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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.[1][2] 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".[3] The scope of practice for a nurse practitioner is defined by jurisdiction.[4][5] Depending on jurisdiction, nurse practitioners may or may not be required to practice under the supervision of a physician. In United States, nurse practitioners have been lobbying for independent practice.[6] 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.[7] The number of patient contact hours in nurse practitioner training is less than or equal to 3% of physician training.[1] Increased utilization of nurse practitioners is leading to increased cost of care through increased use of resources and unnecessary referrals.[8][9][10]

Nurse practitioner
US Navy 031027-N-0000W-001 Family Nurse Practitioner Lt. Cmdr. Michael Service cares for a young girl at the U.S. Naval Hospital (USNH) Yokosuka.jpg
Family Nurse Practitioner Lt. Cmdr. Michael Service cares for a young girl at the U.S. Naval Hospital (USNH) Yokosuka.
Occupation type
Activity sectors
Education required
Master of Science in Nursing, Doctor of Nursing Practice
Related jobs
Nurse Midwife, Nurse Anesthetist



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. 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.[11] 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.[12]

Quality of care

Given the quality and quantity of training, experts have questioned the quality of care delivered by nurse practitioners. 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.[13] Other studies have shown that “there is a tremendous need to enhance nurses’ skills."[14]Studies have also shown multiple concerns associated with lack of training. For example, nurse practitioners are more likely to prescribe antibiotics when they are not indicated.[15] Nurse practitioners are also more likely to make unnecessary referrals.[8] They are also more likely to order unnecessary tests and procedures such as skin biopsies and imaging studies.[9][16] In emergency and critical care, utilization of NPs under physician supervision may improve access to care and improve outcomes.[17]Although a few studies have shown that NPs provide similar quality care when compared physicians, these studies were found to have a medium to high potential for bias and had low to insufficient strength of evidence.[18]

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 other health professionals, while in some states a supervisory agreement with a physician is required for practice.[19] The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, pharmacologic recommendations, etc. again varies widely amongst states of licensure/certification.[20][21][22]

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.[23]


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.[24]

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. 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.[25][26]


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.[27] The Australian professional organisation is the Australian College of Nurse Practitioners (ACNP).[28]


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),[29] and a successful registration within the appropriate territory or province is required in order to practice as a nurse practitioner in Canada.[24]

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.[30] 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]


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.[31]

See also


  1. ^ a b c
  2. ^ "AANP - AANP President Testifies Before Congress on Importance of Investing in NP Workforce". Retrieved 2018-09-23.
  3. ^ "AANP - What's an NP?". Retrieved 2018-09-23.
  4. ^ Stokowski, RN, MS, Laura A. "APRN Prescribing Law: A State-by-State Summary". Medscape. Retrieved 25 November 2015.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" (Pharma and Healthcare: Medicine). Forbes. Retrieved 14 November 2017.
  7. ^ "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". Retrieved 2017-05-10.
  12. ^ "The History of Nurse Practitioners". Retrieved 2017-05-10.
  13. ^ 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.
  14. ^ "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".
  15. ^ 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.
  16. ^ 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.
  17. ^ 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.
  18. ^ "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.
  19. ^ Hancock, Jay (2010-04-14). "Jay Hancock's blog: Md. should make nurse practitioners independent". Retrieved 2011-08-31.
  20. ^ Flanagan, Lyndia (October 1998). "Nurse Practitioners: Growing Competition for Family Physicians?". Family Practice Management. 5 (9): 34–43. PMID 10187057.
  21. ^ 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.
  22. ^ 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.
  23. ^ "Nurse Practitioner State Practice Environment". American Association of Nurse Practitioners. February 2017. Retrieved 2017-06-06.
  24. ^ a b "How to Become an Advanced Practice Nurse in Canada". Retrieved 2017-05-16.
  25. ^ "Opinion: Fellow Physicians, Please Stop Devaluing Your Medical License".
  26. ^
  27. ^ Website - Nursing and Midwifery Board of Australia
  28. ^ Website - Australian College of
  29. ^ RN Exam
  30. ^ "Israeli Ministry of Health - Legislation Library" (PDF).
  31. ^ "Nurse Practitioner Salary | Certified Nurse Midwife | Anesthetist Salaries". Retrieved 2017-05-16.

External links