as prescribing medications. Twelve of those states require NPs to be supervised or delegated by a physician.[26]

Canada

In Canada, an NP is a registered nurse (RN) with a graduate degree in nursing. Canada recognizes them in primary care and acute care practice. NPs diagnose some illnesses, prescribe some medications, order and interpret some diagnostic tests, and perform some procedures, within their scope of practice. Primary care NPs work in places like primary care and community healthcare centers, as well as long term care institutions. The main focus of primary care NPs includes health promotion, preventative care, diagnosis and treatment of simple acute illnesses, and management of simple chronic diseases. Acute care NPs serve a specific population of patients. They generally work in in-patient facilities that include neonatology, nephrology, and cardiology units.[27]

Education, licensing, and board certification

United States

The path to becoming a NP in the U.S. begins by earning an undergraduate degree in nursing and requires licensure and experience as a RN. One must then complete graduate studies in nursing. Overall, to become an NP requires 1.5 to 3 years of post-baccalaureate training, compared to physicians who are required to complete a minimum of 7 years of post-baccalaureate training. A new nurse practitioner has between 500 and 1,500 hours of clinical training compared with a family physician who would have more 15,000 hours of clinical training by the time certification.[1] The quality of education and applicants for NP schools has been cited as a reason to not allow NPs to practice medicine. Many schools have 100% acceptance rates, coursework can be 100% online, and clinical experience is limited to shadowing with no hands-on experience.[28][13]

Australia

In Australia, Registered Nurses who have undertaken the equivalent of three years full-time experience (5000 hours) at the clinical advanced nursing practice level, and have completed a program of study approved by the Nursing and Midwifery Board of Australia (a postgraduate nursing master's degree including advanced health assessment, pharmacology for prescribing, therapeutics and diagnostics and research), or a program that is substantially equivalent to an approved program of study, may apply to the Nursing and Midwifery Board of Australia for endorsement as a Nurse Practitioner.[29] The Australian professional organisation is the Australian College of Nurse Practitioners (ACNP).[30]

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 National Council of State Boards of Nursing (NCSBN),[31] and a successful registration within the appropriate territory or province is required in order to practice as a nurse practitioner in Canada.[27]

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.[32] 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.[citation needed]

Salary

The salary of a NP generally depends on the area of specialization, location, years of experience, and level of education. In 2015, the American Association of Nurse Practitioners (AANP) conducted its 4th annual NP salary survey. The results revealed the salary range to be between $98,760 to $108,643 reported income among full-time NPs. According to the U.S. Bureau of Labor Statistics, NPs 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.[citation needed] 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.[33]

See also

References

  1. ^ a b c d https://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf
  2. ^ "AANP - AANP President Testifies Before Congress on Importance of Investing in NP Workforce". www.aanp.org. Retrieved 2018-09-23.
  3. ^ "AANP - What's an NP?". www.aanp.org. Retrieved 2018-09-23.
  4. ^ Stokowski, RN, MS, Laura A. "APRN Prescribing Law: A State-by-State Summary". Medscape. Retrieved 25 November 2015.{{cite web}}: CS1 maint: multiple names: authors list (link)
  5. ^ "Scope of Practice for Nurse Practitioners" (PDF). AANP Policy Statements. American Association of Nurse Practitioners. Retrieved 14 November 2017.
  6. ^ Jaspen, Bruce (24 February 2017). "More States Lift Patient Hurdles To Nurse Practitioners". No. Pharma and Healthcare: Medicine. Forbes. Retrieved 14 November 2017.
  7. ^ a b c "Nurse Practitioners to Docs, Lawmakers: Give Us Our Independence". Managed Care magazine. 3 September 2018.
  8. ^ a b Lohr, Robert H.; West, Colin P.; Beliveau, Margaret; Daniels, Paul R.; Nyman, Mark A.; Mundell, William C.; Schwenk, Nina M.; Mandrekar, Jayawant N.; Naessens, James M.; Beckman, Thomas J. (2013). "Comparison of the Quality of Patient Referrals from Physicians, Physician Assistants, and Nurse Practitioners". Mayo Clinic Proceedings. 88 (11): 1266–1271. doi:10.1016/j.mayocp.2013.08.013. PMID 24119364.
  9. ^ a b Hughes, Danny R.; Jiang, Miao; Duszak, Richard (2015). "A Comparison of Diagnostic Imaging Ordering Patterns Between Advanced Practice Clinicians and Primary Care Physicians Following Office-Based Evaluation and Management Visits". JAMA Internal Medicine. 175 (1): 101–7. doi:10.1001/jamainternmed.2014.6349. PMID 25419763.
  10. ^ Phillips, Andrew W.; Klauer, Kevin M.; Kessler, Chad S. (2018). "Emergency physician evaluation of PA and NP practice patterns". Journal of the American Academy of Physician Assistants. 31 (5): 38–43. doi:10.1097/01.JAA.0000532118.98379.f1. PMID 29698370.
  11. ^ "Historical Perspectives on an Expanded Role for Nursing". www.nursingworld.org. Retrieved 2017-05-10.
  12. ^ "The History of Nurse Practitioners". www.graduatenursingedu.org. Retrieved 2017-05-10.
  13. ^ a b https://www.usnews.com/education/best-graduate-schools/the-short-list-grad-school/articles/2016-08-16/10-graduate-nursing-programs-with-the-highest-acceptance-rates
  14. ^ Hart, A. M.; MacNee, C. L. (2007). "How well are nurse practitioners prepared for practice: Results of a 2004 questionnaire study". Journal of the American Academy of Nurse Practitioners. 19 (1): 35–42. doi:10.1111/j.1745-7599.2006.00191.x. PMID 17214866.
  15. ^ "The first U.S. Study on nurses' evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes. | AHRQ Patient Safety Network".
  16. ^ Sanchez, Guillermo V.; Hersh, Adam L.; Shapiro, Daniel J.; Cawley, James F.; Hicks, Lauri A. (2016). "Outpatient Antibiotic Prescribing Among United States Nurse Practitioners and Physician Assistants". Open Forum Infectious Diseases. 3 (3): ofw168. doi:10.1093/ofid/ofw168. PMC 5047413. PMID 27704022.
  17. ^ Lohr, Robert H.; West, Colin P.; Beliveau, Margaret; Daniels, Paul R.; Nyman, Mark A.; Mundell, William C.; Schwenk, Nina M.; Mandrekar, Jayawant N.; Naessens, James M.; Beckman, Thomas J. (2013). "Comparison of the Quality of Patient Referrals from Physicians, Physician Assistants, and Nurse Practitioners". Mayo Clinic Proceedings. 88 (11): 1266–1271. doi:10.1016/j.mayocp.2013.08.013. PMID 24119364.
  18. ^ Jalian, H. Ray; Avram, Mathew M. (2014). "Mid-Level Practitioners in Dermatology". JAMA Dermatology. 150 (11): 1149–51. doi:10.1001/jamadermatol.2014.1922. PMID 25110861.
  19. ^ Woo, B. F.; Lee, J. X.; Tam, W. W. (2017). "The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review". Human Resources for Health. 15 (1): 63. doi:10.1186/s12960-017-0237-9. PMC 5594520. PMID 28893270.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  20. ^ "Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses". VA Evidence Synthesis Program Evidence Briefs. VA Evidence Synthesis Program Reports. Department of Veterans Affairs (US). 2011.
  21. ^ Hancock, Jay (2010-04-14). "Jay Hancock's blog: Md. should make nurse practitioners independent". Weblogs.baltimoresun.com. Retrieved 2011-08-31.
  22. ^ Vestal, Christine (2013-07-19). "Nurse Practitioners Slowly Gain Autonomy". Kaiser Health News. Retrieved 2019-05-22. {{cite web}}: Cite has empty unknown parameter: |dead-url= (help)
  23. ^ Flanagan, Lyndia (October 1998). "Nurse Practitioners: Growing Competition for Family Physicians?". Family Practice Management. 5 (9): 34–43. PMID 10187057.
  24. ^ 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. doi:10.1111/j.1745-7599.2007.00261.x. PMID 17897116.
  25. ^ Kaplan, Louise; Brown, Marie-Annette (March 2004). "Prescriptive Authority and Barriers to NP Practice". Nurse Practitioner. 29 (3): 28–35. doi:10.1097/00006205-200403000-00004. PMID 15021500. INIST 15566634.
  26. ^ "Nurse Practitioner State Practice Environment". American Association of Nurse Practitioners. February 2017. Retrieved 2017-06-06.
  27. ^ a b "How to Become an Advanced Practice Nurse in Canada". www.graduatenursingedu.org. Retrieved 2017-05-16.
  28. ^ "Opinion: Fellow Physicians, Please Stop Devaluing Your Medical License".
  29. ^ Website - Nursing and Midwifery Board of Australia
  30. ^ Website - Australian College of
  31. ^ RN Exam https://cna-aiic.ca
  32. ^ "Israeli Ministry of Health - Legislation Library" (PDF).
  33. ^ "Nurse Practitioner Salary | Certified Nurse Midwife | Anesthetist Salaries". www.graduatenursingedu.org. Retrieved 2017-05-16.
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