According to the American Association of Nurse Practitioners (AANP), the number of nurse practitioners (NPs) currently licensed to practice in the United States has reached a record high. The release of new data shows that more 248,000 nurse practitioners are now practicing, compared to an estimated 120,000 in 2007.
Thanks to a rise in the number of nurse practitioners nationwide, patients are seeing the benefits of high quality, comprehensive, patient-centered health care services being provided by NPs. An additional 23,000 new NPs graduated from programs in the 2015-2016 academic year alone, up 15% from the prior year.
AANP President Joyce Knestrick, PhD, APRN, CFNP, FAANP, released the following statement in response to this new data: “This is an important milestone for patients as well as for NPs. Provider shortages, especially in primary care, have become a growing concern, but the growth of the NP profession is addressing that concern head-on. Couple that with news that NPs conducted an estimated 1.02 billion patient visits last year alone, and it’s easy to see why millions of Americans are making NPs their providers of choice.”
In addition to a rise in NPs, an estimated 85% of new graduates have been trained in primary care, with nearly two out of three NPs entering the workforce having graduated from family nurse practitioner programs. The Bureau of Labor Statistics projects that the NP profession will have grown 36% by 2026.
To learn more about the growth of the nurse practitioner profession in the US, visit here.
Many physicians’ offices, hospitals, and urgent care clinics often have nurse practitioners (NPs) working in them. Although it’s usually the patients who aren’t sure what this kind of nurse does, we know that some of our readers may not know as well—at least not all the minutia involved with this kind of job and career path. Considering that more nurses are choosing to become NPs, knowing this information is important—especially in helping you decide if this is where you want to go next.
We interviewed Joyce Knestrick, PhD, APRN, C-FNP, FAANP, a family nurse practitioner and president of the American Association of Nurse Practitioners (AANP), to learn more about what exactly a nurse practitioner is and does. An edited version of our interview follows.
What is a nurse practitioner and what type of work does s/he do? What additional duties and responsibilities are they able to do because of their additional education?
The first thing to know is that NPs provide primary, acute, and specialty health care to patients of all ages and walks of life. We operate in all types of care settings from hospitals to home care, and urgent care clinics to the VA. NPs conducted over a billion patient visits in the last year alone. Many of your readers have probably seen an NP at some point, and we have developed a solid reputation of being close to our patients. The profession’s track record of patient-centered health care and outstanding outcomes have been well established over 50 years of research. NPs assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans—including prescribing medications.
NPs complete a master’s and/or a doctoral degree program, along with having completed advanced clinical training beyond their initial professional RN preparation. If an NP wants to go on to specialize in an area of care, it requires additional education and training.
With over 234,000 NPs across America, each having to undergo rigorous national certification, periodic peer reviews, clinical outcome evaluations, as well as adherence to a code for ethical practices, we’ve quickly become the primary care provider of choice for millions of Americans from rural areas to dense urban ones. About 16% of the profession works in communities of less than 10,000 and over 36% work in communities with a population less than 50,000.
Are there currently any barriers to practicing as a nurse practitioner? If so, what are they?
Yes, there are several barriers to practice for NPs all across the country. Currently, 22 states, plus the District of Columbia, allow NPs to practice to the full extent of their education, training, and licensure. While that may be over 40% of the country, AANP believes every state should enact laws enabling what we call “full practice authority.”
Every state is unique with its own set of public policy and political challenges, but we are committed to removing the barriers between NPs and their patients by drawing on the expertise of NPs who serve at the intersection of health care policy and patient care with the goal of achieving better health and improved access to care, at a lower cost.
We’ve identified several states as priorities this year. Any of you readers who are interested in helping to reduce barriers to practice for NPs should visit AANP.org and look for our state policy guide.
To make it easier for people to understand many of the nuances surrounding the FPA issue, we’ve assigned each state a color (see our map here).
Green states, which we’ve already mentioned, allow NPs to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications and controlled substances—under the exclusive licensure authority of the state board of nursing. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, and National Council of State Boards of Nursing.
Yellow states are called “reduced practice states,” and they reduce the ability of an NP to engage in at least one element of NP practice. State law requires a career-long regulated collaborative agreement with another health provider in order for the NP to provide patient care or limits the setting of one or more elements of NP practice.
Red states are called “restricted practice states,” and they restrict the ability of an NP to engage in at least one element of NP practice. State law requires career-long supervision, delegation, or team-management by another health provider in order for the NP to provide patient care.
There are many reasons why states fail to modernize regulations to enable NPs to practice to the full scope of their education and clinical training, not the least of which is pressure from organized medicine. That’s not to say that there aren’t similarities between yellow and red states’ barriers, but each state requires its own approach, and we actively identify legislation, support state-level NP organizations’ policy initiatives, and develop policy resources that cultivate strong NP leaders and sound health policy in every state.
What states are the best to work in as a nurse practitioner? Why?
Of course, any state colored green on our map will be more favorable to NPs than ones colored yellow or red. As the map demonstrates, western and northeastern states have chosen to enable NPs to practice to the fullest extent of their clinical training and licensure.
Why is it important for NPs to be able to practice fully? What do they bring to the health care table, so to speak, that benefits the health care system as a whole?
As clinicians, NPs blend clinical expertise in diagnosing and treating health conditions with an added emphasis on disease prevention and health management. We bring a comprehensive perspective to health care.
Bethel University has announced the launch of a new Doctor of Nursing Practice (DNP) degree program, available in fall 2018. The DNP program is intended to prepare advanced practice nurses for roles in administration, public policy, advocacy, and specialized care.
Bethel has launched several other healthcare programs in recent year including a physician assistant program in 2015, and a variety of other nursing programs at the undergraduate and graduate level. According to Bethel.edu, the Bureau of Labor Statistics estimates that demand for nurse anesthetists, nurse midwives, nurse educators, and advanced practice nurses with DNP degrees is expected to grow by 31 percent in the next 10 years.
The DNP program will be offered primarily online, putting students on the cutting edge of medical trends with courses in biostatistics, epidemiology, informatics, and healthcare economics and policy. Students will apply evidence-based research, critical thinking skills, and learn to understand nursing from a business perspective to prepare them for roles in hospital management and academia.
Jane Wrede, program director and associate professor of nursing, tells Bethel.edu, “The DNP degree is focused on leadership and transformation in the workplace. Its purpose is to prepare advanced practice nurses to be leaders and change agents in their professional settings.”
Bethel University has pursued initial accreditation of the Doctor of Nursing Practice program by the Commission on Collegiate Nursing Education. To learn more about the launch of the new DNP program, visit here.
Master’s students in the Duke University School of Nursing (DUSON) have the opportunity to enroll in a new major in Psychiatric Mental Health as of the Spring 2018 semester. This newest major being offered is for Advanced Practice Registered Nursing (APRN) students interested in pursuing a specialty nursing track.
Duke believes in the importance of specialty education programs to ensure that nursing students who go into specialty areas have the formal training they need. Students enrolling in the Master of Science in Nursing (MSN) program at Duke have the opportunity to choose from one of eight majors, and to pursue an additional specialty track if they are interested. Each major and specialty has its own course requirements and formal clinical rotation requirements that must be met to earn a specialty certificate.
The Psychiatric Mental Health program is the eighth and latest major offered for nurse practitioner students. Majors are also available in gerontology care, family nurse practitioner, neonatal and pediatric nurse practitioner, and women’s health nurse practitioner. The MSN program also recently added two new specialties in Endocrinology and HIV/AIDS, and a pediatric mental health specialty is set to be launched in the near future.
Beth C. Phillips, PhD, MSN, RN, CNE, tells Nursing.Duke.edu, “To think about why we do a new program – it’s not because we have a faculty member who would be great at it, so let’s create a new program. We create a program based on community need – local, national or global. The newest major, for example, was added after we recognized there was a scarcity of mental health providers in the state. Behavioral concerns and the addiction crisis in our country demanded a more advanced and skilled workforce in nursing.”
With specialty nursing becoming more and more prevalent, Duke is “aiming to identify community health care needs and respond proactively to meet those needs,” according to Nursing.Duke.edu. Creating new programs is a long process for the university, involving tracking legislature and literature to see what needs are already being met by the healthcare community, and which are not. Once new areas are identified, the university has to hire new staff and create partnerships with clinical sites, in addition to approving new financial resources through the Dean.
To learn more about Duke Nursing’s latest nurse practitioner major in Psychiatric Mental Health, visit here.
I have been placing percutaneous intravenous central catheters (PICCs) in neonatal patients for almost 25 years, and I admit taking apart the process seems a bit daunting. One of the most important factors for successful insertion is good planning.
The first thing I do is identify the patient. Any neonate who is less than 1,250 grams, requiring antibiotics or total parental nutrition for more than 5 days is an obvious candidate. An infant over 1,000 grams requiring frequent blood draws could be considered for a larger PICC as the unit I work in uses the line for blood drawing as well as fluids and antibiotics. The patient should not have active bacteremia or fungemia.
Once I identify the patient, I review the current fluid status and recent complete blood count. A platelet count over 50,000 and normal hematocrit are preferable, and if out of acceptable range, it’s best to take time to correct these before attempting the procedure.
After I have identified the patient and assessed the individual factors, I will put in several prep orders. These orders include an intravenous (IV) 20 ml/kg 0.9 Normal Saline bolus, 1 mcg/kg fentanyl, and 0.1mg/kg versed given via IV. The bolus is to be completed immediately prior to procedure, the sedation and analgesia just before the start. I almost always follow this pre-procedure protocol, especially if this is not the first PICC attempt on the patient. Blood vessels in neonates tend to be especially friable and, in my experience, a normal hematocrit, fluid bolus, and appropriate pre-medication minimize that obstacle.
Next, I examine the patient’s vessels and look for the biggest vessel that is suitable for a PICC. I start with extremities as a PICC dressing is maintained easiest on an extremity. Recently, I have preferentially used the right saphenous if it’s suitable. The main reason I have been doing this is that there is more leeway on the placement of the tip of the line than in an upper extremity. Upper extremity lines have a smaller acceptable target area, a higher incidence of line migration; the observation of the tip placement on X-ray is very sensitive to the patient’s arm position when the X-ray is taken. Also, a lower extremity line will often remain in a central position through patient growth.
The procedure of PICC placement is well documented. The few variations I use when I place a PICC include: my own positioning and I cut the catheter to the exact length.
One important pearl I would give to the novice PICC inserter is to practice your IV insertion skills. Proficiency in IV insertion will not guarantee that a PICC insertion will be easier, but without the IV skills, insertion of PICCs in neonates will be less successful.
Like any other procedure, PICC line placement requires patience and practice. The methodology I use has been refined over the 25 years I have been doing this in the NICU. If you are interested and would like to discuss it, please do feel free to email me at Christine.firstname.lastname@example.org.
2017 was an important year for the healthcare industry nationwide, with multiple states enacting new laws to equip advanced practice registered nurses (APRNs) with full practice authority, allowing them to practice to the top of their education scope. APRNs — including nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives — are a critical part of efforts to ensure and expand access to high-quality, cost-effective healthcare across the country.
As we move in 2018, APRNs now have full, autonomous practice and prescribing authority in 25 states and the District and Columbia. In remaining states, APRNs continue to practice under supervision or collaboration with physicians. According to HealthcareFinanceNews.com:
“In 2017, over 20 states reported passage of legislation positively impacting access to and delivery of healthcare nationwide.”
In an effort to respond to the ongoing opioid crisis, several states have also enacted new laws and regulations on the prescribing of controlled substances. California and Oregon passed legislation in 2017 bringing nurses practitioners’ role into line with the federal Comprehensive Addiction and Recovery Act. These new laws clarify the role of nurse practitioners in prescribing buprenorphine, an important part of treatment for opioid use disorders.
To learn more about the national move to grant full practice authority to advanced practice registered nurses, visit here.