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Role of Advance Practice Nurses

My clients today are very educated on the role of the nurse practitioner so it is rare that I hear any confusion, although it does occur on occasion, particularly with regards to our ability to independently practice. Just ten years ago, much of society thought #midwifery for example, was illegal. Even within the profession itself there are midwives and nurse practitioners unclear about the legal parameters of their role and have questioned the efforts of others, including myself, to the point of filing complaints only to later learn they were ill informed.


Today I embark on teaching Roles of the Nurse Practitioner at a new university, Colorado Technical University. I have been teaching this course intermittently at Indiana Wesleyan as well for the past several years, and it's a course I really do enjoy. I thought I would share some of the points we are teaching our graduate students in the event you may have interest in better understanding the profession.



The Nurse Practitioner


The Nurse Practitioner role has the highest number of practicing advanced practice nurses in the United States. In 2019, more than a quarter million nurse practitioners were in practice, primarily in primary care as myself. Most accept Medicare and Medicaid, although we do not.


Most all nurse practitioners have at least a master's degree, but many now also have their doctorate degrees, whether PhD or their clinical doctorate in nursing practice, such as myself. The first doctoral program dates back to the 1970s, but this was rare until the early 2000s when a push for the nursing doctorate was identified as a method for improving the healthcare system. Currently there are over 400 programs which is exciting as I completed mine in 2014 and was only the 9th class from one of the first universities to offer the DNP. This ages me, I suppose.


Although the nurse practitioner may have either a master's or doctoral degree, their specialities may differ greatly. All, of course, have an undergraduate degree in nursing so start as Registered Nurses and have some level of clinical experience; however, they then choose their specific specialty for their graduate focus. Within their focus, each nurse practitioner will take core classes that focus on their population and then a minimum of 500 clinical hours are required to be completed within their population-focus area. Following completion of these requirements, a certification course must be based to earn certification.


The more common specialty areas for nurse practitioners are: adult-gerontology care nurse practitioners (AGPCNP), adult-gerontology acute care nurse practitioner (AGACNP), family nurse practitioner (FNP), women's health nurse practitioner (WHNP), primary care pediatric nurse practitioner (PNP-PC), acute care pediatric nurse practitioner (PNP-AC), neonatal nurse practitioner (NNP), and the psychiatric-mental health nurse practitioner (PMHNP).


Interesting points are that the nurse-midwife and the neonatal nurse practitioner are among the lowest paid of all advanced practice nurses which aligns with mothers and babies having the worst outcomes in our country among all other first world countries in the world. The largest portion of nurse practitioners, at 70 percent, are family nurse practitioners. We care for individuals across the life span focusing on primary, secondary, and even tertiary prevention. Some FNPs work in urgent care, but most work within primary care clinics.


Nurse practitioners must recertify every three to five years through maintaining minimum practice hours and continuing education units. They could also take another exam. Both the certifying boards and each individual state that licenses practitioners has their own requirements, which all must be met for each credential. As a dual certified practitioner myself, as both a family nurse practitioner and certified nurse-midwife, there is a lot to coordinate in effort to maintain up to date with my credentials.


Despite nursing organizations advocating for full practice authority, which is simply being able to practice to the full scope of their training, many states have restrictions on the scope of practice for a nurse practitioner, which largely stems from physician groups having more power and lobbying money so they attempt to squelch their competition. It is the individual state nursing boards rules and regulations we must adhere, and in some states, this includes the oversight of the medical boards as well.



The Nurse-Midwife


One of the oldest professions, dating back to Old Testament times and beyond, midwives have been recognized in the United States at least through the past 100 years. The first nurse-midwifery program was established in the 1930s but of course, midwives were already practicing before this time through apprenticeship. Today, like nurse practitioners, certified nurse-midwives must have their RN license and a minimum of a master's degree to be eligible for certification.


The American College of Nurse Midwives was formed in the 1950s to advocate for midwives. Today, nurse-midwives care for women throughout their lifespan, most specializing in the childbearing years. They are certified by exam through the American Midwifery Certification Board which expires every five years. There are approximately 6,000 certified nurse-midwives in the United States and most are extended prescription authority, but not all states have offered this which is really pretty profound considering life saving medications need to be administered in a moment's notice, and management of chronic disease, often through pharmaceuticals, is necessary for optimizing maternity outcomes.


Advanced Practice Nurses


There are a number of avenues for advanced practice for nurses, including the two pathways above, but also certified registered nurse anesthetists and clinical nurse specialists, neither of which Dr. Layne is certified so that discussion is not offered here. An interesting point though, is that nurse anesthetists make up half of all the anesthesia providers in the United States. They are not offered prescription privileges however, but rather select, order, and administer legend drugs and controlled substances based on facility-specific protocols. There are also nurse educators, nurse informaticists, and nursing administrators. It is not required to be certified by exam for the nurse educators, but many do choose to do so. Nursing informatics is about implementing technology, such as electronic medical records.


The reality is that we haven't sufficient number of physicians to address the needs of healthcare consumers. This was first realized following WWII when there weren't enough physicians to care for the communities so nurses began addressing the needs previously attended by physicians. Today this is more about an aging population, but also about access to care that is affordable. Nurse practitioners and nurse-midwives are certainly more cost effective.


Scope of Practice


This is sort of the buzz word one uses when questioning if one is practicing appropriately or not. The real challenge here though is what one defines as their own scope of practice is not the same for another clinician, even with the same credentials. As we gain additional experience and trainings, our scope advances. What is appropriate for a new graduate for example, and an experienced clinician within a specialty area is not one in the same.


It is important for each practitioner to be cognizant of their own state's nurse practice act, as the board of nursing defines their scope of practice, but more often this is about maintaining up to date with evolving practice as science changes daily so legislating this can be cumbersome and unnecessary hamper care provided consumers. The scope of practice is limited to the population of focus within one's speciality. For example, only the nurse midwife can attend births as the primary care provider. A women's health nurse practitioner and even the family nurse practitioner can care for pregnant women, if this is an area they have demonstrated competency, but they must be specifically certified and licensed to attend births. A geriatric provider would not care for the pediatric population and a pediatric provider would not care for the elderly as well.


Scope of practice can also be the buzz word for appreciating what is permitted based on rules and regulations within each state, so while nurse practitioners and nurse midwives may be trained to care for a particular condition or prescribe independently, laws may prevent them from doing so, but a few minutes drive across the border and this scope changes significantly. It's politics. Here is a little bit more about this scope of practice.


Each of our professional organizations publishes position statements on the more controversial or bigger picture points within the profession and this too helps to establish our scope of practice, but again, these are intentionally written to allow the practitioner the freedom to grow their experience and expertise. It is not within my scope of practice for example, to perform colposcopies on women with an abnormal Pap smear as I have not any training in this regard, but it is within my scope to perform a frenotomy on those with a tight frenulum. Neither of these are appropriate for the new practitioner. None of this should be legislated although it is often. Florida statutes for example require a urine dipstick at each prenatal visit although science thirty years ago determined this unnecessary as a routine, and rather to do so based on symptoms, so this greatly increases cost of care unnecessarily and is unlikely to be addressed at any time into the future as there are more pressing priorities in front of congress.


Having worked to create guidelines for the American College of Nurse Midwives, I can share this is a complex and rigorous process that sometimes takes years for a single publication and this isn't entirely driven by the literature, as the political climate is a significant pressure that must be expertly navigated and sometimes, supersedes what is quite clear in the evidence. When practitioners are experienced, and strongly led by their ethics, they may then work outside these guidelines which they recognize to be politically motivated and not in the best interest of their informed client, but this doesn't make them reckless or ill-informed. Rather, this may mean they are working to the gold standard yet to be widely appreciated by their profession. Interestingly, because it takes about two decades for the standard of care to catch up to newer science unfolding, those at greatest risk for being identified as working outside their scope or outside the standard of care, are actually those at the top of their field. Evolving science depends on these practitioners to advance itself.


For example, the American Association of Nurse Practitioners, the National Council of State Boards of Nursing, and the American Medical Association all having varying views on the scope of practice for the nurse practitioner. For example, the American Association of Nurse Practitioners advocates for full practice authority for all NPs across all states, just as the American College of Nurse Midwives does for nurse-midwifery practice. Based on the required education and training, the AANP asserts that NPs are fully capable of autonomously providing care to individuals across their life span, and same for midwifery. Considering both NPs and CNMs are trained to diagnose and treat acute and chronic conditions, interpret test results, and are major proponents of health promotion, they should be able to independently function. However, the American Medical Association, which is really the lobby group for physicians, has different beliefs. They argue that nurse practitioners lack sufficient training to practice independently and therefore, should work under the supervision of a physician. As such, every diagnosis, treatment, and piece of documentation should be overseen by a collaborating physician (AMA, 2019). This is why many states continue to restrict the practice of advanced practice nurses which manifests itself in a number of ways.


Ironically, the third leading cause of death is from medical error, within a system largely lead by physicians and the opiate crisis was created with physicians writing the vast majority of scripts. The reality is that consumers have made clear that if given the choice, they prefer the nurse practitioner to the physician. The nurse remains the most trusted profession now for decades in a row, minus one year when the fire fighter was chosen during the 911 crisis. As important, advanced practice nurses offer less expensive care with similar or better outcomes, so this restriction isn't about improving care. Rather it reduces access to care simply so physicians can better corner the market and pad their own pockets. Take this a step further and this is truly about oppression on the female healer, but I've written much about that before so I won't digress.


Prescription Writing or Prescription Privileges


The irony of these restrictions is that the entire role of the nurse practitioner is very much based around identifying what medications to give what presentation of symptoms. The pharmaceutical companies have perversed our educational system so greatly that we essentially revolve around being their drug pushers more so than we have any training on actually healing our clients, yet once nurse practitioners and nurse midwives finish their training they are told, just kidding, we're restricting your practice because the physicians don't want you stepping into their territory. Making these collaborations required means we can't work independently and therefore, they can profit off our work.


This does differ across every state line but to date, only about half allow for independent prescription privileges. In some states, advanced practice nurses can't even write for physical or occupational therapy, or even medical equipment such as glucose monitors or wheelchairs. Many states don't allow advanced practice nurses to diagnose death or sign a death certificate which means when you're a midwife, practicing in a setting outside the hospital, the police including a homicide detective may be involved and the parents may undergo evaluation by child protective services.


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