A Nurse Practitioner (NP) is an advanced practice registered nurse (APRN) who has completed advanced coursework and clinical education beyond that required of the generalist registered nurse (RN) role. According to the International Council of Nurses, an NP/advanced practice registered nurse is “a registered nurse who has acquired the knowledge base, decision-making skills, and clinical competencies for expanded practice beyond that of an RN, the characteristics of which would be determined by the context in which he or she is credentialed to practice.”
NPs manage acute and chronic medical conditions (both physical and mental) through comprehensive history taking, physical exam, and the ordering of diagnostic tests and medical treatments. NPs are qualified to diagnose medical problems, order treatments, prescribe medications, and make referrals for a wide range of acute and chronic medical conditions within their scope of practice.
Depending on the state in which they practice, NPs may or may not be required to practice under the supervision of a physician. In consideration of the shortage of primary care/internal medicine physicians, many states are eliminating “collaborative practice” agreements and NPs are able to function independently. NPs—particularly in the area of primary care/internal medicine—fulfill a vital need for patient healthcare services, and NPs work with physicians, medical/surgical specialists, pharmacists, physical therapists, social workers, occupational therapists, and other healthcare workers to achieve the best outcomes for patients.
NPs may serve as a patient’s primary healthcare provider and they may see patients of all ages depending on their specialty. With commensurate education and experience, NPs may specialize in specific areas, such as cardiology, dermatology, oncology, pain management, surgical, orthopedics or women’s health. Similar to all healthcare professions, the core philosophy of the nurse practitioner role is individualized care that focuses on a patient’s medical issues as well as the effects of illness on the life of a patient and his or her family. NPs focus on prevention, wellness, and patient education.
In addition to providing healthcare services, NPs may conduct research, teach, and are often active in patient advocacy activities and in the development of healthcare policy at the local, state, and national level.
The advanced practice nursing role began to take shape in the mid-20th century United States. Nurse anesthetists and nurse midwives were established in the 1940s, followed by psychiatric nursing in 1954. The present day concept of the APRN as a primary care provider was created in the mid-1960s, spurred on by a shortage of medical doctors. The first official training for nurse practitioners was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965, with a vision to help balance rising healthcare costs, increase the number of healthcare providers, and correct the inefficient distribution of health resources.
Scope of practice
In the United States, because the profession is state-regulated, care provided by NPs varies and is limited to their education and credentials. Some NPs seek to work independently of physicians, while in some states a collaborative agreement with a physician is required for practice.The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, pharmacologic recommendations, etc. again varies widely amongst states of licensure/certification.practice.
The “Pearson Report” provides a current state-by-state breakdown of the specific duties an NP may perform in the state. A nurse practitioner’s role may include the following:
- Medical diagnosis, treatment, evaluation, and management of a wide range of acute and chronic diseases
- Obtaining patient histories and conducting physical examinations
- Ordering and performing diagnostic studies (e.g., lab tests, x-rays and EKGs)
- Requesting physical therapy, occupational therapy, and other rehabilitation treatments
- Prescribing drugs 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 and long care facilities
- Performing or assisting in minor surgeries and procedures (e.g., dermatological biopsies/procedures, suturing, casting, etc.)
- Counseling and educating patients on health behaviors, self-care skills, and treatment options in coordination with occupational therapists and other healthcare providers.
Education, licensing, and board certification
To become licensed to practice, the nurse practitioner must graduate from an accredited graduate or doctoral program. The curriculum for a nurse practitioner program includes courses in epidemiology; health promotion; advanced pathophysiology; physical assessment and diagnostic reasoning; advanced pharmacology; laboratory/radiography diagnostics; statistics and research methods; health policy; role development and leadership; acute and chronic disease management (e.g., adults, children, women’s health, geriatrics, etc.); and clinical rotations, which varies depending on the program and population focus. The path to becoming an NP in the United States generally begins by earning a Bachelor of Science in Nursing (BSN) or other undergraduate degree, and requires licensure as a registered nurse (RN) and experience in the generalist RN role. Doctor of Nursing Practice (DNP) programs include additional, advanced coursework in biostatistics; research methods; clinical outcome measures; care of special populations; organizational management; informatics; and healthcare policy and economics. DNP programs also require completion of a research/residency project. Some nurse practitioners, as well as other APRN roles, may choose to pursue the Doctor of Philosophy (PhD) as a terminal degree. The PhD in nursing focuses on nursing research and nursing education, while the DNP focuses more on clinical practice.
There is an initiative to require the DNP as the entry level degree for all APRN roles, including the nurse practitioner, nurse anesthetist, and nurse midwife. Those who have a MSN but are currently practicing in an APRN role would be grandfathered into this change. Many universities have started to phase out MSN programs in lieu of this expected change and have developed BSN-DNP programs. NPs may elect to complete a postgraduate residency or fellowship. The majority of such programs focus on primary care; however, specialized programs (e.g., acute care, emergency medicine, cardiology, general surgery, etc.) also exist.
After completing the required education, the NP must pass a national board certifying exam in a specific population focus: acute care, family practice, women’s health, pediatrics, adult-gerontology, neonatal, or psychiatric-mental health, which coincides with the type of program from which he or she graduated. After achieving board certification, the NP must apply for additional credentials (e.g., APRN license, prescriptive authority, DEA registration number, etc.) at the state and federal level. The nurse practitioner must achieve a certain amount of continuing medical education (CME) credits and clinical practice hours in order to maintain certification and licensure. NPs are licensed through state boards of nursing.
In Australia, NPs are required to be registered by the Australian Health Practitioner Regulation Agency. The Australian professional organisation is the Australian College of Nurse Practitioners. (ACNP)
There are nurse practitioners in over fifty countries world wide. Although credentials vary by country, most NPs hold at least a master’s degree worldwide.
As of November 2013, NPs were recognized legally in Israel. The law passed on November 21, 2013. Although in the early stages, the Israeli Ministry of Health has already graduated two NP classes – in palliative care and geriatrics. The law was passed in response to a growing physician shortage in specific health care fields, similar to trends occurring worldwide.
Increasing need for NPs in the US
Employment of registered nurses and nurse practitioners is expected to increase immensely in the next ten years. Much of the growth came from a result of increase in technology, resulting in better health care and a greater variety of solutions for health problems. Also, life expectancy is getting longer; therefore more patients are living longer and living more active lives. It is further anticipated that the need for NPs will increase because of the passage of the Patient Protection and Affordable Care Act (PPACA).
Growth is also expected to be much faster in outpatient centers, where the patients do not stay overnight. Moreover, the increasing number of procedures that were once only able to happen in hospitals is now able to happen in physicians’ offices. This is mainly because of the expansion and easy access to new and better technology, though the need for NPs is expected to be greatest in places where people have long-term illnesses such as dementia or head trauma patients that are in need extensive rehabilitation.
“Nurse practitioners really are becoming a growing presence, particularly in primary care,” said David I. Auerbach, PhD, the author and a health economist at RAND Corp. In addition, this site says that nurse practitioners are expected to double by 2025. Auerbach also told American Medical News, ”There’s a lot of experimentation going on looking at different ways of working together, and there’s a lot of interest in collaborative team-based models. The new care models, such as the patient-centered medical home and accountable care organizations, really depend on nurse practitioners and physician assistants.”
As a result of the PPACA, hospitals and medical care facilities are forced to rethink the demand for nurses and medical professionals. This is mainly because this new Act allows millions of people the opportunity at medical attention that did not have it before, and because there are so many new people in need of medical attention, the need for medical professionals also grows. With the combination of this new Act, and the aging Baby Boomer population, there is expected to be a large increase in the need for medical staff, especially nurse practitioners. According to a study published in American Medical News, Nurse Practitioners jobs are expected to grow up to 130 percent from 86,000 in 2008 to 198,000 in 2025. Though there is some skepticism to these vast figures, they are backed up by many studies and the opinions of very well known medical professionals. As a result of this extreme need for NPs, they are also expected to receive more autonomy, meaning that nurse practitioners would be able to fill the traditional primary care role like a physician would. For an example, a nurse practitioner would be able to prescribe medication without the oversight of a doctor. Many states are passing laws that allow for independence practice of nurse practitioners. “Currently there are 12 states with active legislation looking at utilizing nurse practitioners at the top of their education to meet patient care needs,” says Tay Kopanos with the American Association of Nurse Practitioners. Many nurses and other leaders in healthcare are advocating for overturning laws that require physicians to look over the work of NPs.
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