Nurse Practitioners inthe United States:
Education, Training, andRoles
Carolyn S. Melby, PhD, ANP, BC, CCH

Health Care Systems Demand
New Nursing Roles

Nursing has the Answers to the Predominant Nurses must have the knowledge and skills to: The problems associated with normal human Understand the health care environment

Health Care Dilemmas, Including:development, particularly aging; Adapt or seek consultation to adapt client care

 Chronic illness management in all ages;

in response to rapidly changing health caresystems
 Access and communicate health careinformation with health care providers fromother disciplines, cultures, and countries.

 Health disparities associated withsocioeconomic dislocations such as global
migration, classism, sexism; and The strategies for health promotion and disease
prevention

Nursing must produce quality
graduates who are prepared for:The US Response: Innovation ofAdvanced Practice Registered
Nurse (APN) Clinical leadership in all health care settings,

 Nurse Practitioner

 Implementing outcomes-based practice and Nurse Anesthetist

quality improvement strategies, Remaining in and contributing to the profession,practicing at their full scope of education andability, Creating and managing systems of care thatwill be responsive to the health care needs ofsociety.

 Nurse Mid-Wife Clinical Nurse Specialist
 Clinical Doctorate for APN

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Advanced PracticeRegistered Nurse

APRN Education

Advanced practice registered nurses manifest a high levelof expertise in the assessment, diagnosis, and treatmentof the complex responses of individuals, families, orcommunities to actual or potential health problems,
prevention of illness and injury, maintenance ofwellness, and provision of comfort

 The advanced practice registered nurse

APRN Clinical Education (requirededucational components for credential)

Primary Care Nursing/Family NP
Sample Program Advanced health assessment
 Pharmacology
 Pathophysiology
 Health promotion and disease prevention
 Differential diagnosis and disease management
 Must include 500 hours of advanced clinical practicum in

specific specialty program Programs vary from 42 to 53 credit hours

has a master’s or doctoral education
concentrating in a specific area ofadvanced nursing practice, has
supervised practice, and has ongoingclinical experiences. Advanced practiceregistered nurses continue to performmany of the same interventions used inbasic nursing practice.



Human Development and Family and or Child Theory
Clinical Pharmacology
Pathophysiology
Advanced Health Assessment
Advanced Practice in Primary Care I
Diagnosis, Symptom and Illness Management (Adult/Pediatrics)
Health Promotion and Disease Prevention
Concepts and Theories in Nursing
Advanced Practice in Primary Care II
Ethics in Health Care
Roles and Systems in Advanced Practice Nursing
Biostatistics
Child or Human Development and Family Theory
Health Assessment and Intervention
Advanced Practice in Women’s HealthDiagnosis, Symptom and Illness Management
Advanced Practice in Primary Care III
Scholarly Project
Research Design Methodology
TOTAL CREDITS

233443233222223341353

Clinical Practice for NP
Students

History and birth of NP (APN)
role in the United States Clinical sites have a certified NP to preceptor students.

 Discussions about the nature of nursing and the scope of Students may observe from time to time or, butthereafter are expected to participate fully in theprocess of assessing, evaluating, diagnosing,prescribing, and teaching patients.
 Clinical rotations are generally 16
hours/week/semester. Summer rotations can involve
40hours/week for 4-6 weeks.
 Faculty work closely with clinical preceptors to monitor
and evaluate students’ learning.
 Preceptors evaluate students work and this evaluation
become a significant part of the student’s grade forthat class.

practice were on the agenda of every nursing organization
 There was social and professional interest in changing the role
 The first program was a demonstration project meant to be astrategy to gain autonomy and self determination in practice, toenergize nursing education curricula, and a way for nursing tofulfill their social mandate to serve humankind
 The program was academically and scientifically grounded,health-oriented and clinically focused. The nurses wereprepared for autonomy in clinical judgment and collegiality andcollaboration in team care.
 There was a perceived shortage of primary care physicians2Evolution of the NP Role

How is an NP different?

 The idea of the nurse practitioner was timely, responsive to The difference in this practice relates toimmediate social needs, and attractive to individuals andinstitutions that before the first four years of test data wereavailable, many programs for the preparation of nurse
practitioners sprang up.
Problems encountered were: Mutations of the original modelallowed academic standards to be variable
The focus of some programs went from nursing to a medicalmodel
Legal authorization and specialty certification were obtained
state by state
Organized nursing was slow to address the need of nurse
practitioners for recognition and affiliationa greater depth and breadth ofknowledge, a greater degree ofsynthesis of data, and complexity ofskills and interventions.
 American Nurses Association (1996). Scope and standards for

Advanced Practice Registered Nursing. Washington DC:
American Nurses Association

Standards of Nurse
Practitioner (NP) PracticeStandards of NP Practice (cont) Qualifications: NPs are licensed independent Process of Care:

practitioners who provide primary and /or
specialty nursing and medical care in
ambulatory, acute and long term care settings.
The are registered nurses with specialized
advanced education and clinical competency toprovide health and medical care for diversepopulations in a variety of primary care, acuteand long term care settings. Master’s post
master’s or doctoral preparation is required forentry level practice. (AANP 2008)

Standards of NP Practice (cont) Care Priorities
 The nurse practitioner’s practice modelemphasizes:
 A. Patient and family education
 B. Facilitation of patient participation in selfcare
 C. Promotion of optimal health D. Provision of continually competent care
 E. Facilitation of entry into the health caresystem
 F. The promotion of a safe environment

 The NP utilizes the scientific process andnational standards of care as a framework for
managing patient care. This process includes: A. Assessment of health status B. Diagnosis
 C. Development of a Treatment Plan
 D. Implementation of the plan E. Follow-up and evaluation of the patientstatus

Research regarding NP’s show thefollowing: NP’s are Well accepted by patients, nurses, andmany other professional, including
physicians.
 Clinically safe, competent, and confident
in caring for a large percentage of all
ambulatory patients
 Cost effective in both preparation andpractice3NP’s Today

NP’s Today (Continued)

 An attractive model for recruiting potential

 Professionally credentialed

students into the profession.
 Institutionalized in Master’s programs and thenew clinical doctorate (DNP) and a variety ofpractice settings.
 An influential political force in shaping healthpolicy Working hard to secure reimbursement forservices and to be free from unnecessarycontrols to practice Enjoying an enhanced public image as

Nurse Practitioners in theUnited States

Nurse Practitioners in theUnited States

 135,000 NPs in the United States
 NPs are independent practitioners and holdprofessional nurses
 Expanding into new settings and newspecialties demonstrating flexibility asneeds, demands, and opportunities arise.

 NPs write approximately 556 millionprescriptions annuallyprescriptive practice in all 50 states
 NP Specialties: Acute care, Adult, Family,
Gerontological, Neonatal, Oncology, Pediatric,
Psych/Mental Health, and Women’s Health Average NP is female (94.6%) and 48 years
old, she has been in practice for 10.5 years
as a family NP (49%).

 The 2008 mean full-time NP base salary

Advanced Practice Nursing
Internationally

Entry Level Core Competencies
for NPs: seven content domains

 International Council of Nurses has

 Management of Patient Health/Illness Status

defined an international standard fornursing and for advanced practicenursing
 The United Kingdom, Australia, andHong Kong all have established the roleof NP

 The Nurse Practitioner-Patient Relationshipis $84,250 across all specialties andsettings
 Average full time NP total income is$92,100

 The Teaching-Coaching Function
 Professional Role Managing and Negotiating Health Care DeliverySystems
 Monitoring and Ensuring the Quality of HealthCare Practices
 Cultural Competence (American Academy of Nurse Practitioners, 2007)

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Developing a Vision for
Innovation in Nursing

Conclusions: How to innovate?
Nursing Leaders MUST: Realistic appraisal of nursing education

Clearly define what nursing is, where nursing
is headed, and what it will be.
2.
Develop a vision for the future
3. Take control of your current and future destiny.
4. Unite to whatever extent possible
5. Do not sacrifice the long term for the short term
4. Keep your eye on your vision
5. Identify the strengths of nursing and use it tobegin moving forward.

in relationship to clinical roles Does the present nursing education
system prepare nurses for their presentroles?
 Where does it fall short?
 What nursing skills will be needed for theevolving health care system?

1.

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