Nurse practitioner
A nurse practitioner and naval officer of the United States assessing a pediatric patient.
Occupation
Occupation type
Professional
Activity sectors
Nursing
Description
Education required
Postgraduate
Fields of
employment
Healthcare
Related jobs
Registered nurse

A nurse practitioner (NP) is an advanced practice registered nurse (APRN) and a type of mid-level practitioner.[1][2] NPs are trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe medications and treatment plans. NP training covers basic disease prevention, coordination of care, and health promotion. One study found that although reasons for referrals to specialists are similar for both physicians and NPs, the quality of documentation in the referrals may be lower for NPs.[3]

Nurse practitioners are currently employed in a wide variety of practice settings. These settings include the ambulatory, inpatient, or emergency room of hospitals, health clinics, and office practices whether private or nurse-run. In addition, they serve in schools and college campuses delivering care as well as nursing homes and assisted living facilities. NPs can work alone or under the supervision of a physician in a wide variety of specializations.[4][5]

The scope of practice for a NP is defined by legal jurisdiction.[6][7] In 27 states of the US, NPs have full practice authority, while in the remaining 23 states, NPs are required to work under the supervision of a physician.[8] In Australia, the scope of practice is guided by health organisation policy and the individual's competency, while their right to access Medicare rebates requires a collaborative practice arrangement with a medical practitioner.[9]

History

United States

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.[10] The first formal graduate certificate program for NPs was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965.[10] 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] In 2012, discussions arose between accreditation agencies, national certifying bodies, and state boards of nursing about the possibility of making the Doctor of Nursing Practice (DNP) degree the new minimum standard of education for NP certification and licensure by 2015.[12]

Canada

Advanced practice nursing first appeared in the 1990s in Ontario.[13] These nurses practiced in neonatal intensive care units within tertiary care hospitals in collaboration with pediatricians and neonatologists.[13] 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.[13]

Education

United States

The nurse practitioner educational pathway starts by completing an accredited Bachelor of Science in Nursing (BSN) degree and passing the National Council Licensure Examination (NCLEX) to become a registered nurse. Nurses must have both a BSN and a valid unencumbered registered nurse license to apply for a nurse practitioner post-graduate training program.

Currently, NPs are only eligible for licensure as an advanced practice registered nurse after completing either a Master of Science in Nursing (MSN) degree or a Doctor of Nursing Practice (DNP) degree. While any registered nurse may pursue a MSN or DNP degree only specific programs qualify an individual to sit for a national nurse practitioner board certification exam.[14] During their studies, nurse practitioners are required to complete a minimum of 500 hours of clinical training which is intended to enhance and augment the clinical skills already possessed by registered nurses. Nurse practitioners must specialize in particular field with the vast majority being family nurse practitioners.[15] There are also pediatric, gerontologic, psychiatric, and emergency specializations available.[16][17][18]

Although nurse practitioners are required to be licensed as registered nurses prior to obtaining their advanced practice registered nurse certification; there are several nurse practitioner training programs that do not require applicants to have work experience as a registered nurse prior to applying.[19] Other nurse practitioner programs have 100% acceptance rates.[20][21][22]

Australia

In Australia, nursing registration including endorsement of a RN as a nurse practitioner is overseen by the Nursing and Midwifery Board of Australia (NMBA) and the Australian Health Practitioner Regulation Agency (AHPRA). Registered nurses working in rural and isolated communities can apply for scheduled medicine prescriber endorsement if clinically necessary and trained, and instead become a prescribing registered nurse rather than a nurse practitioner to better meet the need of less-resourced communities.[23] Nurse practitioners are professionally represented by the Australian College of Nurse Practitioners, as well as the Australian College of Nursing. Endorsement as a nurse practitioner in either Australia or New Zealand is recognised by both countries as part of the Trans-Tasman Mutual Recognition Scheme.

For a RN to apply to the NMBA for nurse practitioner endorsement, they must be able to demonstrate they have completed at least 5000 hours (three years, full-time equivalent) at an "advanced nursing practice" level. Advanced nursing practice is loosely defined, and not a specific role, but rather a recognised process of higher-level clinical practice within a nurse's existing scope of practice. The RN must also complete an approved nurse practitioner postgraduate master's degree, or demonstrate they have completed graduate level education to an equivalent level in advanced health assessment, pharmacology, therapeutics, diagnostics, and research. Nurses applying through the latter pathway must also demonstrate the equivalent training is clinically relevant to the field for which they wish to apply for nurse practitioner endorsement in.[24]

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 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.

Scope of practice

United States

Because the profession is state-regulated, scope of practice may vary between states. Some states allow NPs full practice authority, while others have reduced or restricted practice authority.[7] Independent practice for NPs was first introduced in the 1980s, mostly in states facing a physician shortage or struggling to find enough healthcare providers to work in rural areas.[25] As of 2023, twenty-seven states have granted full practice authority to NPs, allowing them to evaluate patients, diagnose, order, and interpret diagnostic tests, and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.[7] In states with reduced or restricted practice, the law limits the ability of NPs to engage in at least one element of their practice. Twelve states have reduced practice authority, which require NPs to have a collaborative agreement with a physician to provide care;[7] the extent of these collaborative agreements again vary widely between states.[26] The remaining eleven states have restricted practice, which require NPs to be supervised or delegated by a physician.[7] Nurse practitioners employed by the federal government through the uniformed services or the Department of Veterans Affairs are granted full practice authority.[27][28]

Australia

In Australia, a nurse practitioner-endorsed registered nurse has an expanded scope of practice, allowing them to practice certain advanced clinical skills within their endorsed field. As a nurse practitioner, they can complete advanced health assessments, diagnose and treat diseases, order diagnostic testing such as imaging and pathology, and prescribe medications and therapeutics.[29] They are also able to register for a provider number with Medicare for the services they provide to patients, excluding services provided in public facilities (such as a Queensland Health hospital).[30]

Nurse practitioner items on the Medicare Benefits Schedule, however, provide significantly smaller rebates than equivalent items for general practitioners, leading to a higher out-of-pocket cost to patients.[31] To claim Medicare rebates, the NP must also be in a documented collaborative practice arrangement" with a medical practitioner and the episode of care approved by a doctor.[9] Prescriptions issued by NPs must also be verified by a medical practitioner to be eligible to be subsidised under the Pharmaceutical Benefits Scheme.[31]

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 illnesses and medical conditions, prescribe Schedule 1 medications, order and interpret diagnostic tests, and perform procedures, within their scope of practice, and may build their own panel of patients at the same level as physicians.[32] 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 acute and chronic diseases and conditions. Acute care NPs serve a specific population of patients. They generally work in in-patient facilities that include neonatology, nephrology, and cardiology units.[33] There are currently three specialties for nurse practitioners in Canada: family practice, pediatrics, and adult care. NPs who specialize in family practice work at the same level and offer the same services as family physicians with the exclusion of Quebec, where only physicians are allowed to formulate a medical diagnosis.[34]

Ireland

Ireland's publicly funded healthcare system, the Health Service Executive has the advanced nurse practitioner (ANP) grade.[35] ANPs may prescribe medications.[36]

Israel

As of November 2013, NPs were recognized legally in Israel.[37]

United Kingdom

In the United Kingdom nurse practitioners carry out care at an advanced practice level. They commonly work in primary care (e.g. GP surgeries) or A&E departments, although they are increasingly being seen in other areas of practice.

Quality of care

A review of studies comparing outcomes of care by NPs and physicians in primary care and urgent care settings were generally comparable, although the strength of the evidence was generally low due to limited study duration and participant numbers.[38] A recent study showed nurse practitioners practicing in states with independent prescription authority were more than twenty times more likely to overprescribe opioids than nurse practitioners in prescription-restricted states, the same study identified that both nurse practitioners and Physician Associates were more likely to over-prescribe opioids compared to physicians.[39] Nurse practitioners and physician assistants were also associated with more unnecessary imaging services than primary care physicians, which may have ramifications on care and overall costs.[40]

One systematic review suggests "that the implementation of advanced practice nursing roles in the emergency and critical care settings improves patient outcomes in emergency and critical care settings".[41]

Salary

The salary of an 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 fourth 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 fifth most highly sought after advanced health professional in 2016.[42]

Policy during the COVID-19 pandemic

The pandemic expanded the scope of practice for nurse practitioners in some countries as a result of temporary legislative policy adjustments.[43] In the US, the Trump administration waived many requirements for nurse practitioners, permitting NPs to utilize their abilities to the fullest extent in some cases.[44]

See also

References

  1. ↑ "Mid-level health providers: a promising resource to achieve the health Millennium Development Goals" (PDF). World Health Organization. 2010. Archived from the original (PDF) on 19 Jul 2021. Retrieved 4 April 2021.
  2. ↑ "Mid-Level Practitioners Authorization by State" (PDF). US Department of Justice. 4 January 2021. Retrieved 4 April 2021.
  3. ↑ 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. (9 Oct 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.
  4. ↑ "Advanced Practice Nurses | Gale Encyclopedia of Nursing and Allied Health - Credo Reference". search.credoreference.com. Retrieved 2022-03-28.
  5. ↑ "Nurse Practitioner | Encyclopedia of Women's Health - Credo Reference". search.credoreference.com. Retrieved 2022-03-28.
  6. ↑ 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)
  7. 1 2 3 4 5 "Scope of Practice for Nurse Practitioners" (PDF). AANP Policy Statements. American Association of Nurse Practitioners. Retrieved 14 November 2017.
  8. ↑ "State Practice Environment". American Association of Nurse Practitioners. Retrieved 2023-11-20.
  9. 1 2 "Eligible Nurse Practitioners Questions and Answers". Department of Health and Aged Care. 11 October 2018. Retrieved 14 September 2022.
  10. 1 2 "Ford, Loretta C." National Women’s Hall of Fame. Retrieved 2019-11-15.
  11. ↑ "Historical Perspectives on an Expanded Role for Nursing". Nursingworld.org. Retrieved 2017-05-10.
  12. ↑ "The History of Nurse Practitioners". Graduatenursingedu.org. Retrieved 2017-05-10.
  13. 1 2 3 Dicenso, Abla; Bryant-Lukosius, Denise. "Clinical Nurse Specialists and Nurse Practitioners in Canada: A Decision Support Synthesis" (PDF). Canadian Health Services Research Foundation. Archived from the original (PDF) on 2012-03-13. Retrieved 1 June 2019.
  14. ↑ Deering, Maura (13 October 2022). "How to Become a Nurse Practitioner". Nurse Journal. Retrieved 28 October 2022.
  15. ↑ "NP Fact Sheet". Aanp.org. Retrieved 30 January 2022.
  16. ↑ "AANP Certifications". www.aanpcert.org. Retrieved 2023-11-25.
  17. ↑ "ANCC Certifications". ANA. 2022-11-16. Retrieved 2023-11-25.
  18. ↑ "Pediatric Certifications". PNCB. Retrieved 2023-11-25.
  19. ↑ "Accelerated 4+1 BSN and MSN | Simmons University". www.simmons.edu. Retrieved 2023-11-20.
  20. ↑ "Nursing Master's Programs With 100% Admit Rates". Usnews.com. Retrieved 30 January 2022.
  21. ↑ RN, Sarah Jividen; BSN. "Nursing Schools With the Highest Acceptance Rates". Nurse.org. Retrieved 2023-11-20.
  22. ↑ "What's Going on with Nurse Practitioner Education?". Physicians for Patient Protection. 2020-01-10. Retrieved 2023-11-20.
  23. ↑ "Registration standard for endorsement for scheduled medicines registered nurses (rural and isolated practice)". Nursing and Midwifery Board of Australia. 31 March 2010. Retrieved 20 August 2021.
  24. ↑ "Guidelines: For nurses applying for endorsement as a nurse practitioner". Nursing and Midwifery Board of Australia. Australian Health Practitioner Regulation Agency. 8 August 2019. Retrieved 20 August 2021.
  25. ↑ Vestal, Christine (2013-07-19). "Nurse Practitioners Slowly Gain Autonomy". Kaiser Health News. Retrieved 2019-05-22.
  26. ↑ Flanagan, Lyndia (October 1998). "Nurse Practitioners: Growing Competition for Family Physicians?". Family Practice Management. 5 (9): 34–43. PMID 10187057.
  27. ↑ "VA Grants Full Practice Authority to Advance Practice Registered Nurses - VA News". Retrieved 2023-11-20.
  28. ↑ "Army Nurse Corps" (PDF).
  29. ↑ "Nurse practitioner standards for practice". Nursing and Midwifery Board of Australia. 1 March 2021. Retrieved 14 September 2022.
  30. ↑ "Nurse Practitioners Career Guide" (PDF). Australian College of Nurse Practitioners. Retrieved 20 August 2021.
  31. 1 2 Davey, Melissa (16 August 2022). "Nurses are the solution to bulk-billing crisis, says peak body". The Guardian. Retrieved 14 September 2022.
  32. ↑ "Scope of Practice for Nurse Practitioner - College and Association of Registered Nurses of Alberta" (PDF). College and Association of Registered Nurses of Alberta. 2019. Retrieved 6 December 2019.
  33. ↑ "How to Become an Advanced Practice Nurse in Canada". Graduatenursingedu.org. Retrieved 2017-05-16.
  34. ↑ "Scope of Practice for Nurse Practitioner" (PDF). College and Association of Registered Nurses of Alberta. December 2019. Retrieved 6 December 2019.
  35. ↑ "Minister for Health publishes Final Evaluation Report which demonstrates the many benefits of Advanced Nursing Practitioners". Gov.ie. Department of Health (Ireland).
  36. ↑ "Changing role of nursing profession". Sligo Champion. September 26, 2020 – via Independent.ie.
  37. ↑ "ות בריאות העם )אישור תואר מומחה בסיעוד התשע"ד-2" (PDF). Health.gov.il. Retrieved 30 January 2022.
  38. ↑ McCleery, E.; Christensen, V.; Peterson, K.; Humphrey, L.; Helfand, M. (2011). "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). PMID 27606392.
  39. ↑ Lozada, M. James; Raji, Mukaila A.; Goodwin, James S.; Kuo, Yong-Fang (2020). "Opioid Prescribing by Primary Care Providers: A Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns". Journal of General Internal Medicine. 35 (9): 2584–2592. doi:10.1007/s11606-020-05823-0. PMC 7459076. PMID 32333312.
  40. ↑ 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): 101–107. doi:10.1001/jamainternmed.2014.6349. PMID 25419763.
  41. ↑ 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.
  42. ↑ "Nurse Practitioner Salary | Certified Nurse Midwife | Anesthetist Salaries". Graduatenursingedu.org. Retrieved 2017-05-16.
  43. ↑ Stucky, Christopher H.; Brown, William J.; Stucky, Michelle G. (2020-10-12). "COVID 19: An unprecedented opportunity for nurse practitioners to reform healthcare and advocate for permanent full practice authority". Nursing Forum. 56 (1): 222–227. doi:10.1111/nuf.12515. ISSN 0029-6473. PMC 7675696. PMID 33047352.
  44. ↑ "COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers" (PDF). CMS. 30 March 2020. Retrieved 6 March 2022.
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