Health care demands are often the driving force behind the emergence of new and modified positions within the field. In the 1960s the United States began to experience a significant reduction in the number of physicians. Coupled with increasing patient acuity (increasingly ill patients) and funding cutbacks, new types of positions as well as expansions of roles already within the system were introduced into the health care system.
Because of the significant demand for physicians that could not be met by medical training programs currently in place, a new position, the physician assistant (PA) was introduced into the U.S. health care system. In this role registered nurses and retired Army Medical Corps personnel took on certain medical functions. Physician assistants were trained on the medical model, and practiced medicine with a great deal of autonomy—often in geographically isolated regions—while remaining under the supervision of a licensed physician. PAs continue to flourish in the United States, with an estimated twenty-six thousand in practice as of 1996. The average PA program consists of two years of intensive training offered within a medical school curriculum.
As in the United States, Canada experienced a physician shortage in the 1970s and 1980s. However, rather than introducing a totally new type of health care worker into the system, it was decided to expand the scope of registered nursing practice to meet the primary health care needs of Canadians. The new role was established as the nurse practitioner (NP) or expanded role nurse (ERN).
NP education did not develop within the usual university setting because of the urgent demand for NP/ERNs. Moreover, attitudes within many universities fostered skepticism about what was seen as a mixed medical and nursing role rather than a pure nursing role. Thus the NP role was initially perceived to be an extension of the registered nurse role emphasizing many of a physician's responsibilities: histories and physicals, medical diagnoses, ordering and interpreting laboratory and diagnostic tests, prescribing medications, and developing treatment plans in collaboration with a physician. As such, the NP was often compared to the PA. NP courses quickly proliferated in such subspecialties as pediatrics, occupational health, and geriatrics, and their graduates often worked in sparsely populated areas of northern Canada and the western United States that could not attract physicians.
As early as the 1940s a version of the NP, the clinical nurse specialist (CNS), was emerging in both Canada and the United States as a response to nurse educators' concerns for improving nursing care. The CNS specializes in a particular population or disease, emphasizing teaching, role modeling, nurse-to-nurse consultation, education and staff development, and research. The CNS uses specifically developed clinical expertise (e.g., in geriatrics or cardiovascular disease) to guide and mentor nursing staff in improving patient care.
Education and licensure requirements
Initially education for the NP/ERN did not require a baccalaureate nursing degree, provided the registered nurse had experience in the area. Education consisted of on-the-job training for several months, followed by graduation with a certificate or diploma. Though this preparation continues in some areas of North America, Great Britain, and Australia, general agreement now is that educational preparation should be at a master's degree at the nursing level with specific proficiencies and standards, and should focus on advanced clinical and teaching skills. Candidates are limited to registered nurses with a baccalaureate degree in nursing and clinical experience in the field of study. This arrangement clearly establishes the NP program at the graduate level.
Current roles and functions
The NP is now recognized as a registered nurse with specialized skills and knowledge in health assessment and promotion, counseling, disease prevention, and management of selected health problems. While both the PA and the NP undertake medical functions, the NP does so as a registered nurse, applying advanced nursing knowledge. In collaborative practice, NPs and physicians provide health care to a specific population of patients, sharing authority for providing care within the scope of their practice. NPs have shared competencies with physicians and other health professionals, and upon completing specific education have been delegated to perform selected medical functions.
NPs demonstrate a high degree of professional autonomy; working in environments where they are supervised employees of physicians (in a family practice office), in collaborative practices (as in a geriatric ambulatory clinic), or in solo practices (community health care drop-in centers). NPs bring additional skills to the care of patients, including provision of disease-prevention counseling, health education, and health promotion activities, as well as more time than physicians to spend talking to patients. The physician will always be the primary professional providing diagnosis and treatment in complex cases and managing patients with critical and unstable medical conditions.
Gerontological nurse practitioners (GNPs) provide elderly persons with services specifically tailored to frail individuals. Their scope of practice involves management of the patient from the community consultation, through diagnosis and treatment (emergency, outpatient, or inpatient), through home visits following discharge, including a comprehensive discharge plan. These activities have reduced hospital readmissions and costs of care, and have improved the continuity of care. Medical directives and protocols for specific problems, such as cardiac irregularities, delirium, and sudden shortness of breath, are examples of medical functions delegated to the GNP.
Future of the nurse practitioner
Though the NP role has proliferated and formalized, there is still some residual anxiety in both the nursing and the medical communities as to its exact benefits and responsibilities. Is the NP abdicating the role of the nurse, or is the NP a strategy to retain skilled nurses within the profession while providing improved care to specific patient populations and reducing costs? Is the NP position taking jobs from physicians because NPs are less costly, thus affecting physicians' employment opportunities? Regardless, as the role continues to be tested with different populations, it is being heralded as an appropriate role for registered nurses in the care and treatment of specific patient populations within a collaborative and collegial relationship with physicians and other health care professionals.
Deborah A. Vandewater
See also Geriatric Medicine; Gerontological Nursing.
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Pinelli, J. M. "The Clinical Nurse Specialist/ Nurse Practitioner: Oxymoron or Match Made in Heaven?" Canadian Journal of Nursing Administration 10 (1997): 85–110.
Registered Nurses' Association of Nova Scotia and College of Physicians and Surgeons of Nova Scotia. Guidelines for Shared Competencies and Delegated Medical Functions. Halifax, Nova Scotia: RNANS, 1997.
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Nurse practitioners are registered professional nurses who have completed a graduate education program in advanced practice nursing. They provide many of the same services as physicians. A major focus for the nurse practitioner is the promotion of healthy lifestyles to prevent illness. Nurse practitioners can also diagnose and treat common minor health problems as well as chronic conditions, such as high blood pressure or diabetes. They order laboratory tests, prescribe medications, and prescribe various treatments. Studies have shown that they provide cost-effective and high quality care. Although some nurse practitioners practice in hospitals, most work in clinics. Many provide health care to those who may not otherwise have access to care, such as in rural areas, community clinics, shelters, schools, and other settings.
Nurse practitioners must complete a four-year bachelor's degree in nursing and must have experience working as a registered nurse. The graduate nurse practitioner education program takes approximately two years to complete. Graduate study includes nursing coursework as well as advanced study in performing physical examinations, diagnosis, and treatment. The student also has hands-on education with a nurse practitioner and/or a physician preceptor in a clinic or other health care facility.
Students can choose from several specialty areas of study. Some of these specialties include family nurse practitioner (FNP), adult nurse practitioner (ANP), geriatric nurse practitioner (GNP), pediatric nurse practitioner (PNP), and women's health care nurse practitioner (WHCNP).
Students interested in becoming a nurse practitioner would benefit by taking high school sciences and the required college level prerequisites for nursing school. Spending time with a nurse practitioner and working or volunteering in any type of health care service organization is also suggested.
In 1990 nurse practitioners numbered 28,600. In 2000 nearly 70,000 existed, and it was predicted that there would be 116,000 by 2005.
see also Doctor, Family Practice; Nurse; Physician Assistant
American Academy of Nurse Practitioners. <http://www.aanp.org/>.