What Is a Nurse Practitioner?
Individuals who have never experienced the care of a nurse practitioner (NP)— whether they are physicians, reporters, lawmakers, bureaucrats, lobbyists, or new patients—often request clarification of just who NPs are and what they do.
It is their combination of skills of physician and nurse that seems to confuse people. Yet it is that combination of skills that makes an NP unique.
▪ Definition of Nurse Practitioner
The term nurse practitioner has been given a variety of definitions.
According to a state NP organization, “Nurse practitioners are registered professional nurses who are prepared, through advanced graduate education and clinical training, to provide a range of health services, including the diagnosis and management of common as well as complex medical conditions to individuals of all ages.”1
According to a national NP organization, “Nurse practitioners are registered nurses who are prepared, through advanced education and clinical training, to provide a wide range of preventive and acute healthcare services to individuals of all ages.”2
A board of nursing defines an NP as follows: “A nurse practitioner (NP) is an RN who has earned a separate license as an NP through additional education and experience in a distinct specialty area of practice. Nurse practitioners may diagnose, treat, and prescribe for a patient’s condition that falls within their specialty areas of practice. This is done in collaboration with a licensed physician qualified in the specialty involved and in accordance with an approved written practice agreement and protocols. Nurse practitioners are autonomous and do not practice under the supervision of the collaborating physician.”3
According to federal law, “Nurse practitioner means a nurse practitioner who performs such services as such individual is legally authorized to perform (in the state in which the individual performs such services) in accordance with state laws and who meets such training, education, and experience required as the Secretary has prescribed in regulations” [42 U.S.C.A. § 1395x(aa)(5)].
In California state law, “nurse practitioner means a registered nurse who possesses additional preparation and skills in physical diagnosis, psych-social assessment, and management of health-illness needs in primary health care and who has been prepared in a program conforming to board standards as specified in Section 1484” [Cal. Code Regs. tit. 16, § 1480(a)].
For state-by-state definitions of the term nurse practitioner, see Appendix 1-A.
▪ A Nurse Practitioner, By Any Other Name …
Other designations sometimes given NPs include physician extender, mid-level practitioner, and advanced-practice nurse. For a state-by-state listing of states’ official terms for NPs, see Appendix 1-B.
Physician Extender
The term physician extender is used by physicians’ associations and publications aimed at the physician market, and usually is used to refer collectively to nurse practitioners, clinical nurse specialists, nurse anesthetists, nurse midwives, and physician assistants (PAs).
Mid-Level Practitioner
The term mid-level practitioner is used by some physician groups, some states, and the federal government in the Code of Federal Regulation sections dealing with Drug Enforcement Administration (DEA) registration. The DEA defines a mid-level practitioner as follows:
The term mid-level practitioner means an individual practitioner other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices to dispense controlled dangerous substances in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, healthcare providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists, and physician assistants who are authorized to dispense controlled substances by the state in which they practice.
Citation: 21 C.F.R. § 1300.01(28).
Some state laws provide a definition of mid-level practitioner. For example, in Minnesota, “‘Mid-level practitioner’ means a nurse practitioner, nurse midwife, nurse anesthetist, advanced clinical nurse specialist, or physician assistant” [Minn. Stat. § 144.1501(f)].
Advanced Practice Nurse
Advanced practice nurse is an umbrella term used by some states and some nursing associations to cover, collectively, NPs, clinical nurse specialists (CNS), nurse midwives, and nurse anesthetists. NPs differ from other advanced practice nurses in that they offer a wider range of services to a wider portion of the population. Other advanced practice nurses compare with NPs in the following ways:
Nurse anesthetist: Narrow range of services (preoperative assessment, administration of anesthesia, management of postanesthesia recovery) to a narrow base of patients (people having anesthesia).
Clinical nurse specialist: Medium range of services (consultation, research, education, administration, coordination of care, case management, direct care within definition of registered nurse) to a narrow patient base (people under the care of a medical specialist).
Certified nurse midwife: Narrow range of services (well-women gynecologic care; management of pregnancy and childbirth; antepartum and postpartum care) to a medium-sized base of patients (childbearing women).
Nurse practitioner: Wide range of services (evaluation, diagnosis, treatment, education, risk assessment, health promotion, case management, coordination of care, counseling) to a wide base of patients, depending upon area of certification; a family nurse practitioner can have a patient base of any age, gender, or problem.
▪ Services Provided by NPs
NPs may perform any service authorized by a state nurse practice act. Some nurse practice acts are so broad as to allow any service agreed upon by an NP and collaborating physician. Generally, NP services include:
Obtaining medical histories and performing physical examinations
Diagnosing and treating health problems
Ordering and interpreting laboratory tests and X-rays
Prescribing medications and other treatments
Providing prenatal care and family planning services
Providing well-child care and immunizations
Providing gynecologic examinations and Pap smears
Providing education about health risks, illness prevention, and health maintenance
Coordinating care and case management
Typically, an NP has the following duties and responsibilities:
Conducts comprehensive medical and social history of individuals, including those who are healthy and those with acute illnesses and chronic diseases
Conducts physical examination of individuals, either comprehensive or problem focused
Orders, performs, and interprets laboratory tests for screening and for diagnosing
Prescribes medications
Performs therapeutic or corrective measures, including urgent care
Refers individuals to appropriate specialist nurses or physicians or other healthcare providers
Makes independent decisions regarding management and treatment of medical problems identified
Performs various invasive/clinical procedures such as suturing, biopsy of skin lesions, and endometrial biopsy, depending upon education, training, patient needs, and written agreement with physician collaborator
Prescribes and orders appropriate diet and other forms of treatment, such as physical therapy
Provides information, instruction, and counseling on health maintenance, health promotion, social problems, illness prevention, illness management, and medication use
Evaluates the effectiveness of instruction and counseling and provides additional instruction and counseling as necessary
Initiates and participates in research studies and projects
Teaches groups of clients about health-related topics
Provides outreach health education services in the community
Serves as preceptor for medical, nursing, NP, or physician assistant (PA) students
Accepts after-hours calls and handles after-hours problems on a rotating schedule
Participates in development of pertinent health education materials
Participates in development of clinical practice guidelines
Initiates and maintains follow up of noncompliant patients
Makes client home visits and provides care in the home as necessary
Makes hospital visits and follows hospital care of established patients
Consults with other healthcare providers about established clients who have been admitted to hospital, home care, rehabilitation, or nursing homes
Corresponds with insurers, employers, government agencies, and other healthcare providers about established clients as necessary
Manages care of clients; develops plan of treatment and/or follow up and monitors progress, determines when referral to another provider is necessary, makes necessary arrangements for further care, determines when hospital admission or emergency room visit is necessary, and determines when illness is resolved Nurse Practitioner’s Business Practice and Legal Guide
Assesses social/economic factors for each client, and tailors care to those factors
Manages care of clients in a way that balances quality and cost
Tracks outcome of interventions and alters interventions to achieve optimum results
Obtains informed consent from clients as appropriate and necessary
Maintains familiarity with community resources and connects clients with appropriate resources
Contracts with clients regarding provider responsibilities and client responsibilities
Supervises and teaches registered nurses (RNs) and nonlicensed healthcare workers
Participates in community programs and health fairs, school programs, and workplace programs
Represents the practice or the profession as an NP before local and state governing bodies, agencies, and private businesses as needed
▪ Preparation and License Requirements
All NPs are RNs with education beyond the basic requirements for RN licensure. Many NPs have master’s degrees, and some have doctorates. Master’s degrees for NPs are required by law in 32 states. NPs without master’s degrees have completed a program that meets requirements of state law.
State-required qualifications vary widely. For example, in Alaska, NPs must have completed a one-year academic course, have an RN license, be certified by a national certifying agency, and have 30 hours of continuing education every two years. In Pennsylvania, NPs must have an RN license, a master’s degree, certification by a national organization, must provide evidence of continuing competence in medical diagnosis and therapeutics, and must have 30 hours of continuing education per year and 45 hours of advanced pharmacology. Federal law defers to state law regarding NP qualifications (42 C.F.R. § 440.166).
In 46 states, NPs are required by state law to take and pass a national certification exam. A state requirement that an NP be nationally certified leads to a requirement of master’s education because the certifying agencies of adult and pediatric NPs require a master’s degree to sit for the certification examination.
▪ Initials
Among the initials used to designate NPs are CRNP (certified registered nurse practitioner); ANP-C (adult nurse practitioner-certified); CPNP (certified pediatric nurse practitioner); CGNP (certified geriatric nurse practitioner); RN, CS (registered nurse, certified specialist); ARNP (advanced registered nurse practitioner); and APRN (advanced practice registered nurse).
▪ Areas of Practice
NPs may be certified in the following areas:
Adult primary care
Family primary care
Geriatric primary care
Neonatal care
Obstetrics and gynecology
Pediatric primary care
Pediatric acute care
Acute care
Primary care of school-aged children
Family planning
Emergency health care
Maternal child health
Mental health/psychiatric care
Critical care
Oncology
Palliative care
Rehabilitation
Community health
Occupational health
Not all categories are recognized in all states.
▪ Legal History of NPs
Before the emergence of advanced practice nurses, the legal scope of practice of nurses excluded diagnosis and treatment of medical problems. Nurses carried out physicians’ orders. In the mid-1970s, some state nurse practice acts were amended to include “nursing diagnoses” in the scope of nursing practice. A nursing diagnosis “limits the diagnostic process to those diagnoses that represent human responses to actual or potential health problems that are within the legal scope of nursing practice.”4
When a physician shortage arose in the 1960s, it became evident that the shortage and the limitations on nurses’ making medical diagnoses were restricting access to health care for people in medically underserved areas. Certain nurses and physicians joined forces to solve the problem. One answer was the nurse practitioner (NP).
The first NP educational program was a joint effort between Henry K. Silver, a pediatrician, and Loretta C. Ford, a nursing professor, at the University of Colorado in 1965. Their project was one of many efforts to deal with a physician shortage. The first NPs began practicing in the late 1960s.
As the concept was envisioned, NPs would make not only nursing diagnoses but also medical diagnoses. Further, they would treat patients with medical therapeutics,
ordering pharmacotherapeutics and other treatments. It became necessary to broaden the legal scope of nursing practice.
ordering pharmacotherapeutics and other treatments. It became necessary to broaden the legal scope of nursing practice.
As soon as NPs began to emerge from the training programs, a body of law emerged governing NP licensure and scope of practice. Idaho was the first state to revise its regulations to allow diagnosis and treatment by nurses.
By the mid-1970s, state legislators began to consider proposed laws regarding prescriptive authority for NPs. In some states, the prescriptive authority was granted through the regulatory process; in others, it was granted through the legislative process. By 2006, NPs had achieved some degree of prescriptive privileges in all states and the District of Columbia. The main legal goal of NPs for 30 years was achieved. The next legal hurdle became evident with the enrollment of a large percentage of the population into managed-care plans. NPs now need the legal authority to handle the primary care of panels of managed-care patients. In some states, NPs have that legal authority. In others, the law is unclear or does not address the issue.
▪ Demographics
There are 158,348 NPs in the United States, according to statistics kept by Health Resources Services Administration (2008), as reported on the website of the American College of Nurse Practitioners.2
▪ NPs in Primary Care
The concept of the NP emerged from a need for more primary care providers in underserved areas of the nation. While some NPs work in specialty and acute care settings, the majority provide primary care. However, the numbers of NPs working in specialty offices and acute care settings is increasing.
As more and more health plans designate certain generalist physicians—pediatricians, internists, and family practitioners—as primary care providers (PCPs) for groups of patients, it is important for NPs to be included in the definition of PCP. It is also important for NPs to be included as providers who can be a “medical home” for a patient.
Definition of Primary Care
The following are definitions of primary care.
According to a national health policy think tank, the National Academy of Sciences’ Institute of Medicine,
“Primary care is the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community.”5
A nurse practice act written by a state agency defines primary health care as:
“that which occurs when a consumer makes contact with a healthcare provider who assumes responsibility and accountability for the continuity of health care regardless of the presence or absence of disease” [Cal. Code Regs. tit. 16 § 1480(b)].
A state legislature’s definition is:
“the health care which [sic] clients receive at the first point of contact with the healthcare system and [that] is continuous and comprehensive. Primary health care includes health promotion, prevention of disease and disability, health maintenance, rehabilitation, identification of health problems, management of health problems, and referral” [Code Me. R. § 02 380 008(G)].
Finally, here is a definition provided by the American Academy of Family Physicians:
“Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the ‘undifferentiated’ patient) not limited by problem origin (biological, behavioral, or social), organ system, gender, or diagnosis. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis, and treatment of acute and chronic illnesses in a variety of healthcare settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician, utilizing other health professionals, consultation and/or referral as appropriate.”6
Primary care is not controversial in itself. Who performs primary care is somewhat controversial. Who receives reimbursement for primary care is very controversial.
▪ NPs’ Legal Authority to Be Primary Care Providers
Some state’s laws specifically authorize nurse practitioners to be primary care providers (PCPs); i.e., be designated as the individual responsible for the primary care of a patient enrolled in a managed care plan.
An example of one such law is Maryland’s, which provides that “… each member [of a health maintenance organization] shall have an opportunity to select a primary physician or a certified nurse practitioner from among those available to the health maintenance organization….”
The law continues:
“A member may select a certified nurse practitioner as the member’s primary care provider if:
The certified nurse practitioner provides services at the same location as the certified nurse practitioner’s collaborating physician; and
The collaborating physician provides the continuing medical management required under subsections (B)(5) of this section.
A member who selects a certified nurse practitioner as a primary care provider shall be provided the name and contact information of the certified nurse practitioner’s collaborating physician.
This subsection may not be construed to require that a health maintenance organization include certified nurse practitioners on the health maintenance organization’s provider panel as primary care providers” (Md Health-General Code Ann. § 19-705.1).
In Maryland, a clause in the state law governing health maintenance organizations had been construed as prohibiting anyone other than a physician from being a PCP. Maryland NPs went to the legislature asking for a change in that law. In 2003, the change was made, and the language provided above was enacted.
In some states, no law prohibits a nurse practitioner from being designated as a PCP.
Nurse Practitioners as Team Members in Secondary and Tertiary Care
Whereas the role of nurse practitioner was originally contemplated to be in primary care, more and more nurse practitioners are working for specialists and in hospitals. For those nurse practitioners, state law on scope of practice and reimbursement and federal law on reimbursement is most relevant.
▪ NP Versus PA: What’s the Difference?
While NPs and PAs may function very similarly and may, in some states, be interchangeable in terms of job description, there are differences between NPs and PAs in legal definition, scope of practice, licensure, and independence of practice. PAs practice medicine under the license of a physician, never independently. NPs practice under their own licenses. PAs are true physician extenders because they never practice under their own licenses. NPs may be physician extenders or practice independently, depending upon state law. The Institute of Medicine’s definition of primary care provider is misleading because, legally, it is a PA’s physician employer who is practicing primary care. A PA has a job description, not a scope of practice.
Definition and Scope of Practice of PAs, Compared with NPs
By definition, a PA is a healthcare provider who practices medicine with physician supervision. Nurse practitioners define themselves as nurses with a broadened scope of practice and do not define themselves as physician supervised professionals.
PAs include in descriptions of their duties taking medical histories, performing physical examinations, ordering and interpreting laboratory tests, diagnosing and treating illnesses, assisting in surgery, prescribing and/or dispensing medication, and counseling patients.7 NPs would include all of the above activities in their scope of practice, with the exception of assisting in surgery. While some NPs assist in surgery under practice agreements with physicians, it is not so common an activity that it is universally included in the scope of practice of NPs. NPs usually include special attention to healthcare maintenance and illness prevention in their statements of scope of practice. The nurse practice act of at least one state, Oregon, includes hospital admission in the scope of NP practice.
The scope of a PA’s practice corresponds with a supervising physician’s practice, with the understanding that the supervising physician will handle the more complicated medical cases. PAs are authorized to prescribe medications in all 50 states, the District of Columbia, and Guam.7
Physician Involvement with PA Practice
PAs acknowledge their status as physician extenders. According to the American Academy of Physician Assistants, “The physician assistant is a representative of the physician, treating the patient in the style and manner developed and directed by the supervising physician.”7
The Guidelines for Physician/Physician Assistant Practice, adopted by the American Medical Association House of Delegates in 1995, state the following:
Healthcare services delivered by physicians and PAs must be within the scope of each practitioner’s authorized practice as defined by state law.
The physician is ultimately responsible for coordinating and managing the care of patients and, with the appropriate input of the PA, ensuring the quality of health care provided to patients.
The physician is responsible for the supervision of the PA in all settings.
The role of the PA in the delivery of health care should be defined through mutually agreed-upon guidelines that are developed by the physician and the PA and based on the physician’s delegatory style.
The physician must be available for consultation with the PA at all times, either in person or through telecommunication system or other means.
The extent of the involvement by the PA in the assessment and implementation of treatment will depend on the complexity and acuity of the patient’s condition and the training and experience and preparation of the PA as adjudged by the physician.
Patients should be made clearly aware at all times whether they are being cared for by a physician or a PA.
The physician and PA together should review all delegated patient services on a regular basis, as well as the mutually agreed-upon guidelines for practice.
The physician is responsible for clarifying and familiarizing the PA with his or her supervising methods and style of delegating patient care.7
Demographics
As of May 2010, there were approximately 74,469 individuals in clinical practice as PAs.7
Education
PAs are educated in programs that use the medical model and are designed to complement physician training. The American Academy of Physician Assistants differentiates PA education from physician education in the following way:
One of the main differences between PA education and physician education is not the core content of the curriculum, but the amount of time spent in formal education…. [P]hysicians are required to do an internship, and the majority also complete a residency in a specialty afterwards. PAs do not have to undertake an internship or residency.7
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