The Rise of the Nurse Practitioner
Nurse Practitioners are among the fastest growing medical professions, according to the Bureau of Labor Statistics. In fact, the profession has more than doubled in the past 12 years and was up 9% in less than a year. More Registered Nurses are choosing to advance their education and practice to that of a Nurse Practitioner (NP) than ever before in the history of nursing. Is this a flash-in-the-bedpan phenomena or a sustainable rise in the field of nursing?
Licensed Nurse Practitioners (NPs) have been providing acute, primary and specialty care to patients of all ages for over 50 years. In a recent survey by the American Association of Nurse Practitioners (AANP), the average NP is 49 years old, female, and practices in rural areas. Most have practiced more than 10 years, but over a third have been practicing for less than five years – which is a significant increase in the past two years. The survey of more than 4,000 NPs also reported that most (87%) were trained in Primary Care and many (89%) contribute in some way as nursing faculty while working in settings such as private offices, hospitals, or outpatient medical clinics.
More and more bedside nurses are choosing the path of the Nurse Practitioner to further their careers. For example, Willa Illustrisimo, MSN-FNP, RN spent 21 years as an Intensive Care Nurse after deciding to attend University of Phoenix's Nurse Practitioner program. "Bedside patients are getting heavier and I'm not getting younger! I needed to find a way to still be able to care for patients and apply my medical knowledge without the extreme physical exertion." Stories such as this are prevalent in the nursing community, as more nurses seek advance practice to continue to apply their learned skills.
One reason for the incredible growth in the number of NPs is the availability of Nurse Practitioner programs across the globe. Nurses can choose from a variety of educational settings including traditional full-time-in-the-classroom, to complete online didactic and arranged clinical rotations, to hybrids of both settings, such as the program at Sacred Heart University. Current NP programs also cater to specific nurses in order to streamline their educational goals. For example, Simmons University has two programs: one designed to take a nurse from
One career change that we see in the world of nursing is non-nurses looking to become advanced-practice registered nurses. While it may seem difficult, if not impossible, for a non-nurse to become a nurse practitioner, there are options out there for students - including online pathways.
The most popular route for non-nurses to enter an online Nurse Practitioner program is through a Master's Entry to Nursing Program (MENP). Admission to this type of program typically requires that the non-nurse holds a minimum of a bachelor's degree in any non-nursing discipline. Beyond this, prospective students usually need to provide:
- Written statement of purpose
- Letters of recommendation
- Complete any pre-requisite courses related to nursing, if required. Courses may include:
Upon completion of core coursework, the student may begin their specialty track. Schools offer different tracks for NPs, including Adult-Gerontology, Pediatric, and more.
It’s important to recognize that while an NP program may advertise an “online” curriculum, nurse practitioner students must complete a specific number of supervised clinical hours to graduate. This is usually done on their own time. Additionally, some programs prepare students to earn an RN along the way.
Nurse practitioners practice under the rules and regulations of the Nurse Practice Act of the state in which they work. NPs can prescribe medication in every state and in the District of Columbia. The degree of independence with which they can prescribe drugs, medical devices (crutches, boots, etc.), or medical services varies from state to state. In many states and the District of Columbia, NPs have what is called "Full Practice Authority" - meaning they can practice independently without physician collaboration or supervision. Many nurse practitioners have their own practices and can be reimbursed by Medicare, Medicaid, or other third parties.
States that don’t allow Full Practice Authority for NPs may fall under what is called “Reduced Practice Authority”. This means that NPs must have a collaborative agreement with a supervising physician in order to practice and prescribe meds.
States that don’t fall into either of these two categories are considered Restricted Practice states, which require even more regulations, including career-long oversight, delegation, or management by another medical team member.
There are many organizations that advocate for full practice authority for nurse practitioners to include prescriptive privileges, including the American Association of Nurse Practitioners (AANP).
The short answer is…yes!
Nurse Practitioners (NPs) are able to treat patients in most cases without the supervision of a doctor, ruled by guidelines on what they can and cannot treat. Nurse practitioners play a crucial role in helping administer medical attention to individuals in need, including women in labor. Their training teaches many aspects of health care, and the delivery of babies is among those aspects.
While RNs who work in labor and delivery might deliver a baby if the doctor doesn't make it into the room fast enough, the only nurses specifically trained and legally allowed to deliver babies are Certified Nurse-Midwives, also known as CNMs. Certified Nurse-Midwives assist at around 8 percent of all deliveries in the United States, according to the American College of Nurse-Midwives. Certified Nurse-Midwives advocate for client-driven birth choices with minimal medical intervention.
In some states, a collaborative agreement may be required for a nurse practitioner to practice. This agreement is a document that establishes a “joint practice” between the NP and MD. It usually includes:
- The parties involved
- Date of initiation of the agreement
- The scope of practice of the NP with regards to diagnosing, treating, and prescribing (specific scope of practice is regulated by each state)
- Documentation review requirements
- Physician availability requirements
Based on the state of practice, the amount of time closely spent with an MD is variable. Some states allow NPs to practice and prescribe independently, and they can even open and run their medical clinic. Other states require physician oversight and periodic documentation review. Some states require physicians to be on-site while others allow for telephonic consultation.
Regardless of state requirements, nurse practitioners should feel comfortable collaborating with physicians if needed. For example, if faced with a challenging case, the NP should collaborate with a physician to ensure the proper treatment is rendered. For the most part, nurse practitioners and physicians have a cohesive, respectful relationship. Physicians appreciate the high-quality care they deliver to patients, as well as the assistance they provide to an MD’s practice.
A DEA number is a number assigned to specific healthcare providers that allows them to prescribe medications, including controlled substances, legally. It includes a series of numbers and letter which identifies the type of provider; for example, nurse practitioner, physician, dentist, etc.
To obtain a DEA number online, the NP must first be licensed in the state in which they practice. Applicants must complete six different sections:
- Section 1 includes personal information, i.e. name, address, SSN, etc.
- Section 2 requires the applicant to report the business activity and drug schedule information. For example, which medications the NP plans to prescribe. The NP must be cognizant of any state restrictions on which controlled medications they can prescribe (Schedule III, IV, etc.)
- Section 3 requires licensure information
- Section 4 requires the applicant to provide background information about controlled substances
- Section 5 is the payment section. According to the DEA website, an NP can expect to pay $731 for a three-year period
- Section 6 is for confirmation, in which the applicant reviews/edits all entries and submits the application
Once submitted, it can take four to six weeks to obtain a DEA number. It is crucial that nurse practitioners begin the application process as soon as possible to prevent delays in practice.
Advanced directives and Physicians Orders for Life-Sustaining Treatment (POLST) forms are used to ensure a patient’s healthcare wishes are carried out in the event that they cannot make decisions on their own. These directives are extremely important not just to honor the wishes of patients, but for healthcare providers to avoid legal difficulties as well.
In a nutshell, yes - nurse practitioners can sign advanced directives or POLST forms depending on their state.
Nurse practitioners have a different scope of practice depending on the state in which they practice. Operating at the level of an MD in many states, signing Advanced Directives and POLST forms should not be excluded from their duties. However, the ability to sign these forms is specific to each state. Nurse practitioners should find the state’s specific scope of practice laws to find out if this is within their scope.
The American Association of Nurse Practitioners has information on NP scope of practice by state. It outlines which states have full, reduced, or restricted practice. NPs can click on their state and find a link to the state’s nurse practice act, which delineates if advanced directives / POLST forms can be completed independently.
Registered nurses looking to advance to nurse practitioners must first start with a bachelor of science degree (BSN) in nursing. This takes about four years to complete.
The minimum degree needed for an entry-level NP is a master’s degree in nursing (MSN), which takes an additional two or more years beyond the BSN. Some programs allow for online, classroom, or hybrid (both online and classroom) learning. The Family Nurse Practitioner program at Samuel Merritt University, for example, outlines the curriculum based on full or part-time status, and whether learning is hybrid or online. Semesters can range from five to eight depending on full or part-time status.
This depends on each student's needs. Some employers support and work with nurses as they advance their career, and allow time off for classes and study time. However, some cannot accommodate employees without interrupting operational need. Moreover, sometimes it is not financially possible for nurses to reduce hours, or family obligations are too great for them to take on the demand of graduate school. Nurses should discuss with their employer and families to see if, and which type of NP program would work to meet their individualized needs.
It can take two to four years to obtain an MSN depending on the student’s starting point. This is if the student attends full-time. Generally, the first semester is primarily lecture/classroom courses. Clinicals may be one or two days a week. Online NP programs allow for more flexibility and self-directed learning, which is an excellent choice for nurses who work.
Because NP programs can be demanding, it can be difficult to work full time. However, the beauty of being an RN is that there are a variety of positions available. Nursing is not always a nine-to-five job. Nurses can work nights, evenings, weekends, on-call, or per diem. Luckily, this allows for more flexibility in terms of going back to school.
There are many published reports that patient satisfaction scores are higher when seeing an NP as opposed to their physician colleagues. The role as the patient educator is reinforced throughout every stage of nursing education and for this reason, patients report that they feel that the Nurse Practitioner spends valuable time explaining disease processes and treatment plans. Joyce Knestrick, PhD, APRN, CFNP, FAANP and president of AANP stated that NPs treated over 1 billion patients in 2018; evidence that NPs are becoming the provider of choice for patients in the United States. The upward trend of Nurse Practitioners in the medical community is not likely to decrease anytime soon. Changes to each state's scope of practice laws for the NPs are moving more towards independent practice and billing for services. This rise is not only good for nurses as it offers career advancement, it is also good for patients and medicine as a whole. With less doctors choosing primary care or family medicine as a specialty, communities need NPs to care for populations at all ages and levels of illness.
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