Nurse practitioners: A vital force in healthcare delivery NPs still confront barriers to practice. Yet our healthcare system can t improve without them. By Janet Selway, DNSc, ANP-BC, CPNP-PC THE PAST FEW YEARS have cast nurse practitioners (NPs) in the spotlight, thanks to passage of the Affordable Care Act, the 2011 Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health, and physician shortages. In underserved areas, NPs may be the only healthcare practitioners available. So this is an ideal time to examine developments in and continued challenges of the NP role in nursing and health care. APRN Consensus Model Confusion and inconsistency have surrounded NP role definitions, titles, and regulation since the 1960s, when the first NP educational program began. In July 2008, after years of discussion, a consensus regarding the regulation of NPs and other advanced practice registered nurses (APRNs) resulted in the landmark document Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. Achieved through the efforts of a consensus work group, the model defines APRN practice, describes the APRN regulatory model, identifies the titles to be used, defines specialty, describes the emergence of new roles and population foci, and presents strategies for implementation. It recommends a consistent title (APRN) and recommends four APRN roles Certified NP (CNP), Certified Nurse Midwife (CNM), Certified Registered Nurse Anesthetist (CRNA), and Clinical Nurse Specialist (CNS). It also offers model legislative language for optimum APRN practice. To date, 48 nursing organizations (including all national NP organizations) have endorsed the Consensus Model; the target date for implementation is 2015. The IOM recommends state legislatures conform to the Model Nurse Practice Act of the National Council of State Boards of Nursing, which is based on the Consensus Model. So far, 16 states, the District of Columbia, and Northern Mariana Islands have APRN legislation in alignment or near alignment with the Model. (See Speaking with one voice.) Although the Model is helping to reduce confusion and inconsistency, some uncertainty remains especially for NPs because of wide variations in state regulation of NP practice. NP role definitions, titles, scopes of practice, prescriptive authority, and physician oversight still vary across 8 American Nurse Today Volume 7, Number 9 www.americannursetoday.com
the 50 states. This can cause problems when an NP moves to a different state or prescribes through an out-of-state pharmacy. What types of NPs are in practice? The answer isn t a simple one. APRNs are educated and licensed at the level of role and population focus. One goal of the Consensus Model was to ensure APRNs first complete a broad-based education in a specific role and a specific population. The Model names six population foci for APRNs, reflecting recent changes that are affecting future national NP certification exams. The six current population foci for entry-level NP practice are Family, Adult-Gerontology, Neonatal, Pediatrics, Women s Health/Gender, and Psychiatric- Mental Health (across the lifespan). Take, for instance, NP as the role and pediatrics as the population. To be licensed as a pediatric NP (PNP), the candidate has to complete a pediatric NP education program and pass a national PNP certification examination. Those choosing the NP role with a pediatric or adult population focus must further select either acute care or primary care. Acute-care NPs (ACNPs) often function in the hospitalist role, managing the problems of critically ill patients. Although many ACNPs practice in intensive care units and emergency departments (EDs), the role has expanded. Rather than practice in specific settings, ACNPs focus on patients with acute and complex illnesses or chronic illnesses. They may practice in clinics, home and hospice care, and specialty practices. ACNPs are prepared to perform invasive procedures to stabilize critically ill patients and to provide restorative care. Five certification boards offer different exams for entry-level NP certification in the six population foci. National certification is required for Speaking with one voice Who speaks for nurse practitioners (NPs)? At times, that has been a tough question to answer. Presenting confusing or conflicting messages to legislators doesn t serve any profession well. With healthcare reform, communication among national nursing organizations on legislative initiatives has improved. On July 3, 2012, the American College of Nurse Practitioners and the American Academy of Nurse Practitioners (the two major NP-specific national organizations) formally announced their intent to consolidate into one new organization. The new entity should be finalized before 2013, with an expectation of achieving greater strength and visibility, along with improved participation in the political arena. Medicare reimbursement; 93% of NPs are nationally certified. NPs may seek additional specialty certifications beyond initial entry-level certification. NP certifications are available in such specialties as dermatology, oncology, and orthopedics. These have a focus of practice beyond the role and population; although they don t require licensure, they do require prior entrylevel NP certification. DNP degree: Recommended option for NPs In 2006, the American Association of Colleges of Nursing recommended the Doctor of Nursing Practice (DNP) degree as the entry-level degree for all APRNs by 2015. Not exclusively for NPs, DNP is the highest degree for nurse clinicians. Salary survey data from 2009 found DNP salaries are about $7,688 higher than those of master s-prepared nurses. In 2011, DNP graduates numbered 1,595 an increase from 1,282 in 2010. DNP programs enrolling students now number 184, with 101 more in the planning stages. In contrast, research-focused nursing doctoral programs numbered 125 in 2011, increased from 103 programs in 2006. NP certification boards don t require a DNP for entry-level exam eligibility. No evidence suggests better clinical performance in an NP with a DNP compared to a master sprepared NP. Nor does any state require a DNP as a condition of APRN licensure. The Consensus Model recommends APRN entry-level education be formal education with a graduate degree or post-graduate certificate (either postmaster s or post-doctoral) awarded by an academic institution and accredited by a nursing or nursing-related accrediting organization. Innovative NP practice settings Emerging practice settings for NPs include EDs in rural hospitals, convenient-care clinics, and house-call practices. Nurse-managed health centers, many owned and operated by nursing schools, also are a growing option. Some NPs are successful independent practice owners, though their exact number isn t known. According to a 2009 national NP salary survey, 3% of respondents (n = 5,908) identified themselves as private practice owners; half of these practices had been open less than 3 years. A similar survey 1 year later found about 10% of respondents (n = 2,956) intended to open a healthcare-related business in the next 5 years. (See Tracking NP growth and practice patterns.) Edge Runners The American Academy of Nursing s Raise the Voice Edge Runner Program showcases innovative nursing practice models, including creative examples of NP practices meeting the needs of underserved communities. One example is Tel- Emergency a distance emergency- www.americannursetoday.com September 2012 American Nurse Today 9
Tracking NP growth and practice patterns Nurse practitioners (NPs) are the largest group of advanced practice registered nurses (APRNs), accounting for 63% of APRNs. Approximately 89% of NPs are employed in nursing; 70% have the job title of NP. More than 93% are nationally certified. In 1992, the National Registered Nurse Sample Survey found that 48,237 RNs were prepared as NPs in the United States. By 2008, this number had increased to 158,348. More recent data (2012) show the total number of NPs has risen to 180,233. Most NPs practice in nursing in a wide variety of healthcare delivery settings in every state and U.S. territory. Nearly two-thirds of those employed as NPs work in primary care; roughly 42% work in family care. By 2025, NP jobs are expected to nearly double to 244,000. The need for more data Although some NP workforce information is available, more data are needed. If the Affordable Care Act is implemented as planned within the next few years, 30 million uninsured Americans will be enrolled in health insurance plans, greatly increasing the demand for primary-care providers. The Association of American Medical Colleges Center for Workforce Studies predicts a shortage of about 63,000 physicians by 2015, with greater shortages on the horizon 91,500 and 130,600 for 2020 and 2025, respectively. NPs have become a crucial sector of the healthcare workforce, spurring the federal government to recognize the importance of obtaining accurate NP workforce data. In August 2011, the Health Resources and Services Administration announced plans to disseminate the first National Sample Survey of Nurse Practitioners. This unprecedented survey seeks to improve estimates of NP positions, roles, specialties, practice settings, activities, services, and job satisfaction. It will examine variations in NP practice patterns and sectors. In keeping with recent Institute of Medicine recommendations, the survey also will determine NPs perception of the extent to which they re working to the full scope of their practice. It has been distributed to 22,000 NPs in 50 states. Results should be available to the public in the spring of 2013. care service that can help improve clinical and financial outcomes. This 24/7 system links a specially trained NP in a rural ED with a board-certified emergency physician at a distant location. Nearly half of ED patients require collaborative care by the NP and emergency physician, with the NP independently treating the remaining patients. TelEmergency has trained more than 45 NPs and treated more than 150,000 patients. It has been implemented in 15 hospitals. Nurse-managed health centers Another exciting NP practice setting is the nurse-managed health center. Currently, 250 such centers exist in the United States, with more than 2.5 million patient encounters per year. They are staffed primarily by NPs, other APRNs, other nurses, and members of other disciplines. St. Francis Health Center in Will County, Illinois (an Edge Runner), represents a successful collaboration between NPs and CNSs to serve the poor and uninsured. In 2006, the University of St. Francis School of Nursing obtained a $2.1 million grant from the federal Health Resources and Services Administration to support its nursemanaged health center a primarycare clinic staffed by NPs, a social worker, a registered nurse, a dietitian, and support staff. The center takes a one-stop approach to meeting the health needs of its patients (mostly place-bound elderly and disabled persons). NPs provide primary care and a psychiatric CNS provides onsite psychiatric care. Convenient-care clinics The convenient-care industry (also called retail health) has evolved as a response to the floundering U.S. healthcare system. Convenient-care clinics are located in retail stores (such as Target and Walmart) and pharmacies (such as CVS). Staffed primarily by NPs, they offer a limited, defined scope of services. The clinics are designed to meet basic healthcare needs, such as treatment of acute otitis media or urinary tract infections. They also provide certain vaccines, such as flu vaccine. According to the Convenient Care Association, NPs are ideal to staff such clinics because they possess advanced clinical skills and a strong desire to expand access to care. The United States now has more than 1,300 retail clinics in 40 states; most employ NPs. A RAND Corporation study examining trends in retail-clinic use found that use increased tenfold between 2007 and 2009. Web-based house-call practices NPs are using technology to enhance house-call practices. Raymond Zakhari, ANP-BC, FNP-BC, owns Metro Medical Direct in New York City. This web-based private practice is a primary-care, housecall service that delivers holistic primary care in a person s home or office, or (if traveling) in a hotel. The website features a patient portal, a blog, and a patient-education library. Zakhari makes house calls with his laptop and a therapy dog. He takes full advantage of a webbased electronic health record system for charting, billing, and e- prescribing. Appointments can be scheduled online. NP practice barriers Turf battles between NPs and organized medicine continue at both the federal and state levels. NPs aren t replacements for physicians, any more than physicians are replacements for NPs. Each type of professional has completed specific education to prepare for their respective roles. These roles happen to overlap in many ways, but certainly aren t 10 American Nurse Today Volume 7, Number 9 www.americannursetoday.com
identical. Most NP educational programs are highly rigorous master s programs that prepare nurses to be NPs, not junior doctors. Currently, 27 states don t require physician oversight of NP practice. But 16 states still require NPs to practice under severe restrictions that limit patients access to care. Florida and Alabama are prime examples; these are the only states that continue to restrict NPs from prescribing controlled substances. Such restrictions can have dire consequences. After the April 2011 tornado disaster in Alabama, NPs couldn t fulfill a request to staff a free clinic to help disaster victims because of a restrictive collaborative practice agreement requirement. Strong evidence suggests NPs are safe, effective providers. A recent systematic review of 1990-2008 literature by multidisciplinary authors clearly shows that in a range of situations, NP outcomes are comparable to, and sometimes exceed, physician outcomes. NPs don t require physician oversight of their practice to ensure patient safety. No single type of healthcare provider works alone or in isolation. Competent providers are responsible for making appropriate patient referrals to other healthcare team members when a patient s needs would be better met by another provider. Staff nurse and NP relationship If you re a staff nurse, you may wonder how best to work with an NP. Remember that she or he is a nurse, just like you. NPs value the same things you value: empathy, a holistic view, and concern for the patient s comfort and well-being. They re concerned about the patient s medical and nursing needs, and should value your input on both. With a predicted physician shortage of 90,000 in the not-sodistant future, a chronic disease epidemic, an aging population, and anticipated addition of 30 million primary-care patients to insurance rolls by way of the Affordable Care Act, NPs are vital to our nation s health. Without nurses or NPs, the U.S. healthcare delivery system can t improve. As Jeff Susman, MD, editor of the Journal of Family Practice, stated in a 2010 editorial, I urge my fellow family physicians to accept...a full partnership with APNs... let s celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care. Visit www.americannursetoday.com/archives/ aspx for a list of selected references, a history of the NP role, a chart showing changes in APRN population foci, and a table of NP certification boards, examinations, and credentials. Janet Selway is director of the adult-gerontology nurse practitioner program and assistant professor in the School of Nursing at The Catholic University of America in Washington, DC. She is the immediate past-president of the American College of Nurse Practitioners. Certified Documentation Improvement Practitioner Distinguish Yourself Validate Your Specialty Knowledge I am a BSN-prepared registered nurse and have been active in nursing for 33 years... [and as] a case manager for 10 years my CDIP certification shows others that I am dedicated to my field MX6959 Dianne Stephens, RN, BSN, CDIP Clinical Documentation Specialist Learn more, register, and find exam prep materials at ahima.org/certification.
How the NP role emerged During the 1960s, a time of rapid change and unrest, gender and racial equality issues came to the forefront. The women s movement cast the underpaid, overworked, female-dominated nursing profession in a new light. Urban populations were growing, while rural communities continued to struggle with an inadequate healthcare delivery infrastructure. Much like today, the country saw a growing consumer demand for greater access to higher-quality and more sensitive health care, in the setting of a significant primary-care physician shortage and out-of-control costs. Often, the poorest were those most in need of health care. This critical need spawned the new role of the nurse practitioner (NP). The first NP educational program was developed at the University of Colorado in 1965 by Dr. Loretta Ford, then a public health nurse who worked with underserved rural populations, and Dr. Henry Silver, a pediatrician. Private philanthropy played a major supporting role in the birth of the NP role. Early NP programs were funded by the Commonwealth Foundation and later by the Robert Wood Johnson Foundation and the Carnegie Corporation of New York. Initially, many nursing school deans opposed the NP role, concerned that medicine would control nursing because physicians were teaching technical skills. But the early pediatric programs had strong evaluation data, and those deans fears proved to be unfounded. By the early 1970s, NP programs had expanded to include family and adult primary care. Nurse practice acts were changed and the NP role was further legitimized. In 1986, A.M. Harvey and Susan Abrams wrote in their book For the Welfare of Mankind: The Commonwealth Fund and American Medicine: The value of nurse practitioners is now widely recognized, and nurses are seen as a key group in meeting the need for well-trained professionals to provide primary care. In the mid-1990s, NP programs expanded further to include practice in acutecare settings. The first certification exam for acute-care NP was given in 1995.
Changes in APRN population foci To conform with the new population foci recently defined by the Advanced Practice Registered Nurse (APRN) Consensus Model, some nurse practitioner certification boards have announced retirement of the Gerontology, Adult Primary Care, Adult Acute Care, and Psychiatric-Mental Health Adult certification exams by 2013-2014. Previous population focus Adult Primary Care Adult Acute Care Gerontology Pediatric Primary Care Pediatric Acute Care Women s Health/Gender-related Neonatal Family Adult Psychiatric-Mental Health Family Psychiatric-Mental Health Population focus change Adult-Gerontology Primary Care Adult-Gerontology Acute Care Will be retired Will be retired
NP certification boards, entry-level examinations, and credentials Five nurse practitioner (NP) certification boards offer a variety of national entry-level NP certification exams, which address the various NP roles and population foci. These boards and exams are recognized by Medicare and all state nursing boards. To align with the new population foci identified by the Advanced Practice Registered Nurse Consensus Model, some exams are being retired and replaced by new exams. Certification board Certification exam Retirement date New exam date Credential ANCC Adult Primary Care 2014 N/A ANP-BC ANCC Acute Care 2014 N/A ACNP-BC ANCC Adult-Gerontology N/A 2013 AGPCNP-BC Primary Care ANCC Adult-Gerontology N/A 2013 AGACNP-BC Acute Care ANCC Gerontology 2013 N/A GNP-BC ANCC Family N/A N/A FNP-BC ANCC Pediatric Primary Care N/A N/A PNP-BC ANCC Adult Psychiatric- 2014 N/A PMHNP-BC Mental Health ANCC Family Psychiatric- N/A N/A PMHNP-BC Mental Health AANPCP Adult 2014 N/A ANP-C AANPCP Gerontology 2013 N/A GNP-C AANPCP Adult-Gerontology N/A 2013 AGNP-C AANPCP Family N/A N/A FNP-C PNCB Pediatric Primary Care N/A N/A CPNP-PC PNCB Pediatric Acute Care N/A N/A CPNP-AC NCC Women s Health Care N/A N/A WHNP-BC NCC Neonatal N/A N/A NNP-BC AACNCC Adult Acute Care 2015 N/A ACNPC AACNCC Adult-Gerontology 2015 N/A ACNPC-AG Acute Care AACNCC: American Association of Critical-Care Nurses Certification Corporation AANPCP: American Academy of Nurse Practitioners Certification Program ANCC: American Nurses Credentialing Center NCC: National Certification Corporation PNCB: Pediatric Nursing Certification Board N/A: Not applicable