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Family Nurse Practitioner Lt. Cmdr. Michael Service cares for a young girl at the U.S. Naval Hospital (USNH) Yokosuka.
|Master of Science in Nursing, Doctor of Nursing Practice|
|Nurse Midwife, Nurse Anesthetist|
A nurse practitioner (NP) is an advanced practice registered nurse (APRN) classified as a mid-level practitioner. A nurse practitioner 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 cases in which multiple symptoms suggest more serious conditions. According to the American Association of Nurse Practitioners, a nurse practitioner is educated at the masters or doctoral level to provide "primary, acute, chronic, and specialty care to patients of all ages and all walks of life". In United States, nurse practitioners have been lobbying for independent practice. The opponents of independent practice have argued that nurse practitioner education is "flimsy," because it can consist of online coursework with few hours of actual patient contact. The number of patient contact hours in nurse practitioner training is less than or equal to 3% of physician training.
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 to diagnose medical problems, order treatments, perform non-surgical procedures and minor surgical procedures, prescribe medications, and make referrals for a wide range of acute and chronic medical conditions within their scope of practice which is defined depending on the state. 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. NPs work in hospitals, private offices, clinics, and nursing homes/long term care facilities. Some nurse practitioners contract out their services for private duty and may also work for private agencies that provide medical staffing to clinics or hospitals called locum tenens.
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. In consideration of the shortage of primary care/internal medicine physicians, an increasing number of states are eliminating requirements "collaborative practice" agreements and providing for the independent practice of nurse practitioners in areas of primary care. The US National Institute of Medicine, the States Boards of Nursing, the American Association of Nursing Practitioners and the Robert Wood Johnson Foundation have proposed a national model of full autonomy in professional practice to provide better accessibility to primary, to reduce costs and to increase the capacity of the United States Health System.
NPs may serve as a patient's primary healthcare provider, 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. 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. 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.
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. 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.
Scope of practice
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 other health professionals, while in some states a supervisory agreement with a physician is required for practice. The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, pharmacologic recommendations, etc. again varies widely amongst states of licensure/certification.
The "Pearson Report" provides a state-by-state breakdown of the specific duties an NP may perform in the state. A nurse practitioner's role may include the following:
- Medical diagnosis, treatment, evaluation, and management of a wide range of acute and chronic diseases
- Obtaining patient histories and conducting physical examinations
- Requesting diagnostic imaging
- Performing diagnostic studies (e.g., lab tests 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 and long care facilities
- Performing or assisting in minor surgeries and procedures (e.g., dermatological biopsies/procedures, suturing, casting, etc.)
- Counseling and educating patients on health behaviors, self-care skills, and treatment options in coordination with occupational therapists and other healthcare providers.
Nurse practitioners can legally examine patients, diagnose illnesses, prescribe medication, and provide treatments. 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 restrict NPs even more. In order for NPs to provide care to patients, they are required to be supervised or delegated by a physician. 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.
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.
Education, licensing, and board certification
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. 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. The typical curriculum for a nurse practitioner program includes courses in epidemiology; health promotion; pathophysiology; physical assessment and diagnostic reasoning; pharmacology; 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. 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. Some nurse practitioners, as well as other APRN roles, may choose to pursue the Doctor of Philosophy (PhD) as a terminal degree.[quantify] 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.
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.
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 masters 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. The Australian professional organisation is the Australian College of Nurse Practitioners (ACNP).
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), and a successful registration within the appropriate territory or province is required in order to practice as a nurse practitioner in Canada.
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. 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.
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. 
Increasing need in US
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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).
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."
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.
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