The term “midwife” literally means “with woman.” Although nurse-midwives are best known for their work during pregnancy and specifically labor and delivery, nurse midwives care for women’s health in a comprehensive way. Certified nurse midwives (CNM) are advanced practice nurses specializing in prenatal care, labor and delivery, postpartum care, gynecology, well women’s health care, and family planning. They work anywhere other advanced practitioners do: in the hospital, at the clinic, and at home.
In the past, many people thought of midwives as only assisting women in home births, water births, and labor without anesthesia. Although some women may choose to deliver their babies in this way, midwives actually oversee all types of births, including those that are more conventional in the hospital. Nurse midwives have the credentials and authority to empower patients, so the kind of care given is according to their preferences and in their best interest.
Despite common misunderstandings, nurse midwives are qualified
to care for women during various stages of life. Furthermore, as prescribers
and independent providers, they are able to manage all types of pregnancies,
whether straightforward or complicated. Like other advanced practice nurses,
many midwives have years of experiences as registered nurses in labor and
delivery and other areas of women’s health. Many contend that the unique
experience of working as a registered nurse before advancing is what sets nurse
practitioners, including midwives, apart from their physician counterparts.
Within midwifery, there are stratified scopes of practice and levels of education; this is both location and training-dependent. Just like other advanced practice nurses, midwives work with varying degrees of independence from physician oversight in an ever-changing climate of advanced practice patient care. The majority of midwives hold a master’s or doctorate nursing degree (CNM); there are also certified midwives (CM) who have passed their advanced practice boards while maintaining a bachelor-level degree of education. For those who don’t have a bachelor’s, master’s, or doctorate degree can qualify to be a certified professional midwife (CPM). They are either trained through apprenticeship and/or formal education, and their scope of practice is narrower than CNMs.
As standards of health care providers evolve, the accreditation process for nurse midwives has increasing standards. The good news is that nurse midwives are learning through rigorous training and experience to provide high-quality patient care independently. Nurse midwives are more than the overseers of alternative birthing methods. They are fully licensed and independent women’s health providers.
For more information on this career path, visit DailyNurse.com/nurse-midwife.
A 2018 study by the American Enterprise Institute (AEI) called “Nurse Practitioners: A Solution to America’s Primary Care Crisis,” by Peter Buerhaus, suggested that NPs can help with the problems of not having enough primary care physicians in particular areas of the United States.
David Hebert, JD, Chief Executive Officer of the American Association of Nurse Practitioners (AANP), recently explained how NPs can make a difference and what can stand in their way.
What follows is an edited version of the interview.
How many states restrict NPs scope-of-practice? What are the limits—what are they not allowed to do in these states that other states allow them to do? If they are allowed their total scope-of-practice, are they able to do everything that a primary care doctor can do?
Currently, 28 states don’t allow NPs to practice to the fullest extent of their training and licensure. Twelve of these—including California, Texas, and Florida—are “restricted practice” states, where the law restricts NPs ability to provide care without a formal contract with a physician. Sixteen other states, including Pennsylvania, Ohio, and Kentucky, are “reduced practice” states, where state regulations limit NPs’ ability to treat patients in certain care settings.
In 22 states, the District of Columbia, and Guam, NPs have full practice authority. This means NPs evaluate patients, diagnose, order and interpret diagnostic tests, as well as initiate and manage treatments under the exclusive licensure authority of the state board of nursing.
NPs and physicians both have the skill set to provide the full range of primary care services to patients. It’s not really about the provider—it’s about giving patients a choice of provider and ensuring them access to high-quality health care. NPs are a critical component of care teams. We work with all kinds of providers in every care setting to make sure patients get the best possible care. When it comes to scope-of-practice laws, we want NPs to be allowed to practice to the fullest extent of their training and licensure.
With the lack of primary care physicians, especially in rural and medically underserved areas, what can the NP bring to the community?
NPs ensure patients in rural communities have greater health care access, especially in primary care. The AEI report confirmed that while the NP workforce is growing significantly, the physician workforce is growing at a much slower rate. The study also concluded what we’ve seen in our own work: primary care NPs (PCNPs) are more likely to practice in rural areas, where the need for primary care is greatest.
It’s important to remember that primary care can prevent additional health complications for patients, making NPs a vital resource for rural communities. People living in states with laws that reduce or restrict NPs’ scope-of-practice have significantly less access to PCNPs. This finding indicates that such state regulations have played a role in impeding access to primary care. This alone should be cause for concern among policymakers seeking to improve public health.
When NPs have moved into areas and had the complete ability to practice, what have been some of the results?
In U.S. News & World Report’s 2018 Best State Rankings, nine of the top ten states for best health care allow patients full and direct access to NP care. According to Buerhaus, author of AEI’s report, people living in states that do not restrict NP scope-of-practice have significantly greater geographic access to primary care. More and more people are choosing NPs because the quality is high and accessible as well as because NPs take into account the needs of the whole patient, which resonates with today’s families.
What would you say to patients who might be afraid that they are getting lesser care in being treated by an NP as opposed to a doctor? How can NPs and other health care providers help patients to understand the benefits?
It’s important for patients to feel comfortable in their selection of a health care provider. Research shows that NPs achieve health outcomes for their patients equal to—and in some cases—greater than their physician counterparts. We encourage patients to consider an NP, take time to learn more about the care NPs provide at www.WeChooseNPs.org, and if it’s the right choice for them, to visit NPfinder.org, where they can find an NP in their area.
We’ve launched a nationwide campaign called We Choose NPs that showcase patients who choose NPs as their primary care providers. We believe it’s important for patients to have access to high-quality primary care and to have the information available to make the right health care choice for their family.
NPs are strengthening health care in a variety of important ways. Recently, Congress passed comprehensive opioid legislation that makes permanent the temporary authorization granted nurse practitioners (NPs) and PAs to provide lifesaving medication assisted treatments (MATs) for patients battling addiction. After conducting a billion patient visits last year alone, we’re very excited about the future and the opportunity to help patients nationwide.
According to Joyce Knestrick, PhD, C-FNP, APRN, FAANP, President of the American Association of Nurse Practitioners (AANP), Congress recently passed and President Trump signed “a comprehensive package of anti-opioid bills into law with a key provision permanently authorizing NPs to prescribe Medication-Assisted Treatments (MATs), further expanding patient access to these critical treatments.”
This passage is extremely important to those fighting opioid addictions as well as those health care workers who are treating them. “Recognizing the ongoing impact of the opioid crisis, Congress and the President moved quickly to get this critical legislation across the finish line. We applaud their actions, which acknowledge the vital role nurse practitioners play in treating patients with opioid use disorder with Medication Assisted Treatments (MATs),” says Knestrick.
What does this mean for the health care community? Knestrick answered questions to explain.
Why is this important—both for NPs and for opioid addicts?
First and foremost, for the millions of American families struggling with addiction today, passage of this legislation ensures patients continuity of care, knowing that their NPs can continue to provide their loved ones access to MAT treatment.
Second, knowing that NPs are now permanently authorized to prescribe MAT, we anticipate significant growth in the number of America’s NPs who will become waivered to prescribe MATs—which will help turn the tide of opioid addiction in communities nationwide.
How will this help more opioid addicts?
As primary care professionals, NPs really are on the front lines of combating the opioid epidemic. Tragically, eighty percent of patients addicted to opioids don’t receive the treatment they need, due in part to health care access challenges, stigma, cost, and other factors. Thanks to advances in Medication-Assisted Treatment—which combines medications that temper cravings with counseling and therapy—and this new law granting NPs permanent authority to prescribe MATs, the opportunities to reach and treat patients struggling with addiction are better than ever before.
In addition to helping addicts, will this make the process more cost-effective? If not, how else will it be beneficial to health care facilities and/or treatment centers?
We do know that treating people with addiction to opioids and other substances is costly—in part because of the need for in-patient treatment and more frequent hospitalizations. Yet, most people in need of treatment simply don’t receive it. As a nation, we are facing significant shortages of specialty treatment facilities for addiction, and this makes it all the more important to ensure that NPs and other primary care providers have the tools to meet the patient need for MATs
AANP has formed a collaborative with the American Society of Addiction Medicine and the American Association of Physician Assistants to provide the 24-hour waiver training for NPs and physician assistants. We invite NPs to visit AANP’s CE Center at https://www.aanp.org/education for more information.
Vanderbilt University School of Nursing recently received a $1.43 million award from the US Health Resources and Services Administration (HRSA) to develop and implement a Sexual Assault Nurse Examiner (SANE) education program for emergency nurse practitioner (ENP) students. The program is expected to increase the number of SANE-trained advanced practice registered nurses practicing in emergency departments and rural or underserved communities across the country.
Mavis Schorn, PhD, FACNM, the grant’s principal investigator, tells Nursing.Vanderbilt.edu, “Currently, there are just over 800 sites in the country that provide SANE services, yet nationally, one in six women and one in 33 men will experience an attempted or completed rape in their lifetime. Sexual assault nurse examiners have specialized education to conduct forensic examinations that have been shown to provide better physical and mental health care for assault survivors, deliver better evidence collection and support higher prosecution rates. Most important, SANEs treat patients holistically with compassionate and comprehensive care that takes into account the patient’s current acute care needs and the possible long-term effects of sexual assault.”
ENPs are positioned in emergency departments and are often the first to discover a patient who has been sexually assaulted. Their education and experience allows them to provide primary, episodic, and critical care of males and females of all ages.
Vanderbilt will offer SANE education to students in the Emergency Nurse Practitioner Post-Master’s Certificate program. Students in the program are current family nurse practitioners who want to become ENPs, and they will complete SANE training and their ENP education simultaneously with an option to select adult/adolescent and/or pediatric/adolescent SANE training.
The initiative is supported by Vanderbilt University Medical Center, Our Kids, Nashville’s Sexual Assault Center, and EmCare. To learn more about Vanderbilt Nursing’s $1.43 million HRSA grant to develop sexual assault nurse examiner education, visit here.
Registered nurses looking to advance their practice have several career paths they can take. One option is to become a nurse practitioner. Nurse practitioners are advanced practice providers who differ from registered nurses in several ways.
First, RNs either have a diploma, associate’s degree, or bachelor’s degree. The degree level corresponds with the type and length of time that was spent in school. Nurse practitioners are advanced degree nurses with either a master’s or doctorate in nursing. These degrees translate to an additional two to three years beyond a bachelor’s degree.
Another significant difference between RNs and nurse practitioners is the scope of practice. NPs have a greater scope of practice to include conducting physical exams, ordering and interpreting diagnostic tests, and prescribing medications. The board of nursing in each state sets forth the specifics of the NP scope of practice, and some states are more restrictive than others.
The highest degree a nurse can obtain is a doctorate of nursing degree. The length of time it takes to earn a DNP depends on the RN’s starting point:
- RN to BSN takes around two years
- BSN to MSN takes around two years
- BSN to DNP takes about three to four years
- MSN to DNP takes about one to two years
Additionally, some students opt to attend part-time. If so, the length of time to earn a DNP can take a little longer.
Many prospective students may wonder what they will learn in a DNP program. The curriculum can vary between schools, but some of the concepts students can expect to learn include evidenced-based practice, theoretical concepts for advanced-practice nurses, planning, evaluation, and leadership. Additionally, depending on the DNP track the nurse chooses as well as their starting point, they may need to take courses in advanced pharmacology, physiology, and health assessment. These three courses are typically required for BSN students enrolled in a DNP program and following a nurse practitioner track. MSN-prepared students have likely already completed them unless they are changing specialties (i.e., a nurse educator earning a DNP to become a nurse practitioner).
In addition to the core courses and specialty track courses, DNP students are required to complete a final DNP project. The project is to demonstrate that the nurse can identify issues or concerns in health care and provide evidence-based solutions to enhance patient care and improve outcomes.
Aside from it being a commendable academic achievement, earning a DNP can enrich the nurse in many ways. For example, nurses can expand their knowledge base. A bedside BSN nurse can earn a DNP and become a certified registered nurse anesthetist. An adult primary care NP can earn a DNP and become an educator. A clinical nurse specialist can earn a DNP and become a nurse executive. There are so many possibilities available to nurses with a DNP degree—which means a wider scope of career mobility.
Another way a DNP can improve a nurse’s career is that DNP nurses are trained to identify important issues in health care and have the knowledge, and sometimes power, to create change in their work environment. From the time one becomes a nurse, patient care remains the top priority. Nurses serve as advocates for patients on so many different levels, from the new grad bedside nurse to the executive-level DNP nurse. With each academic step, the nurse’s reach becomes longer, sometimes affording the ability to motivate and facilitate change within the highest level of an organization.
DNP nurses also have more of a critical thinking and holistic view of health care. Not only are they considered clinical experts, but they are also experts in leadership, management, and business. Being able to influence decision-making from a business standpoint with a patient-centered point of view is something unique and extremely valuable in health care. This exclusive approach allows patients to have a voice in health care, yet keep an organization sustainable.
In some organizations, DNP-prepared nurses have an edge when it comes to hiring. There is a push for the DNP becoming required for nurses looking to enter advanced practice, so those who earn one may currently have an advantage. Some employers offer higher compensation for DNP nurses as well. Nurses may want to consider earning either a PhD or DNP to become doctorate-level practitioners.
Each nurse has his or her own career and academic goals. One is not “better” than the other. However, for those looking to advance their practice and become clinical experts, the doctor of nursing practice is a great choice.
The Arizona State University (ASU) College of Nursing and Health Innovation has announced that it will be offering a new advanced practice nursing degree this coming fall with a focus on acute care for children. The Acute Care Pediatric Nurse Practitioner speciality program is an addition to ASU’s Doctor of Nursing Practice (DNP) program which aims to meet the needs of students and community partners.
Daniel Crawford, associate director of the DNP program and clinical assistant professor, believes the pediatric nursing program will prepare advanced practice nurses in the acute-care setting. He tells ASUNow.ASU.edu, “Those settings may include pediatric emergency rooms, pediatric intensive-care units, pediatric inpatient-care units and some pediatric specialties.”
Students who join the program can expect a hybrid format that requires in-person classes and online classes. The courses will focus on the development of a framework for developmentally supportive, family-centered, culturally appropriate advanced-practice nursing for infants and children with unstable chronic, complex acute, and life-threatening illnesses.
ASU’s Acute Care Pediatric Nurse Practitioner program is one of few in the country and will help prepare advanced practice nurses to treat a vulnerable population in need of specialized care. To learn more about ASU’s new pediatric nursing program, visit here.