Nurse Practitioner

A Nurse Practitioner (NP) is a registered nurse who has completed specific advanced nursing education (generally a master's degree or doctoral degree) and training in the diagnosis and management of common as well as complex medical conditions. Nurse Practitioners provide a broad range of health care services. Nurse Practitioners, in many states, are considered "Mid-level Providers/Practitioners," along with Clinical Nurse Specialists, Certified Nurse Midwives, Certified Registered Nurse Anesthetists and Physician Assistants. Nurse practitioners, along with other advanced practice nurses, function within the scope of their state's nurse practice act and have varying levels of physician collaboration or supervision. In some states, nurse practitioners function independent of physician involvement.

In some states, NPs admit and follow their patients in hospitals. Some NPs work in emergency rooms evaluating, diagnosing and treating patients with lacerations and fractures. In 10 states, NPs can open their own clinics and offices, in 27 states they are required to work in collaboration with physicians, and in 11 states they are required to work under supervision of a physician.The American Academy of Nurse Practitioners defines Nurse Practitioners as licensed independent practitioners who practice in ambulatory, acute and long term care as primary and/or specialty care providers. They provide nursing and medical services to individuals, families, and groups according to their area of practice/specialty. In addition to diagnosing and managing acute episodic and chronic illness, they also emphasize health promotion and disease prevention, incorporating teaching and counseling of individuals, families, and groups as a major part of their practice. some nurses may specialise in certain fields of medicine such as laser eye surgery

In the US, NPs are licensed by the state in which they practice, and have a national board certification (usually through the American Nurses Credentialing Center or American Academy of Nurse Practitioners). Nurse Practitioners can be trained and nationally board certified in areas of Family & Community Medicine (FNP), Pediatrics, including Pediatric Acute/Chronic Care, Pediatric Critical Care, Pediatric Oncology and general Pediatrics (PNP), Neonatology (NNP), Gerontology (GNP), Women's Health (emphasis on reproductive & gynecological health) (WHNP), Psychiatry & Mental Health (PMHNP), Acute Care (ACNP), Adult Health (ANP), Oncology (ONP), Emergency Medicine (as FNP or ACNP), Occupational Health (as ANP), etc. These programs, offered by many universities with a School of Nursing, are graduate-level programs; upon successful completion, students may be awarded a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) degree.

Nurse Practitioners treat both acute and chronic conditions through comprehensive history taking, physical exams, physical therapy, ordering tests and therapies for patients, within their scope of practice. An NP can serve as a patient's "point of entry" health care provider, and see patients of all ages depending on their designated scope of practice.

Scope of practice

Because the profession is state regulated, care provided by NPs varies widely. In some states, nurse practitioners work completely independently and autonomously of physicians while, in most states, a collaborative agreement with a physician is required for practice; the extent of this collaborative agreement, and the role, duties, tasks, medical treatments, pharmacologic prescriptions, et al it affords a Nurse Practitioner to perform and prescribe again varies amongst states of licensure. A nurse practitioner's job may include the following:

  • Diagnosing, treating, evaluating and managing acute and chronic illness and disease (e.g. diabetes, high blood pressure)
  • Obtaining medical histories and conducting physical examinations
  • Ordering, performing, and interpreting diagnostic studies (e.g., routine lab tests, bone x-rays, EKGs)
  • Prescribing physical therapy and other rehabilitation treatments
  • Prescribing pharmacologic treatments and therapies for acute and chronic illness (extent of prescriptive authority varies by state regulations)
  • Providing prenatal care and family planning services
  • Providing well-child care, including screening and immunizations
  • Providing primary and specialty care services, health-maintenance care for adults, including annual physicals
  • Providing care for patients in acute and critical care settings
  • Performing minor surgeries and procedures (with additional training and usually under supervision) (e.g., dermatological biopsies, suturing, casting)
  • Counseling and educating patients on health behaviors, self-care skills, and treatment options

Practice Settings

NPs practice in all U.S. states. The institutions in which they work may include, but are not limited to, the following:

  • Community clinics, health centers, urgent care centers
  • Health departments
  • Health maintenance organizations (HMOs)
  • Home health care agencies
  • Hospitals
  • Hospice care
  • Nurse practitioner practices/offices
  • Nursing homes
  • Private & public schools, universities and colleges
  • Physician/private medical practices
  • Veteran's administration facilities

Education, licensing, and board certification

o be licensed as a nurse practitioner, the candidate must first complete the education and training necessary to be a registered nurse (RN).

Requirements for a registered nurse (RN) include either an Associate of Science in Nursing (ASN), a Bachelor of Science in Nursing (BSN), or completion of a diploma program, as well as direct patient care for acutely or chronically ill patients. ASN programs, which are offered by community and junior colleges, usually take 2 years plus prerequisites. BSN programs are offered by colleges and universities and take 4 years plus necessary prerequisites before acceptance into the program. -

While not every state includes specific language requiring a masters degree for NPs, the majority of states do require a masters degree, post-master's certificate or doctoral degree. Further, the current nurse practitioner programs offered by all universities and colleges are at the masters or post-master's certification level. Lastly, all states require national board certification for nurse practitioners before they are permitted to practice and the two biggest certifying bodies, the American Nurses Credentialing Center and the American Academy of Nurse Practitioners, do require applicants to hold a masters degree or post-master's certificate to be eligible to test for certification. In 2015 these organizations will require a Doctor of Nursing Practice (DNP) degree for a candidate to be eligible to take the certification examination.

To become a Nurse Practitioner (NP), nurses trained at the associate degree or diploma level must first complete a Bachelor of Science in Nursing (BSN) or enter various programs offering an ADN-to-MSN "bridge program," some of which award the bachelors degree while completing the requirements for the masters; others, upon completion, only award the MSN with only the BSN coursework being completed instead of an actual degree awarded.

Once state licensure as a registered nurse is attained by successful completion of the NCLEX-RN, the candidate must complete a state-approved advanced nursing education program that usually specializes in a field such as family health, adult health, acute care, women's health, etc. The degree can be granted by a university which grants an MSN or doctorate in nursing.

The variety of educational paths for NPs is a result of the history of the field. In 1965, the profession of nurse practitioner was instituted and required a master's degree. In the late 1960s into the 1970s, predictions of a physician shortage increased funding and attendance in nurse practitioner programs. During the 1970s, the NP requirements relaxed to include continuing education programs, which helped accommodate the demand for NPs. The certifying organizations, states, and employers require a minimum of a master's degree for new NPs (already established NPs with lesser education were grandfathered in).

After completing the education program, the candidate must be licensed by the state in which he or she plans to practice. The state boards of nursing regulate nurse practitioners and each state has its own licensing and certification criteria. In general, the criteria include completion of a master's degree in nursing and certification by an accrediting body (ANCC, AANP). The license period varies by state; some require biennial relicensing, others require triennial.

Before or after receiving state licensing, a nurse practitioner can apply for national certification from one of several professional nursing organizations such as the American Nurses Credentialing Center (ANCC) or the American Academy of Nurse Practitioners (AANP). The American Nurses Association (ANA) does not offer certification directly, but through its credentialing center, the ANCC. Some NPs pursue certification in a specialty. Several organizations oversee certification, including the following:

  • American Association of Critical-Care Nurses
  • American Psychiatric Nursing Association
  • Board of Certification for Emergency Nursing
  • Pediatric Nursing Certification Board
  • National Certification Corporation for the Obstetric, Gynecologic, and Neonatal Nursing Specialties
  • Oncology Nursing Certification Corporation

Future Trends

There is currently a large push by many nurse practitioner professional organizations to obtain full independence from physician collaboration or supervision in all jurisdictions in the United States. The Pearson Report, an annual report published in the American Journal for Nurse Practitioners, was issued in February 2009 describing how nurse practitioners should approach lobbying their state legislatures to push for full autonomy. In the report, the main justification was an analysis of malpractice claims in the National Practitioner Data Bank to show that NPs have much lower rates of malpractice than MDs or DOs. Such analysis need further research investigation as malpractice suits target NPs less compared to their collaborating or supervising physicians, and because there has been a growing trend among state boards of nursing for under-reporting malpractice claims against these Advance Practice Nurses.

In addition, the NP profession face great opposition from physician constituents as they achieve Doctor of Nursing Practice health care provider status. Physicians argue there is little uniformity among DNP programs as some DNP-granting programs are offered online. Many physicians oppose DNP programs suggesting they contain few extra clinical training that would unseemingly justify the granting of a clinical doctorate degree. As DNP programs develop across the nation, there is a growing consensus of DNP essentials (implemented by the AACN) as degree granting institutions add emphasis to the various components of the DNP degree. Currently, the CCNE is the accrediting body for these nurse practitioner programs and will strive to assure congruence among the standards for accreditation of nurse midwifery, nurse anesthesia, and all DNP programs.

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