Nurse practitioner

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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
A Navy nurse practitioner assessing a patient
Occupation
Occupation type
 Professional
Activity sectors
 Nursing
Description
Education required
Depends on the country, but generally includes at least a post-graduate nursing degree
Fields of
employment
 Healthcare
Related jobs
 Registered nurse

A nurse practitioner (NP) is an advanced practice registered nurse 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, prescribe medications and formulate treatment plans. NP training covers basic disease prevention, coordination of care, and health promotion.

Contents

The scope of practice for a NP is defined by legal jurisdiction. [3] [4] In 27 US states, NPs have full practice authority, while in the remaining states, NPs are required to work under the supervision of a physician. [5] 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. [6]

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. [7] The first formal graduate certificate program for NPs was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965. [7] In 1971, the U.S. Secretary of Health, Education and Welfare, Elliot Richardson, made a formal recommendation for expanding the scope of nursing practice to be able to serve as primary care providers. [8] 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. [9]

Canada

Advanced practice nursing first appeared in the 1990s in Ontario. [10] These nurses practiced in neonatal intensive care units within tertiary care hospitals in collaboration with pediatricians and neonatologists. [10] 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. [10]

Nurse practitioners in the United States

Education requirements

Becoming a nurse practitioner in the United States requires either a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP). [11] During their studies, nurse practitioners are required to receive a minimum of 500 hours of clinical training in addition to the clinical hours required to obtain their RN. Upon completion of the graduate program, they must pass the National NP Certification Board Exam, specific to their specialization. After passing this exam, candidates must apply for NP licensure, which varies by state regulations. [12] [13] [14]

Although nurse practitioners are required to be licensed as registered nurses prior to obtaining their advanced practice registered nurse certification, there are several programs that combine a nursing undergraduate degree with nurse practitioner training. Some US nurse practitioner programs are highly selective, with admission rates as low as 6% of applicants at University of California, Irvine in 2020, [15] and others are more inclusive, with up to 100% acceptance rates in 2019 at public universities such as Northwestern State University of Louisiana and the online branch of Purdue University. [16]

Training pathways

There are many types of nurse practitioner programs in the United States, with the vast majority being in the specialty of a family nurse practitioner (FNP). [17] There are also psychiatric, adult–geriatric acute care, adult–geriatric primary care, pediatric, women's health, and neonatal nurse practitioner programs. [18] Many of these programs have their pre-clinical or didactic courses taught online with proctored examinations.[ citation needed ] Once the students start their clinical courses, they have online material but are required to perform clinical hours at an approved facility under the guidance of an NP or physician.[ citation needed ] Each clinical course has specific requirements that vary depending on the program's degree or eligibility for certification. For instance, FNPs are required to see patients across the lifespan, whereas adult geriatric NPs do not see anyone below the age of 13. [19]

Quality of care

A review of studies comparing outcomes of care by NPs and physicians in primary care and urgent care settings was generally comparable, although the strength of the evidence was generally low due to limited study duration and participant numbers. [20] 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 overprescribe opioids compared to physicians. [21] 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. [22]

One systematic review suggests "that the implementation of advanced practice nursing roles in emergency and critical care settings improves patient outcomes in emergency and critical care settings". [23]

Job setting

Nurse practitioners are currently employed in a wide variety of practice settings. These settings include the ambulatory, inpatient, or emergency departments of hospitals, health clinics, and office practices, whether private or nurse-run. In addition, they deliver care in schools and on college campuses, as well as in nursing homes and assisted living facilities. NPs can work alone or under the supervision of a physician in a wide variety of specializations. [13] [24]

Scope of practice

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. [25] 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). [26]

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. [27] 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. [6] Prescriptions issued by NPs must also be verified by a medical practitioner to be eligible to be subsidised under the Pharmaceutical Benefits Scheme. [27]

Canada

In Canada, an NP is a registered nurse (RN) with a graduate degree in nursing.[ citation needed ] Canada recognizes them in primary care and acute care practices. 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. [28] 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, and the 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. [29] 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 exception of Quebec, where only physicians are allowed to formulate a medical diagnosis. [30]

Ireland

In Ireland's publicly funded healthcare system, the Health Service Executive has the advanced nurse practitioner (ANP) grade. [31] ANPs may prescribe medications. [32]

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.[ citation needed ]

The nurse practitioner role was recommended by the Cumberlege Report 1986, which recommended nurses being given the ability to prescribe. [33]

United States

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. [5] [34] 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. [35] The extent of this collaborative agreement and the roles, duties, responsibilities, nursing treatments, and pharmacologic recommendations again vary widely between states. [36] [37] [38]

NPs are legally able to examine patients, diagnose medical conditions, prescribe most medications, and deliver treatments. [39] There is variation in the level of supervision required for NPs across different states. As of 2023, 27 states grant NPs full practice authority, meaning they can practice independently without physician oversight. The remaining 23 states require NPs to have a collaborative agreement with a physician to provide patient care. Within these 23 states, 11 further require NPs to have physician supervision or delegation for specific aspects of practice, though the physician might not be physically present at the treatment location. [5]

Licensing and board certification

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). [40] 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 needs of less-resourced communities. [41] 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 possess an unrestricted RN licence and 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 gained qualifications to an equivalent level in advanced health assessment, pharmacology, therapeutics, diagnostics, and research. Nurses applying through the latter pathway must also demonstrate that the equivalent training is clinically relevant to the field for which they wish to apply for nurse practitioner endorsement in. [40] [42]

Canada

In Canada, the educational standard is a graduate degree in nursing.[ citation needed ] The Canadian Nursing Association (CNA) notes that advanced practice nurses must have a combination of graduate-level education and 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 the 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.

Israel

As of November 2013, NPs were recognized legally in Israel. [43]

United States

The most common path to becoming a nurse practitioner in the United States begins by earning a Bachelor of Science in Nursing (BSN) and passing the National Council Licensure Examination (NCLEX) to become an RN. One must then be accepted into and complete a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) (most of which require at least 1-2 years of RN experience) to gain additional medical training in their specialty area. Finally, one must pass a national NP board certification exam. [11]

Salary

The salary of an NP generally depends on the area of specialization, location, years of experience, and level of education. In 2022, the American Association of Nurse Practitioners (AANP) conducted a NP salary survey. The results revealed the reported median base salary among full-time NPs was $113,000. [17] As of 2024, according to the U.S. Bureau of Labor Statistics, the median salary of NPs was $126,260. [44]

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. [45] 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. [46]

See also

Related Research Articles

<span class="mw-page-title-main">Registered nurse</span> Nurse who has graduated from a nursing program

A registered nurse (RN) is a nurse who has graduated or successfully passed a nursing program from a recognized nursing school and met the requirements outlined by a country, state, province or similar government-authorized licensing body to obtain a nursing license. An RN's scope of practice is determined by legislation, and is regulated by a professional body or council.

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.

<span class="mw-page-title-main">Pediatric nursing</span> Nursing involving children

Pediatric nursing is part of the nursing profession, specifically revolving around the care of neonates and children up to adolescence. The word, pediatrics, comes from the Greek words 'paedia' (child) and 'iatrike' (physician). 'Paediatrics' is the British/Australian spelling, while 'pediatrics' is the American spelling.

Psychiatric nursing or mental health nursing is the appointed position of a nurse that specialises in mental health, and cares for people of all ages experiencing mental illnesses or distress. These include: neurodevelopmental disorders, schizophrenia, schizoaffective disorder, mood disorders, addiction, anxiety disorders, personality disorders, eating disorders, suicidal thoughts, psychosis, paranoia, and self-harm.

A licensed practical nurse (LPN), in much of the United States and Canada, is a nurse who provides direct nursing care for people who are sick, injured, convalescent, or disabled. In the United States, LPNs work under the direction of physicians, mid-level practitioners, and may work under the direction of registered nurses depending on their jurisdiction.

An advanced practice nurse (APN) is a nurse with post-graduate education and training in nursing. Nurses practicing at this level may work in either a specialist or generalist capacity. APNs are prepared with advanced didactic and clinical education, knowledge, skills, and scope of practice in nursing.

Nursing credentials and certifications are the various credentials and certifications that a person must have to practice nursing legally. Nurses' postnominal letters reflect their credentials—that is, their achievements in nursing education, licensure, certification, and fellowship. The letters usually appear in the following order:

A clinical nurse specialist (CNS) is an advanced practice nurse who can provide advice related to specific conditions or treatment pathways. According to the International Council of Nurses (ICN), an Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice.

<span class="mw-page-title-main">Nursing in the United States</span> Overview of nursing in the United States of America

Nursing in the United States is a professional health care occupation. It is the largest such occupation, employing millions of certified professionals. As of 2023, 3,175,390 registered nurses were employed, paid a median income of $86,070.

In the United States, a psychiatric-mental health nurse practitioner (PMHNP) is an advanced practice registered nurse trained to provide a wide range of mental health services to patients and families in a variety of settings. PMHNPs diagnose, conduct therapy, and prescribe medications for patients who have psychiatric disorders, medical organic brain disorders or substance abuse problems. They are licensed to provide emergency psychiatric services, psychosocial and physical assessments of their patients, treatment plans, and manage patient care. They may also serve as consultants or as educators for families and staff. The PMHNP has a focus on psychiatric diagnosis, including the differential diagnosis of medical disorders with psychiatric symptoms, and on medication treatment for psychiatric disorders.

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, 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.

<span class="mw-page-title-main">Flight nurse</span> Specialist in rescue/evacuation patient care

A flight nurse is a registered nurse specializing in the field of providing comprehensive pre-hospital, emergency critical care, and hospital care to a vast scope of patients. The care of these patients is generally provided during aeromedical evacuation or rescue operations aboard helicopters, propeller aircraft, or jet aircraft. On board a rescue aircraft, is a flight nurse, accompanied by flight medics and respiratory practitioners, as well as the option of a flight physician for comprehensive emergency and critical transport teams. The inclusion of a flight physician is more common in pediatric and neonatal transport teams. A critical care flight nurse must be able to deal with all age groups with broad critical emergencies. With no physicians on site, the nurses scope of practice is expanded. The critical care experience is transferred over to a flight nurse with impacting factors such as altitude and changes in pressure, gravitational forces, and weather. Some patients may experience exacerbations because of factors related to the cabin environment, including hypoxia, limited mobility, gas expansion, and the risk of injury related to turbulence. Resources for definitive care are limited. Aeromedical evacuation crews coordinate with other organizations to plan for the safe and timely care and evacuation of patients. Crews must be prepared for patients with trauma and mental health illnesses.

<span class="mw-page-title-main">Family nurse practitioner</span> Type of certified nurse practitioner

A family nurse practitioner (FNP) provides continuing and comprehensive healthcare for the individual and family across all ages, genders, diseases, and body systems. Primary care emphasizes the holistic nature of health and it is based on knowledge of the patient in the context of the family and the community, emphasizing disease prevention and health promotion.

A pediatric nurse practitioner (PNP) is a nurse practitioner who specializes in care for newborns, infants, toddlers, pre-schoolers, school-aged children, adolescents, and young adults. Nurse practitioners have an in-depth knowledge and experience in pediatric healthcare including well childcare, and prevention/management of common pediatric acute illnesses and chronic conditions. This care is provided to support optimal health of children within the context of their family, community, and environmental setting. In order to be a pediatric nurse practitioner one must be compassionate, resourceful, good at communicating and have good attention to detail.

<span class="mw-page-title-main">Neonatal nurse practitioner</span> Type of certified nurse practitioner

A neonatal nurse practitioner (NNP) is an advanced practice registered nurse (APRN) with at least 2 years experience as a bedside registered nurse in a Level III NICU, who is prepared to practice across the continuum, providing primary, acute, chronic, and critical care to neonates, infants, and toddlers through age 2. Primarily working in neonatal intensive care unit (NICU) settings, NNPs select and perform clinically indicated advanced diagnostic and therapeutic invasive procedures. In the United States, a board certified neonatal nurse practitioner (NNP-BC) is an APRN who has acquired Graduate education at the master's or doctoral level and has a board certification in neonatology. The National Association of Neonatal Nurse Practitioners (NANNP) is the national association that represents neonatal nurse practitioners in the United States. Certification is governed by the National Certification Corporation for Obstetrics, Gynecologic and Neonatal Nursing Specialties (NCC).

An adult-gerontology nurse practitioner (AGNP) is a nurse practitioner that specializes in continuing and comprehensive healthcare for adults across the lifespan from adolescence to old age.

Advanced practice registered nurses (APRNs) are registered nurses with graduate degrees in nursing. APRN roles include: certified nurse midwife, clinical nurse specialist, certified registered nurse anesthetist, and nurse practitioner. APRNs assess, diagnose, manage patient medical problems, order diagnostic tests, and prescribe medications. Rules, regulations, and credentialing for APRNs vary by state. This page outlines the regulatory processes for nurse practitioners in Wisconsin, including education, certification, licensing, and credentialing. Regulatory and credentialing processes are continuously changing, and the information contained on this page is current as of November 2015.

Nursing is the largest healthcare profession in the United States, with more than 3.1 million registered nurses. Between 2012 and 2022, employment for nurses is projected to grow by 19 percent, which is more than any other profession. Nurses make up the largest component of staff in hospitals but are also able to provide care in clinic settings, patient's homes, schools, nursing homes, public health agencies, and mental health centers. In addition, nurses can be found in the military, in industry, nursing education, and do health care research. Nurses in these various roles and settings can provide direct patient care and case management, but also develop and establish nursing practice and quality standards within complex healthcare systems. As each degree can provide a different level of care for patients and function in vastly different roles, it is important to differentiate between them. The levels of nursing degrees have different educational requirements, licensure, and credentialing that can vary state to state.

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".

References

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