A nurse practitioner (NP) is an advanced practice registered nurse 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 conditions. According to the American Association of Nurse Practitioners, a nurse practitioner 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.
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|
The scope of practice for a nurse practitioner is defined by legal jurisdiction. In some places, NPs are required to work under the supervision of a physician, and in other places they can practice independently.
The advanced practice nursing role began to take shape in the mid-20th century in the United States. Nurse anesthetists and nurse midwives were established in the 1940s, followed by psychiatric nursing in 1954. 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. The first formal graduate certificate program for NPs was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965. 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. During the mid 1970s to early 1980s, the completion of a master's degree became required in order to become a certified NP. 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.
In Canada, advanced practice nursing first appeared in the 1990s in Ontario. These nurses practiced in neonatal intensive care units within tertiary care hospitals in collaboration with pediatricians and neonatologists. Although the role of these nurses initially resembled a blended version of clinical nurse specialists and NPs, today the distinction has been more formally established.
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. In Oklahoma, NPs experience patient care 5,000 hours compared with 20,000 hours for MDs. To become an NP requires 1.5 to 3 years of post-baccalaureate training, in addition to prior training and experience as a RN, 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 (in addition to previous training and experience as a RN), compared with a family physician, who would have more than 15,000 hours of clinical training by the time of certification. 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.
Quality of care
A review of studies comparing outcomes of care by NPs and by physicians in primary care, urgent care, and anesthesia conducted by the Department of Veteran Affairs found that outcomes in the assessed studies were generally comparable, although the VA noted that the strength of evidence of the assessed studies was often low.
In emergency and critical care, utilization of NPs under physician supervision may improve access to care and improve outcomes.
Scope of practice
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. 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. The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, and pharmacologic recommendations again varies widely between states.
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.
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.
Education, licensing, and board certification
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 NP 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. The quality of education and applicants for NP schools has been cited as a reason to not allow NPs to practice medicine independently. Many schools accept all applications regardless of quality, coursework can be entirely online, and clinical experience can be limited to shadowing with no hands-on experience.
In Australia, RNs who have the equivalent of three years of full-time experience (5000 hours) 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. 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 advanced practice nursing: 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. All advanced practice nurses must meet individual requirements set by their provincial or territorial regulatory nursing body.
As of November 2013, NPs were recognized legally in Israel.
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. 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.
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|Wikimedia Commons has media related to Nurse practitioners.|
- The Nurse Practitioner: The American Journal of Primary Health Care
- AANP Standards for NP practice in retail based clinics
- CNS and NP Practice in Canada (PDF), Archived from the original on 2012-03-13CS1 maint: BOT: original-url status unknown (link)