Nurse Practitioners (NPs) are advanced practice registered nurses who provide comprehensive care to patients. Not only do nurse practitioners provide diagnostic care and treatment, but they also focus on preventive health maintenance. Nurse practitioners are first and foremost nurses, which means patient education and holistic care is a large part of their practice. Depending on the state in which they practice, oversight by physicians may or may not be required.
Nurse practitioners can diagnose and treat patients as well as perform procedures. They differ from physicians in that their patient care approach is more holistic. Being nurses, they gather information about a patient not only to include physical symptoms but psychosocial and environmental information as well. They are skilled in education and therefore can spend time teaching patients and family about disease processes, treatments, and healthcare prevention as well as diagnosing acute health issues.
According to the American Association of Nurse Practitioners, nurse practitioners can also help lower the cost of healthcare, as patients who use NPs as their primary care provider have fewer emergency room visits and shorter hospital stays. Additionally, they help to fill the gap with the primary care physician shortage in the United States. They also tend to have high patient satisfaction.
To advance to a master's degree or doctoral in nursing, a student must complete an accredited nursing program and obtain a Bachelor's of Science in Nursing (BSN). Upon graduating with a nursing degree, successful completion of the NCLEX-RN is needed for licensure. The length of time it takes to obtain an MSN depends on the nurse's starting point:
- Nursing students enrolled in a BSN program complete in about four years
- RN to BSN takes about two years
- BSN to MSN takes about two years
- BSN to DNP takes three to four years
- MSN to DNP takes one to two years
Additionally, both online programs and classroom programs are available to accommodate students. Both types have pros and cons depending on students' needs, therefore researching individual schools is encouraged.
Research nurse practitioner programs.
Nurses who enjoy practicing independently and who wish to diagnose and prescribe while still utilizing nursing skills can advance to the field of advanced practice nursing. Nurses who seek to pursue their NP should value autonomy, integrity, and leadership.
Some graduate programs require nurses to gain a few years of clinical experience before enrollment. Some schools allow nurses to work concurrently during the program. Regardless, obtaining clinical experience is crucial as it prepares the future nurse practitioner to be able to address a multitude of medical concerns and situations.
Nurses are also required to have a baccalaureate nursing degree (BSN). Nurses who hold an Associate's Degree in Nursing (ADN) will need to obtain a BSN. There are many opportunities to obtain a BSN. Many healthcare organizations also assist employees in advancing degrees and assist in tuition reimbursement, cost of books, and granting time off for nurses.
Nurse Practitioner Program Specialties
There are many clinical areas in which a nurse practitioner can work. From primary care to specialty care, acute care, and long-term care, nurse practitioners are valuable members of the patient care team. Some NP programs include training in certain specialties; otherwise, certification can be obtained through the American Nurses Credentialing Center (ANCC). Some areas include:
Examination, Licensure, and Certification
Certification in a specific specialty area can be completed concurrently within the MSN/DNP program or obtained via an independent study from the ANCC or other learning institute. Not all specialties offer formal certifications. In this case, the NP student can choose areas of specialization to work on during the program to obtain clinical competency. Eligibility for certifications obtained outside of an MSN/DNP program can differ and students are encouraged to research requirements when choosing a specialty.
Once a specialty program is completed, the nurse may take an examination for certification. For example, a nurse can take the Family Nurse Practitioner Exam to earn an FNP-C (Family Nurse Practitioner Certified) title.
Licensure and certification are different—certification means the NP is competent to perform care in their chosen specialty; licensure means they are legally permitted to practice in their state of residence. For example, a nurse living in California can obtain certification in acute care but needs to apply for licensure to practice in the state of California. State nursing boards list the requirements for testing and can vary from state to state. The certified nurse practitioner can, after meeting the specified requirements, apply with the state board for licensure.
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.
Nurse practitioners are valuable members of the healthcare team. As providers, teachers, leaders, and patient advocates, nurse practitioners approach patient care in a holistic manner to ensure patient needs are met at the time of visit.
Nurse Practitioner Responsibilities & Duties
NPs have many responsibilities and duties. These may include:
- Provide acute (i.e. illness) and preventive care (check-ups)
- Take a patient history
- Maintain their own patient panel
- Order diagnostic testing/therapies
- Order prescriptions
- Assist in surgery
- Admit, transfer and discharge hospitalized patients
- Collaborate with specialty departments as needed, refer patients appropriately
- Assess patient/family needs
- Provide education to patients/families
- Promote family-centered patient care
Nurse Practitioner Specialties
There are many areas in which a nurse practitioner can specialize. The following are areas in which an NP can obtain formal certification:
- Acute Care NP: may work in the emergency room, ICU, urgent care clinic, or operating room. They may perform duties such as:
- Rounds on hospitalized patients
- Managing the patient's hospital stay
- Assisting in surgical procedures
- Inserting central lines, intubating, suturing, performing lumbar punctures
- Ordering diagnostic tests/treatment and formulating a plan based on the results
- Writing orders for nursing/ancillary staff
- Learn more about ACNP careers
- Adult-Gerontology NP: Specializes in young adults to elderly patients. May work in clinics, long-term care facilities, or specialty departments. Specific duties may include:
- Performing routine physicals
- Ordering preventive tests/screenings
- Managing chronic conditions
- Educating patients and families on preventive health
- Learn more about AGNP careers
- Emergency NP: primarily works in emergency departments, may also work in urgent care departments. Specific duties may include:
- Diagnosing and treating patients needing emergent care
- Admitting patients from the ED to the floor
- Ordering diagnostic tests/treatments
- Learn more about ENP careers
- Family Nurse Practitioner: may work in primary care clinics, hospitals, specialty departments, or long-term care facilities. Specific duties may include:
- Caring for a patient population from birth through aging/death
- Performing exams on acute complaints
- Performing routine physicals
- Preventive health maintenance
- Ordering diagnostic tests/procedures
- Learn more about FNP careers
As baby boomers age, and health care needs continue to grow, nurse practitioner opportunities are opening up nationwide. According to the Bureau of Labor Statistics, nurse practitioner careers are expected to increase by 26 percent between 2018 and 2028, a growth rate that is much faster than most professions.
The working conditions of nurse practitioners, as with any career, have positive and negative aspects. Nurse practitioners can suffer from stress as they may carry a heavy patient load and have many critical decisions and diagnoses to make. As with physicians, there is no room for error, which can put a lot of pressure on nurse practitioners. Some NPs must work swing or graveyard shifts, and some may need to be on call, leading to erratic schedules that can take their toll.
Additionally, nurse practitioners, as with other healthcare workers, may work in high-risk areas that can expose them to workplace violence, bloodborne pathogens, and chemicals.
Not all work areas are risky, such as research and education. Regardless of the chosen work area, workplace safety training is mandatory and ongoing, and most organizations strive to protect the health and safety of its workers.
Nurse practitioners are highly respected and appreciated in their workplaces. They provide a holistic approach to patient care which complements conventional medicine. While NPs may not have full unrestricted practice, the collaborative team approach is appreciated not only by physicians but by the patients they serve.
Additionally, according to the American Association of Medical Colleges (AAMC), there will be a projected shortage of physicians by the year 2030, ranging between 46,900 and 121,900 physicians. Nurse practitioners are already beginning to fill the gaps to meet the needs of the growing and aging population, especially in primary care. The American Association of Nurse Practitioners reports that 89.7% of NPs are certified in primary care medicine. The addition of NPs to primary care helps to offload primary care physicians while ensuring patient care needs are met.
How Can an NP Start & Own Their Own Practice?
One exciting prospect of becoming a nurse practitioner is the concept of opening his/her own practice. This is possible only in states that allow a Nurse Practitioner (NP) to practice independently of direct supervision by a physician or other practice guidelines. Currently, select states plus the District of Columbia allow full practice for nurse practitioners. Full practice is when the NP is exclusively governed by the state's board of nursing and not contingent on a collaborative agreement with a physician. The following are steps needed for nurse practitioners to start their own practice:
- Determine the practice requirements. The first step an NP should do is determine the practice requirements in their state. Not all states allow for independent practice, so NPs must find out if opening their own practice can be done, if a physician needs to be on-site, or a physician needs to be nearby and accessible.
- File the paperwork. NPs must also file the required paperwork. Opening a practice is a business, so permits and licenses need to be obtained.
- Become credentialed. NPs need to apply for an NPI number to be able to bill Medicare. Becoming credentialed with Medicare can be daunting, and NPs are encouraged to visit their website to start the application process.
- Create a plan-both business and financial. The NP should determine which specialty they wish to focus on- which might be primary care, pediatrics, aging adults, family practice, etc. Usually, it's based on their population foci and certification, but NPs might choose to narrow down their specialty further. Financially, startup costs are needed to start any business to cover location, application/licensing fees, equipment, advertising, and staffing. Securing startup costs is essential.
- Choose a location. As with any business, location is vital. It can reflect credibility. For example, a patient may be more reluctant to visit a healthcare provider in a strip mall than in a business park.
- Determine insurance reimbursements. Most patients don't pay out of pocket for insurance. An NP wishing to open an independent practice should determine which insurances will be accepted, what the compensation is, and what services are covered.
- Malpractice insurance. The NP should carry malpractice insurance and should know what specifically is covered/ not covered.
- Determine which supplies are needed. Exam tables, office supplies, blood pressure monitors, computers, etc. are items that are necessary for starting a private practice, and they can be pricey. The good news is that there is no requirement that the equipment is new. Equipment can be purchased second-hand or through surplus companies.
- As with any business, advertising is critical. In today's digital and social media age, advertising online is essential. However, printed advertising is also important; phone books, newspapers, even flyers can help build a practice.
- Determine staffing needs. As a business grows, inevitably staffing needs increase as well. NPs may eventually need to hire ancillary staff such as receptionists and medical assistants to help with the growing practice. Along with hiring staff comes determining pay wages, health insurance coverage, labor laws, and training.
Because of the physician shortage, aging population, and healthcare legislation, demand for nurse practitioners is expected to rise 26 percent by 2028, which is faster than average. The BLS projects that 242,200 nurse practitioners will be employed by 2028, compared to the 189,100 NPs who were employed in 2018.
As for compensation, indeed.com reports the average annual salary for a nurse practitioner is $111,705. The Bureau of Labor Statistics reports the highest-paying states for NPs are California, Alaska, Massachusetts, New Jersey, and New York. Salary is also dependent on any specialty certifications held years of experience and the organization in which the NP is employed.
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