Nurse Practitioner profession (NP)
Information:
History of Profession:
The first nurse practitioner (NP) educational program was developed as a master's degree curriculum at the University of Colorado School of Nursing in 1965 by Henry K. Silver (a pediatrician) and Loretta C. Ford (a nursing faculty member). During the late 1960s and into the 1970s, a projected physician shortage stimulated increased interest and funding sources for nurse practitioner programs. Many of the more than 500 NP programs in existence in the early 1970s had moved from the master's degree educational model to a continuing education model. In the 1980s, preferred educational preparation for the nurse practitioner role shifted back to the graduate (master's degree) level.
Currently (1993), there are over 40 NP programs in the United States, the vast majority of which prepare students at the graduate level. Applicants for most NP programs must have a bachelor's degree and three or more years of successful experience as a registered nurse in a variety of settings. The majority of NP applicants tend to have experience in critical care, emergency room, and/or community health care settings.
As with the nursing profession in general, NPs are primarily female. However, a steadily increasing number of males are moving into the nurse practitioner role. In most areas, NPs work in collaboration with physicians. Several states (including Alaska, Oregon, and Washington) recognize the ability of NPs to practice independently; some may require physician collaboration only in conjunction with prescriptive practice privileges (including Utah, West Virginia, Wyoming, and Massachusetts); some require physician collaboration to be eligible for licensure as an NP (including Idaho, New Mexico, Maryland, Pennsylvania, and South Dakota), and a few states still do not recognize advanced practice nursing roles or do not have specific language pertaining to NPs in the state's Nurse Practice Act (including Ohio, Illinois, and Indiana).
The potentially more independent nature of the nurse practitioner role has created, in some areas, a perceived competitive threat to medical practice. Historically, the states that have very limited or no recognized NP practice have experienced an inability of state nursing and medical associations to agree upon proposed legislation affecting NPs and/or the influential medical (physicians') lobbyists within the states' legislatures. This has negatively impacted such proposed legislation. Numerous studies conducted over the past 25 years have documented the ability of NPs to independently manage 80 to 90% of outpatient primary care visits. These studies have also noted the exceptional skills of NPs in the areas of health promotion, patient education, and general communication with patients. Typically NPs spend more time with patients, including not only services traditionally performed by doctors, but also incorporating more preventive or anticipatory guidance and patient education specific to the prescribed course of treatment.
Scope of Practice:
The nurse practitioner is prepared, both academically and clinically, to provide a broad range of health care services employing a "holistic" approach. NP functions include performing diagnostic skills (history taking, physical assessment, ordering appropriate laboratory tests/procedures), therapeutic management (outlining care, providing prescriptions, coordinating consultations and referrals), and promoting health activities, all done in collaboration with the patient.
As of 1993, nurse practitioners in 42 states plus the District of Columbia have prescriptive practice privileges. Thirty-eight states allow some form of third-party (insurance) reimbursement for NPs and 24 states specifically mandate such reimbursement. Federal law allows for Medicaid reimbursement to certified family or pediatric nurse practitioners. Specific rules and regulations outlining such Medicaid reimbursement exist in 42 states: 20 states reimburse NPs at 100% of physician payment for the same service, 4 states pay NPs at 90% of the MD rate, 9 states pay NPs at 80 to 85% of the MD rate, and the remainder reimburse NPs at 75% or less of MD payment levels for the same services. (See also types of health care providers)
Practice settings:
In 1991, a study of nearly 6,000 NPs reported that 16% were in private practice, either by themselves or with a collaborative MD; 7% worked in health maintenance organizations (HMOs); 8% worked in hospital settings; 14% worked in freestanding primary care centers; 10% worked in hospital outpatient clinics; 2% worked in extended care facilities (nursing homes); 3% worked in occupational health settings; and 1% worked in home health. Traditionally, NPs have facilitated continuity of patient care by working with undeserved populations, both in rural areas and inner-city settings.
Regulation of profession:
Like many other professions, nurse practitioners are regulated at two different levels. Licensure is a process that takes place at the state level in accordance with specific state laws. In contrast, certification is established through a national organization(s) with requirements for minimal professional practice standards being consistent across all states.
Licensure: Laws specific to NP licensure vary greatly from state to state. The current trend is moving in the direction of more states requiring master's degree educational preparation and national certification. In some states, NP practice is completely independent, others require proof of a collaborative MD only for prescriptive practice privileges, some require proof of a collaborative MD for licensure at all, and an isolated few states still do not have specific nurse practitioner licensure or recognize practice of NPs.
Certification: National certification is offered through various nursing organizations (such as the American Nurses' Association, National Association of Pediatric Nurse Practitioners and Assistants, and others), most of which require completion of an approved master's-level NP program prior to taking the certification exam. The exams tend to be offered by specialty areas such as family nurse practitioner, pediatric nurse practitioner, school nurse practitioner, adult nurse practitioner, women's health care nurse practitioner, geriatric nurse practitioner. Recertification involves proof of continuing education. Only certified nurse practitioners may use a "C" either in front of or behind their other credentials (e.g., Certified Pediatric Nurse Practitioner, FNP-C, Certified Family Nurse Practitioner). Some nurse practitioners may use the credential APN rather than NP, denoting advanced practice nurse, a broader category that includes clinical nurse specialists, certified nurse midwives, and nurse anesthetists, as well as nurse practitioners.
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