Occupation | |
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Synonyms | advanced practice practitioner, advanced practice provider, advanced practice clinician, advanced clinical practitioner, advanced clinical provider, non-physician practitioner, non-physician provider, physician assistant (hyponym), nurse practitioner (hyponym), advanced practice nurse (hyponym) |
Occupation type | Professional |
Activity sectors | Medicine, health care |
Description | |
Fields of employment | Clinics, hospitals |
Mid-level practitioners, also called non-physician practitioners, advanced practice providers, or commonly mid-levels are health care providers who assess, diagnose, and treat patients but do not have formal education or certification as a physician. The scope of a mid-level practitioner varies greatly among countries and even among individual practitioners. Some mid-level practitioners work under the close supervision of a physician (such as doing pre-op and post-op assessment and management, thus allowing surgeons to spend more of their time operating), while others function independently and have a scope of practice difficult to distinguish from a physician. The legal scope of practice for mid-level practitioners varies greatly among jurisdictions, with some having a restricted and well-defined scope, while others have a scope similar to that of a physician. Likewise, the training requirement for mid-level practitioners varies greatly between and within different certifications and licensures.
Because of their diverse histories, mid-level providers' training, functions, scope of practice, regulation, and integration into the formal health system vary from country to country. They have highly variable levels of education and may have a formal credential and accreditation through the licensing bodies in their jurisdictions. [1] In some places, but not others, they provide healthcare, particularly in rural and remote areas, to make up for physician shortages. [2]
The World Health Organization includes in this category all healthcare providers with all of the following qualifications: [2]
In Canada there are four "allied primary health practitioners" identified under the National Occupational Classification (NOC) section 3124: physician assistant, nurse practitioner, midwife, and anesthesiologist assistant. [3] Nurse practitioners are permitted to provide several, but not all, of the health care services physicians provide. [4]
In 2016, a new mid-level healthcare provider role was introduced in India(Dealing With modern Medicine), known as Community Health Officer (CHO) or Nurse Practioner, Physician Associate/Assistant. The role was intended to support the community-level Health and Wellness Centres in India. [5] Community Health Officers (CHOs) and Physician Associate/Assistant (PA), also called Mid Level Health Providers (MLHPs) and non-physician practitioners(Physician Associate/Assistant), are trained in Health Sciences model who have a defined scope of Mondern medicine practice. [6] In India, Nursing, AYUSH and Healthcare Professionals (Healthcare profession like Physiotherapy, Physician Assistant/Associate,Optometrist Etc prescribed in NCAHP ACT 2021, NCAHP,MOHFW, Government of India)are eligible for this cadre.This means that they are trained in Modern Health Sciences model and legally permitted to provide healthcare in fewer situations than physicians but more than other health professionals. [7] [8] In India, Community Health Officer or Nurse practioner, Physician Associate/Assistant are another name for mid-level practitioner. [9] Apart from doctor and nurses there was a list of Healthcare providers as recently NCAHP,Ministry of Health and Family Welfare published Guideline in Ayusman Bharat digital Health Mission control of health related cases in rural areas of India. According to these guidelines, symptomatic cases can be triaged at village level by tele-consultation with a Physician Associate/Assistant or a Community Health Officer (CHO). [10] [11] [12]
In 2008, a new mid-level practitioner role was introduced in South Africa, known as clinical associates. The role was intended to support the district hospital workforce. [14]
Mid-level practitioners in the UK are known as Advanced Clinical Practitioners (ACP) or Advanced Practitioners (AP) and occurred as an evolution of many differing professions which use various titles such as ‘Extended Scope Practitioner’. Historically there has been debate over the consistency of quality in these senior clinicians and therefore it became necessary to generate a distinguished definition of the ACP role.
The ACP:
ACPs may practice in the acute setting (ED, critical care, etc) or community General Practice / Family Medicine. The majority can independently assess, investigate (through blood tests / imaging etc.), diagnose and formulate a treatment plan including prescribing medications or referring to specialist care.
The deployment of ACPs is considered to be part of a Value Based Recruitment framework driven by Health Education England (HEE)[ citation needed ]. This seeks to appoint clinicians based upon their competencies, values and behaviours in support of collaborative working and delivering excellent patient care. [15]
Physician Associates (PAs) practising in the United Kingdom is the equivalent title to physician assistant, these clinicians are described as "dependent practitioners", meaning that they require supervision at all times by a physician. They cannot prescribe medications nor can they request tests that use ionising radiation such as X-rays.
In the United States, mid-level practitioners are health care workers with training less than that of a physician but greater than that of nurses or medical assistants.
The term mid-level practitioner or mid-level provider is related to the occupational closure of healthcare. This concept centered around physicians as the ultimate professional responsible for healthcare. As healthcare demands have increased in the United States due to an aging population, a physician shortage and the implementation of the Patient Protection and Affordable Care Act of 2010 there has been a shift toward more independence in practice for professionals such as physician assistants, nurse practitioners, pharmacists, and dental therapists.
In recent years some organizations and specialties have proposed the discontinuance of the term mid-level in reference to professional practitioners who are not physicians. Each organization prefers to use their specific title, and physicians' organizations are concerned about title inflation.
*preferred even over physician assistant, which was what the acronym historically stood for
The term mid-level practitioner as found in the DEA classification in Section 1300.01(b28), Title 21, of the Code of Federal Regulations is used as a means of organizing drug diversion activities. The term mid-level practitioner as defined by the DEA Office of Diversion Control, "...means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice." [16] [17] Some health professionals considered mid-level practitioners by the United States DEA include:
A respiratory therapist is a specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people who have acute critical conditions, cardiac and pulmonary disease. Respiratory therapists graduate from a college or university with a degree in respiratory therapy and have passed a national board certifying examination. The NBRC is responsible for credentialing as a CRT, or RRT in the United States. The CBRC is responsible for credentialing as an RRT in Canada.
An emergency medical technician is a medical professional that provides emergency medical services. EMTs are most commonly found serving on ambulances and in fire departments in the US and Canada, as full-time and some part-time departments require their firefighters to at least be EMT certified.
A podiatrist is a medical professional devoted to the treatment of disorders of the foot, ankle, and related structures of the leg. The term originated in North America but has now become the accepted term in the English-speaking world for all practitioners of podiatric medicine. The word chiropodist was previously used in the United States, but it is now regarded as antiquated.
A physician assistant or physician associate (PA) is a type of healthcare professional. While these job titles are used internationally, there is significant variation in training and scope of practice from country to country, and sometimes between smaller jurisdictions such as states or provinces. Depending on location, PAs practice semi-autonomously under the supervision of a physician, or autonomously perform a subset of medical services classically provided by physicians.
Primary care is a model of health care that supports first-contact, accessible, continuous, comprehensive and coordinated person-focused care. It aims to optimise population health and reduce disparities across the population by ensuring that subgroups have equal access to services.
The American College of Physicians (ACP) is a Philadelphia-based national organization of internal medicine physicians, who specialize in the diagnosis, treatment, and care of adults. With 161,000 members, ACP is the largest medical-specialty organization and second-largest physician group in the United States. Its flagship journal, the Annals of Internal Medicine, is among the most widely cited peer-reviewed medical journals in the world.
A feldsher is a health care professional who provides various medical services limited to emergency treatment and ambulance practice. As such, a feldsher is one kind of mid-level medical practitioner.
A paramedic is a healthcare professional, providing pre-hospital assessment and medical care to people with acute illnesses or injuries. In Canada, the title paramedic generally refers to those who work on land ambulances or air ambulances providing paramedic services. Paramedics are increasingly being utilized in hospitals, emergency rooms, clinics and community health care services by providing care in collaboration with registered nurses, registered/licensed practical nurses and registered respiratory therapists.
Allied health professions (AHPs) are a category of health professionals that provide a range of diagnostic, preventive, therapeutic, and rehabilitative services in connection with health care. While there is no international standard for defining the diversity of allied health professions, they are typically considered those which are distinct from the fields of medicine, nursing and dentistry.
A nurse practitioner (NP) is an advanced practice registered nurse and a type of mid-level practitioner. NPs are trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, prescribe medications and formulate treatment plans. NP training covers basic disease prevention, coordination of care, and health promotion.
In the United Kingdom, operating department practitioners (ODPs) are allied healthcare professionals who are involved in the planning and delivery of perioperative care. As the name suggests, they are primarily employed in surgical operating departments, but they may also work directly within a variety of acute clinical settings, including pre-hospital emergency care, emergency departments, intensive care units (ICUs), endoscopy suites, interventional radiology, cardiac catheter suites, obstetric theatres and reproductive medicine.
A health professional, healthcare professional, or healthcare worker is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician, physician assistant, registered dietitian, veterinarian, veterinary technician, optometrist, pharmacist, pharmacy technician, medical assistant, physical therapist, occupational therapist, dentist, midwife, psychologist, audiologist, or healthcare scientist, or who perform services in allied health professions. Experts in public health and community health are also health professionals.
In the United States, anesthesia can be administered by physician anesthesiologists, an anesthesiologist assistant, or nurse anesthetist.
Clinical pharmacy is the branch of pharmacy in which clinical pharmacists provide direct patient care that optimizes the use of medication and promotes health, wellness, and disease prevention. Clinical pharmacists care for patients in all health care settings but the clinical pharmacy movement initially began inside hospitals and clinics. Clinical pharmacists often work in collaboration with physicians, physician assistants, nurse practitioners, and other healthcare professionals. Clinical pharmacists can enter into a formal collaborative practice agreement with another healthcare provider, generally one or more physicians, that allows pharmacists to prescribe medications and order laboratory tests.
The prescriptive authority for psychologists (RxP) movement is a movement in the United States of America among certain psychologists to give prescriptive authority to psychologists with predoctoral or postdoctoral graduate-level training in clinical psychopharmacology; successful passage of a standardized, national examination ; supervised clinical experience; or a certificate from the Department of Defense Psychopharmacology Demonstration Project; or a diploma from the Prescribing Psychologists Register to enable them, according to state law, to prescribe psychotropic medications to treat mental disorders. This approach is non-traditional medical training focused on the specialized training to prescribe for mental health disorders by a psychologist. It includes rigorous didactics and supervised clinical experience. Legislation pertaining to prescriptive authority for psychologists has been introduced over 180 times in over half of the United States. It has passed in seven states, due largely to substantial lobbying efforts by the American Psychological Association (APA), the largest professional organization of psychologists in the world with over 157,000 members. Prior to RxP legislation and in American states where it has not been passed, this role has been played by psychiatrists, who possess a medical degree and thus the authority to prescribe medication, but more frequently (60-80%) by primary care providers who can prescribe psychotropics, but lack extensive training in psychotropic drugs and in diagnosing and treating psychological disorders. According to the APA, the movement is a reaction to the growing public need for mental health services, particularly in under-resourced areas where patients have little or no access to psychiatrists.
A clinical officer (CO) is a gazetted officer who is qualified and licensed to practice medicine.
Unlicensed assistive personnel (UAP) are paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living (ADLs). UAPs also provide bedside care—including basic nursing procedures—all under the supervision of a registered nurse, licensed practical nurse or other health care professional. UAPs must demonstrate their ability and competence before gaining any expanded responsibilities in a clinical setting. While providing this care, UAPs offer compassion and patience and are part of the patient's healthcare support system. Communication between UAPs and registered nurses (RNs) is key as they are working together in their patients' best interests. The scope of care UAPs are responsible for is delegated by RNs or other clinical licensed professionals.
Certified anesthesiologist assistants (CAAs) are master’s degree level non-physician anesthesia care providers. CAAs are members of the anesthesia care team as described by the American Society of Anesthesiologists (ASA). This designation must be disambiguated from the Certified Clinical Anesthesia Assistant (CCAA) designation conferred by the Canadian Society of Respiratory Therapists. All CAAs possess a baccalaureate degree, and complete an intensive didactic and clinical program at a postgraduate level. CAAs are trained in the delivery and maintenance of most types of anesthesia care as well as advanced patient monitoring techniques. The goal of CAA education is to guide the transformation of student applicants into competent clinicians.
An acute care nurse practitioner (ACNP) is a registered nurse who has completed an accredited graduate-level educational program that prepares them as a nurse practitioner. This program includes supervised clinical practice to acquire advanced knowledge, skills, and abilities. This education and training qualifies them to independently: (1) perform comprehensive health assessments; (2) order and interpret the full spectrum of diagnostic tests and procedures; (3) use a differential diagnosis to reach a medical diagnosis; and (4) order, provide, and evaluate the outcomes of interventions. The purpose of the ACNP is to provide advanced nursing care across the continuum of health care services to meet the specialized physiologic and psychological needs of patients with acute, critical, and/or complex chronic health conditions. This care is continuous and comprehensive and may be provided in any setting where the patient may be found. The ACNP is a licensed independent practitioner and may autonomously provide care. Whenever appropriate, the ACNP considers formal consultation and/or collaboration involving patients, caregivers, nurses, physicians, and other members of the interprofessional team.
Advanced Practice Registered Nurse (APRN) refers to a nurse with advanced education, typically at least a master's degree, and certification by a national certifying program. The APRN provides specialized and multifaceted care and are able to do 60 to 80 percent of preventative and primary care done by physicians. Minnesota Statutes section 148.171, subd. 3 states that in Minnesota, APRN "means an individual licensed as a registered nurse by the board, and certified by a national nurse certification organization acceptable to the board to practice as a clinical nurse specialist, nurse anesthetist, nurse midwife, or nurse practitioner".
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