In the year 2000, the U.S. Department of Health and Human Services reported that 2,694,540 of the workforce were licensed registered nurses, representing the largest segment of health care personnel. Of this number, 102,829 were nurse practitioners (NPs). The most recent Advanced Practice Nursing Survey indicates that women represent 81% of this population with approximately 80% being women over 40 years of age.
Broadly defined, an NP is an advanced practice registered nurse who has attained a formal NP education, primarily at the master’s degree level. The NP’s scope of practice is delineated by The Nurse Practice Act in each state, with specialization in one of seven patient populations, including acute care (ACNP), adult (ANP), family (FNP), gerontology, pediatrics, women’s health care, and adult or family psychiatric and mental health. Other advanced practice nursing specialties that are not considered to be part of the NP discipline, include the nurse anesthetist (CRNA), clinical nurse specialist (CNS), and midwife. Formal educational programs for NPs and all advanced practice nurses must meet accreditation standards and graduates must pass a certification exam administered by one of five certifying bodies: The American Academy of Nurse Practitioners (AANP), American Nurses Credentialing Center (ANCC), the National Certification Board of Pediatric Nurse Practitioners (NCBPNP/N), the Council on Certification of Nurse Anesthetists, and The National Certification Corporation for the Gynecological/Obstetrics and Neonatal Nursing Specialties. Currently, a minimum of a master’s level education is required by some of the organizations listed, but will be required by all by the year 2007.
The NP’s scope of practice is continually evolving, but in general is characterized by education and health promotion, diagnosis, and the provision of services necessary for the treatment of acute and chronic illnesses. In all 50 states, NPs are granted at least some prescriptive privilege, with state formularies that include controlled substances, to states that require physician supervision and impose formulary limits.
Advanced practice in nursing dates back to 1877 when Sister Mary Bernard administered anesthesia at St. Vincent’s Hospital in Erie, Pennsylvania. Schools for nurse anesthesia were established from 1909 to 1914. The American Association of Nurse Anesthetists was founded in 1931. Midwifery, the second oldest advanced nursing specialty, began when Clara D. Noyes proposed the training of nurses as midwives and Mary Breckinridge established the Frontier Nursing Service in eastern Kentucky. A long-established discipline in Europe, Mary Breckinridge traveled throughout England and France observing the nurse midwives’ contributions to health care. In 1929, she brought British nurse midwives to the United States to join with public health nurses to serve in rural and remote areas. Neither anesthesia nor midwifery advance practice required an advanced education until the late 1950s and early 1960s. The first advanced practice program to require a master’s degree was the Clinical Nurse Specialist track developed by Hildegard Peplau at Rutgers University in 1963.
Responding to a physician trend toward medical specialization and a subsequent shortage of primary care providers, the first NP program was established at the University of Colorado in 1965. Loretta Ford, collaborating with a physician, Henry Silver, developed a collaborative practice certificate program, with an emphasis on health and wellness. Diagnosing and treating health problems in children, particularly in rural areas, signaled a trend toward broadening the NP’s responsibilities and increased autonomy. Federal funding increased to support the NP’s professional development and set the stage for nurses to be designated as primary care providers. In 1971, additional support for NPs assuming primary care for patients came when the secretary of Health, Education, and Welfare issued the recommendation that NPs and physicians could share the responsibility of providing primary care for all populations. By the mid1970s there were more than 500 NP certificate programs across the United States. The emphasis shifted to advanced education in nursing and by the beginning of the 1980s several master’s programs were developed, outnumbering certificate programs. Currently, 70% of nurse-midwives graduate from Master’s of Science in Nursing (MSN) programs accredited by the American College of Nurse Midwives. There are over 7,000 certified nurse-midwives in the United States and abroad in developing countries. In the year 1995 there were more than 200 university or college programs offering a master’s level preparation. This rapid increase in advanced practice necessitated The American Nurses Association (ANA) to establish standard curriculum guidelines for the burgeoning number of preparatory programs and initiate credentialing requirements to ensure a level of competence.
Presently, the NP works in a number of settings, including the community or public agencies, private practice with their collaborating physician, or in the ambulatory, inpatient, or emergency and operating room settings of hospitals. Nurse-midwives attend approximately 300,000 deliveries per year. However, despite continued rural health care shortages, and the role these shortages played in the development of the NP role, less than 15% of all NPs practice in rural areas. Additionally, rural areas continue to lose primary care physicians as managed care recruits MDs out of these rural settings. Telemedicine may potentially present a solution by making it possible for NPs to communicate and collaborate with urban-based physicians, and thereby to work independently in remote areas.
Since the inception of the NP role, there have been several studies supporting the NP’s effectiveness and safety in providing independent care comparable to that of a primary care physician. The most recent findings of a Columbia University study were published in the Journal of the American Medical Association, which concluded that in an ambulatory care site, with no disparity in assigned responsibilities, there were no significant differences between the primary care outcomes of a physician and those of an NP.
Traditional registered nurses, drawn to advanced practice role, with its greater professional autonomy and more flexible work scheduling, is likely a factor in today’s nursing shortage. However, as the largest group of nonphysician, primary care providers, NPs occupy an important place among the health care workforce, and offer health care consumers an additional choice, while permanently altering health care delivery in this country.
SEE ALSO: Midwifery, Nursing, Physicians, Rural health
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