AMA demographics education and training Scope of licensure and regulation Practice professional organization current literature Data Series A resource compendium for state medical associations and national medical specialty societies Nurse practitioners American Medical Association October 2009 Disclaimer: This module is intended for informational purposes only, may not be used in credentialing decisions of individual practitioners, and does not constitute a limitation or expansion of the lawful scope of practice applicable to practitioners in any state. The only content that the AMA endorses within this module is its policies. All information gathered from outside sources does not reflect the official policy of the AMA. Table of contents I. Overview.................................................................................. 4 II. Introduction ............................................................................. 5 III. Nurse practitioner profession ........................................................... 8 Definition(s) .................................................................................. 8 General duties and responsibilities ................................................................. 8 Specialization................................................................................. 10 Brief history of the profession .................................................................... 11 Demographics ................................................................................ 14 Employment types and locales ........................................................... 14 Salary data........................................................................... 15 IV. Billing for services...................................................................... 16 Medicare .................................................................................... 16 Medicaid .................................................................................... 16 V. Education and training of NPs .......................................................... 20 NP master’s programs in the United States.......................................................... 20 Degrees and areas of study............................................................... 20 Accrediting bodies............................................................................. 20 Commission on Collegiate Nursing Education .............................................. 21 National League for Nursing Accreditation Commission ...................................... 22 Competencies required for accreditation ........................................................... 23 AACN’s 1996 Essentials recommendations for master’s-level APN core curriculum ................. 23 AACN’s 1996 Essentials recommendation for clinical practice.................................. 24 Requirements for admission into NP master’s programs................................................ 25 RN to MSN-NP ...................................................................... 25 BSN-RN to MSN-NP.................................................................. 26 RN-BS to MSN-NP ................................................................... 26 Bachelor’s degree non-nurse to MSN-NP................................................... 27 MSN to NP (post-master’s certificate)..................................................... 27 Characteristics of current NP master’s programs...................................................... 27 Program curriculum and clinical experience ................................................ 27 Criticism of the NP curriculum................................................................... 28 Doctorate in Nursing Practice degree .............................................................. 29 Impetus for development of the DNP...................................................... 29 Concerns with clinical doctorates ........................................................ 30 Critiques of the DNP mandate from advanced practice nursing organizations...................... 31 AACN’s DNP Essentials ................................................................ 32 AACN’s DNP Essentials foundational outcome competencies............................. 33 AACN’s DNP Essentials specialty-focused competencies................................. 34 Scope of Practice Data Series: Nurse practitioners • Table of contents 2 Return to table of contents VI. NP specialty certification............................................................... 35 Licensure examination.......................................................................... 36 NP specialty certification and recertification ........................................................ 37 Standards for certifying bodies ........................................................... 37 Eligibility requirements for NP specialty certification ......................................... 38 NP certifications in primary care fields ............................................................. 38 American Academy of Nurse Practitioners ................................................. 38 American Nurses Credentialing Center.................................................... 39 Pediatric Nursing Certification Board ..................................................... 40 National Certification Corporation ....................................................... 41 VII. State licensure and regulation......................................................... 44 Licensure as an RN ............................................................................ 44 Recognition as an advanced practice nurse and/or NP................................................. 44 Licensure reciprocity ........................................................................... 44 VIII. Professional NP organizations ........................................................ 45 NP organizations .............................................................................. 45 Related professional organizations................................................................. 46 IX. Professional journals of interest........................................................ 47 Appendix .................................................................................. 48 Roster of state nursing boards .................................................................... 48 Roster of state nurse practitioner associations........................................................ 51 National medical association policy concerning nurse practitioner scope of practice ........................ 55 Literature and resources … ...................................................................... 64 Figures Figure 1: State licensure requirements for nurse practitioners Figure 2: State scope of practice for nurse practitioners Figure 3: State nursing board operating information Acknowledgments Many people have contributed to the compilation of information contained within this module. The American Medical Association (AMA) gratefully acknowl- edges the contributions of the Missouri State Medical Association, the American Academy of Family Physicians and the American Osteopathic Association. Scope of Practice Data Series: Nurse practitioners • Table of contents 3 Return to table of contents I. Overview The American Medical Association (AMA) Advocacy ceived shortages simply do not justify scope-of-practice Resource Center (ARC) has created this information expansions that expose patients to unnecessary module on nurse practitioners to serve as a resource for health risks. state medical associations, national medical specialty societies and policymakers. This guide is one of 10 In November 2005 the AMA House of Delegates separate modules, collectively comprising the Scope of approved Resolution 814, which called for the study of Practice Data Series, each covering a specific limited the qualifications, education, academic requirements, licensure (non-physician) health care profession. licensure, certification, independent governance, ethi- cal standards, disciplinary processes and peer review of Without a doubt, limited licensure health care provid- limited licensure health care providers. By surveying ers play an integral role in the delivery of health care in the type and frequency of bills introduced in state legis- this country. Efficient delivery of care, by all accounts, latures, and in consultation with state medical associa- requires a team-based approach, which cannot exist tions and national medical specialty societies, the AMA without inter-professional collaboration between physi- identified 10 distinct limited licensure professions that cians, nurses and other limited licensure health care are currently seeking scope-of-practice expansions that providers. With the appropriate education, training may be harmful to the public. and licensing, these providers can and do provide safe and essential health care to patients. The health and Each module in this Scope of Practice Data Series is safety of patients are threatened, however, when limited intended to assist in educating policymakers and oth- licensure providers are permitted to perform patient care ers on the qualifications of a particular limited licensure services that are not commensurate with their education health care profession, as well as the qualifications phy- or training. sicians attain that prepare them to accept the responsi- bility for full, unrestricted licensure to practice medicine Each year in nearly every state, and sometimes at the in all its branches. It is within the framework of educa- federal level, limited licensure health care provid- tion and training that health care professionals are best ers lobby state legislatures, their own state regulatory prepared to deliver safe, quality care under legislatively boards and federal regulators for expansions of their authorized state scopes of practice. scopes of practice. While some scope expansions may be appropriate, others definitely are not. It is important, It is the AMA’s intention that these Scope of Practice therefore, to be able to explain to legislators and regu- Data Series modules provide the background informa- lators the limitations in the education and training of tion necessary to challenge the state and national advo- non-physician health care providers that may result in cacy campaigns of limited licensure health care provid- substandard or harmful patient care. These limitations ers who seek unwarranted scope-of-practice expansions are brought into focus when compared with the compre- that may endanger the health and safety of patients. hensiveness and depth of physicians’ medical education and training. Michael D. Maves, MD, MBA Patients’ difficulties in securing access to qualified phy- Executive Vice President, Chief Executive Officer sicians in rural or underserved areas provide limited American Medical Association licensure providers with what at first glance seems to be a legitimate rationale on which to lobby for expanded scope of practice. However, solutions to actual or per- Disclaimer This module is intended for informational purposes only, may not be used in credentialing decisions of individual practitioners, and does not constitute a limitation or expansion of the lawful scope of practice applicable to practitioners in any state. The only content that the AMA endorses within this module is its policies. All information gathered from outside sources does not reflect the official policy of the AMA. Scope of Practice Data Series: Nurse practitioners • I. Overview 4 Return to table of contents II. Introduction With the creation of Medicare and Medicaid in 1965, only NP master’s degrees but also the higher compensa- the United States and state governments were caught tion accompanying this added training. As a result, by short in their new missions to provide health care ser- 2000 there were around 88,000 NPs,5 and there are more vices to segments of the population that had previously than 139,000 today.6 been unable to afford or find medical care. Because the many baby boomers who aspired to become physicians1 Several studies conducted after 1990 helped promote were still in college, medical school, residencies or the NPs as a profession. These studies concluded that for armed forces, the country looked to nurses who were routine health problems—such as the treatment of already experienced in patient care to help fill the gaps. colds, flu and earaches, control of high blood pressure, Seasoned registered nurses (RNs) completed additional immunizations, and imparting wellness advice—NPs’ course work and training to become nurse practitioners performance, patient outcomes and patient-satisfaction (NPs), secure state licensure and serve as “primary care rates equaled those of primary care physicians.7 Because providers.” Additional schooling that would make RNs treatments for common problems often entail prescrib- eligible for such advanced practice nursing in the late ing medications, most states now allow NPs broad 1960s involved paths ranging from a four-month uni- prescribing authority—whether for cough medicine versity continuing education program2 to a two-year and antibiotics or HIV medications, opiates and psycho- nursing school master’s program. Eventually, these pro- tropic medications. Moreover, many state regulations fessionals were sanctioned by Medicare to offer—under requiring that NPs be supervised by a physician have physician supervision and, often, written protocols— been amended to permit “collaborative practice agree- general medical and preventive, safety-net care to ments” with physicians, the definitions of which vary people in rural and inner-city areas where physicians enormously from state to state. Eleven states and Wash- were scarce. Each state had the power to determine the ington, D.C., however, do not require collaborative level of prescribing authority and physician supervision agreements with physicians. These states allow NPs to it would require for NPs to practice. autonomously practice and prescribe.8,9 The number of NPs leapt from about 250 in 1970 to Despite this trend, some recent studies have begun rais- 15,400 in 1980,3 and then grew more slowly to 23,600 ing questions about appropriate prescribing by NPs, and in 1992 as physicians filled primary care needs.4 In 1997 even about their basic primary care training. When a the Balanced Budget Act launched Medicare managed six-year study published in 2006 found that rural NPs care, and with it NPs gained authority to bill Medicare were writing more prescriptions than their urban NP for their services anywhere—not just in underserved counterparts, physicians and physician assistants, the areas—and in any practice setting that state laws authors suggested, “This is a phenomenon that bears allowed. What ensued was a surge in nurses seeking not further observation in future studies to investigate 1. In 1961 there were 49,899 medical students, interns and residents, and clinical fellows in the United States, but by 1973 that number was 86,914, and by 1984 it was 127,879. Institute of Medicine, Personnel Needs and Training for Biomedical and Behavioral Research: 1985 Report (1985). 2. Yankauer A, Tripp S, et al. The costs of training and the income generation potential of pediatric nurse practitioners. Pediatrics. 1972;49:878–887. 3. Fairman J. 2001. Delegated by default or negotiated by need? Physicians, nurse practitioners and the process of clinical thinking. Enduring Issues in American Nursing. Baer E, et al (eds). New York: Springer Publishing Co.; p. 327. 4. Institute of Medicine. 1996. Primary care: America’s health in a new era. Donaldson, Molla S., et al. eds. Washington: National Academy Press, p. 159. 5. Blackman A. Is there a Doctor in the house? Wall Street Journal Online, October 11, 2004. Retrieved December 20, 2007. 6. Web. Verispan. Healthcare List Division. Retrieved February 26, 2008. www.ehealthlist.com/sourceselect_New.asp.(Registration required) 7. See, for example: Mundinger M, et al. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association, 283(1), 59–68; Hooker R, McCaig L. Use of physician assistants and nurse practitioners in primary care, 1995–1999. Health Affairs, July–August 2001. 231–238; McCaig L, Hooker R, et al. 1998. Physician assistants and nurse practitioners in hospital outpatient departments, 1993– 1994. Public Health Rep. 1998 Jan–Feb; 113(1): 75–82. 8. Web. National Council of State Boards of Nursing. 2008. Regulation of states boards of nursing. Retrieved March 23, 2008. www.ncsbn.org; Pearson L. The Pearson Report. The American Journal for Nurse Practitioners. February 2008, Vol. 12, No. 2. 9. Some states, however, still require a fair amount of supervision. For example, in Maine, NPs must have a written plan of supervision, and must complete two years of practice under the supervision of a physician. Scope of Practice Data Series: Nurse practitioners • II. Introduction 5 Return to table of contents whether they are managing this role in a safe, effective, warn that the profession is moving too fast. Take, for and responsible manner.”10 In addition, two nursing pro- example, a conclusion drawn by nurse researchers who fessors relaying the results of a 2004 survey of practicing explored how NPs in Washington state adapted to NPs reported that only 10 percent of those surveyed new regulations allowing them in 2001 to prescribe perceived that they were very well prepared for actual Schedule II drugs under joint practice agreements with practice as NPs after completing their basic NP training, physicians, and in 2005 to prescribe those same drugs while a full 51 percent perceived that they were only independently. By 2006, these researchers determined, somewhat or minimally prepared.11 These findings sug- 42 percent of NPs in the state had not applied for U.S. gest that the limited clinical training required for NPs Drug Enforcement Administration endorsement to (it can range from 500 to 720 hours), even with their prescribe these drugs. In fact, the researchers reported prior RN experience, does not provide NPs with an that some of these NPs indicated they did not want the adequate clinical foundation for independent practice. responsibility of having to deal with potentially drug- The clinical experiences of NPs are not comparable to abusing patients. Instead, many of these NPs stated they the two years of inpatient clinical training that medical “wanted additional education about controlled sub- students undergo during their third and fourth years stances to feel more competent with prescribing these of medical school, plus the three years of full-time, medications.”12 As a result, one researcher concluded intensive residency training for physicians in the that “NPs need preparation for a new scope of practice primary care specialties. long before legislation actually passes.”13 What began in the late 1960s as a way to provide basic The time is ripe for legislators, health care policy ana- primary care services and advice to people in regions lysts and nurses to thoroughly assess the quality of NP where physicians were scarce has opened the door for training in relation to the scope-of-practice expansions NPs, with the assistance of various NP advocacy groups, sought at the state level. It is the AMA’s position that to demand that they be allowed to deliver the same patient safety should always be the foremost concern medical care that physicians do—primary and specialty when any health care profession attempts to secure care—albeit under the auspices of advanced practice authority to provide services that may or may not be nursing. Furthermore, nursing schools are now preparing commensurate with its education and training. Impor- for the American Association of Colleges of Nursing’s tant questions to consider while exploring this module 2004 mandate that by 2015, all entry-level advanced include: practice nurses (APNs), including NPs, attain a doctorate • Is the NP educational system currently ensuring that degree, the Doctor of Nursing Practice (DNP). Notably, NPs are adequately trained to provide appropriate the DNP degree is not academic- or research-oriented care for patients? like a PhD degree in nursing, nor is it comparable to a Doctor of Medicine (MD) or a Doctor of Osteopathy • Are NPs being granted scopes of practice for which (DO) in its didactic or clinical content quality or rigor. they are not adequately prepared? Nonetheless, the DNP graduate, prepared for clinical • Why is there not—as there is for physicians—a single practice (unlike the scholarly PhD in nursing), may national exam that would evaluate all NP graduates’ conceivably introduce himself or herself as “doctor” in competency to provide patient care? the health care setting, where patients may be confused as to a provider’s credentials. • Are nursing education resources being spent wisely in light of the nursing shortage that has already affected NP advocacy organizations continue to lobby for imme- many regions in the United States? There are too diate scope-of-practice expansions and development few nurses with graduate-level degrees to teach the of DNP programs, even while some APN advocates increasing number of baccalaureate RN candidates 10. Cipher D, Hooker R. Prescribing trends by nurse practitioners and physician assistants in the United States. Journal of the American Academy of Nurse Practi- tioners. June 2006, Vol. 18, No. 6, p. 6. 11. Hart A, Macnee C. “How well are nurse practitioners prepared for practice: results of a 2004 questionnaire study.” Journal of the American Academy of Nurse Practitioners. 2007, Vol. 19, No. 1, p. 37. 12. Kaplan L and Brown MA. The transition of nurse practitioners to changes in prescriptive authority. Journal of Nursing Scholarship. June 2007, Vol. 39, No. 2, p. 187. 13. Id. p. 190. Scope of Practice Data Series: Nurse practitioners • II. Introduction 6 Return to table of contents that hospitals will require to properly care for our certification of NPs with respect to the advanced prac- aging population.14 (In fact, 30,000 qualified candi- tice nursing care they currently provide, including the dates for Bachelor of Science degrees in nursing are independent delivery of such care, is the surest way to turned away each year.15) Some NP programs recruit assess whether patients receive the quality of care they nursing students before they gain RN experience, thus deserve from NPs. siphoning off staff power that might go to hospitals. At the same time, graduate-level NP programs are We hope the information contained in this module will struggling to fill faculty slots and to find appropriate provide the tools necessary to allow physicians to pres- clinical training sites for their students. ent relevant facts in response to NPs’ efforts to increase their scope of practice. The AMA stands ready to assist • How do NPs help alleviate the nursing shortage? state medical societies and national medical specialty societies in their efforts to protect the health and safety State laws differ greatly from one another in terms of patients. By focusing the resources of organized medi- of NPs’ scopes of practice. This variation reflects the cine, we can protect patient safety and preserve the widespread and decades-long confusion about what highest quality of care for our patients. exactly an NP is and does. The following information on current NP education, certification and credential- Advocacy Resource Center ing illustrates the reasons for this confusion. Careful American Medical Association consideration on the education, training, licensing and AMA Scope of Practice Data Series module distribution policy The modules are advocacy tools used to educate legislators, regulatory bodies and other governmental decision- makers on the education and training of physician and nonphysician health care providers. As such, the AMA will distribute the modules to the following parties: (1) State medical associations (2) State medical boards (3) National medical specialty societies (4) National medical organizations In line with the express purpose of the modules being governmentally directed advocacy, it will not be the policy of the AMA to provide the modules to individual physicians. Organizations supplied with the module shall mirror the intent, purpose and standards of the AMA distribution guidelines. 14. Dozens of newspaper stories have focused on this issue, including Medical News Today. Pennsylvania Mobilizes In Response To Nursing Shortage Crisis. March.14, 2008. Retrieved March 28, 2008 from www.medicalnewstoday.com; Solomont, EB. Labor Strife Hits Hospitals Amid Nursing Shortage. New York Sun. February 27, 2008. Retrieved March 28, 2008 from www2.nysun.com; Adams, LT. Fixing state’s nursing shortage requires creative partnerships. Detroit News, Feb. 6, 2008. Retrieved March 28, 2008 from www.detnews.com. 15. Web. American Association of Colleges of Nursing. Press release, December 3, 2007. www.aacn.org. Retrieved March 28, 2008. Scope of Practice Data Series: Nurse practitioners • II. Introduction 7 Return to table of contents III. Nurse practitioner profession Definition(s) practitioner (NP), certified nurse-midwife (CNM), certified registered nurse anesthetist (CRNA) or clinical A nurse practitioner (NP) is a licensed registered nurse nurse specialist (CNS).19 State regulations may require (RN) who has advanced nursing credentials (demon- that an APN obtain a master’s degree or may place strated through formal education and/or training). Most other requirements on candidates for APN licensure. states now specify in their nursing practice acts that NPs must obtain a master’s degree in nursing to be authorized for advanced practice nursing in their state. General duties and responsibilities Some states, however, require only such advanced Nurse practitioners conduct physical exams; diagnose training as a post-basic program certificate in a clinical and treat common acute illnesses and injuries; provide nursing specialty or a certificate program. (See Figure 1.) immunizations; order and interpret X-rays and other lab tests; and counsel patients on adopting healthy Official definitions of “nurse practitioner” consistently lifestyles.20 Other duties and responsibilities depend state that NPs receive training beyond that of an RN, on the NP’s practice setting and the scope-of-practice but otherwise the definitions diverge with regard to regulations of the state in which the NP holds a license. NP duties and/or responsibilities. The California Board of Registered Nursing, for example, states, “The nurse NP organizations frequently extol NPs’ holistic practitioner is a registered nurse who possesses additional approach to treating patients, as evidenced by an preparation and skills in physical diagnosis, psychosocial AANP “frequently asked questions” document for assessment, and management of health and illness needs patients, which reads, “NPs have distinguished them- in primary health care.”16 In another example, the U.S. selves from other health care providers by focusing on Department of Health and Human Services defines NPs the whole person when treating specific health prob- as RNs who have advanced academic and clinical expe- lems and educating their patients on the effects those rience that enables them to diagnose and manage acute, problems will have on them, their loved ones, and their episodic and chronic illnesses.17 The American Asso- communities.”21 The provocative implication made by ciation of Nurse Practitioners (AANP), a professional the AANP is that other health providers, including organization representing NPs, defines NPs as advanced physicians, not only fail to treat the “whole” person practice nurses who “provide high-quality health care but also neglect to counsel their patients on the issues services similar to those of a doctor” (albeit, without pertinent to their specific health conditions. a doctor’s education and training) and who “diagnose and treat a wide range of health problems. They have a Two NP professors who authored an opinion piece in unique approach and stress both care and cure.”18 the first issue of the Journal of the Academy of Nurse Practitioners in 1989 wrote that the NPs’ ultimate goal An advanced practice nurse (APN) is typically defined is “serving as the principal providers of primary care.”22 as an RN who has a current license to practice profes- Articles in NP journals and literature of NP associations sional nursing in a state, and maintains certification continue to regularly present the profession as dedicated from a national nursing certifying body as a nurse to primary care for underserved populations, with an emphasis on disease prevention, health care counseling, case management and community health. 16. Web. California Board of Registered Nursing. The certified nurse practitioner. Retrieved March 25, 2008. www.rn.ca.gov/pdfs/regulations/npr-b-23.pdf. 17. Web. The Health Resources and Services Administration, U.S. Department of Health and Human Services. www.bhpr.hrsa.gov/healthworkforce/reports/nursing/ changeinpractice/chapter4.htm. Retrieved November 30, 2007. 18. Web. American Academy of Nurse Practitioner (AANP). Find a nurse practitioner/what is a nurse practitioner. Retrieved November 30, 2007. www.aanp.org. 19. See, for example, State of Wisconsin. Department of Regulation and Licensing. Advanced Practice Nurse Prescriber page. http://drl.wi.gov/prof/nura/def.htm. Retrieved June 2, 2008. 20. Web. American Association of Colleges of Nursing. www.aacn.nche.edu/Education/nurse_ed/career.htm. Retrieved December 17, 2007. 21. Web. American Academy of Nurse Practitioners (AANP). http://npfinder.com/faq.pdf. Retrieved December 31, 2007. 22. Martin E, et al. Nurse practitioner political strength through union. Journal of the Academy of Nurse Practitioners. January 1989,Vol. I, No.1, p. 2. Scope of Practice Data Series: Nurse practitioners • III. Nurse practitioner profession 8 Return to table of contents Nonetheless, specialization, rather than primary care, The authors reply: is fast becoming an NP practice trend. Some NPs are The answer is no. The acute care NP program practicing as first surgical assistants or palliative care prepares graduates for a specialty focus in acute, providers, while others have obtained certification as episodic, and critical conditions that are primarily specialists in cancer or cardiovascular diseases. A cardio- managed in a hospital-based setting. The program vascular NP might simply work in a cardiologist’s office, of study does not contain adequate clinical and helping the physician with follow-up care, such as blood didactic content to support the [acute care] NP for pressure checks and advising patients on healthy life- a broader role in outpatient primary care diagnosis, styles. Other NPs, however, might press their specialist treatment, and follow-up. Diagnosis and outpatient certification deep into what patients may reasonably management of stable and unstable chronic illness, assume is a physician’s realm. For example, an oncology as well as directing health maintenance of a wide NP who authored an article in Community Oncology, range of conditions, is a required competency for a journal directed to outpatient cancer-care providers, practice in the primary care role.24,25 claimed having near-equal expertise as the physician she worked for. She wrote that she introduces herself Oftentimes, scope-of-practice expansions are spearheaded to patients as a “practice partner” and advises her NP by national NP professional organizations, even while colleagues in oncology practices on how to handle “dif- some practicing NPs recognize that they may be inad- ficult patients,” namely those who say that they really equately prepared for these new expansions. Two Uni- want to see their physician.23 There is some irony to the versity of Wyoming nursing professors summarized the notion that a health care professional would discour- surge of NPs and other APNs into greater and greater age cancer patients—who would view their situations, responsibility in medicine as follows: “Blurred boundaries rather than themselves, as difficult—from meeting with and ‘disruptive innovation’ have always been hallmarks their oncologist. After all, it is the oncologist, with 10 of APN practice and identity. The historical roots of or more years of medical school, residency and fellow- NP role development are replete with evidence of push- ship education, as well as annual continuing medical ing the envelope of accepted practice and consistent education requirements far greater than those of NPs, attempts to expand roles as the potential benefits who has the medical expertise cancer patients expect. of APN practice became apparent.”26 In contrast to this oncology NP, many in the NP profes- “Blurred boundaries” is the term that doctors, nurses sion appropriately caution one another on the limits of and government regulators often resort to in trying to their NP specialty education and training. Consider a identify the differences in practice competencies and 2005 Topics in Advance Practice Nursing eJournal article authority between NPs and physicians, and between on NP scope of practice, which NPs can access online primary care NPs and specialty NPs. Unfortunately, it for professional continuing education credit. Part of appears that some NP advocates may purposefully pro- a question-and-answer section presents the question, mote blurred boundaries between NPs and physicians. “Should an NP who is educationally prepared as an For example, the Oncology Nursing Society’s most acute care NP work in an adult primary care setting?” recent Statement on the Scope and Standards of Advanced Practice Nursing in Oncology makes no mention of the word physician or oncologist within its 22 pages. Instead, it frequently reduces the importance of the physician by referring to NPs working “in collaboration with other members of the health care team.”27 23. Young T. Utilizing oncology nurse practitioners: A Model Strategy, Community Oncology, May/June 2005, Vol. II, No. 3. 24. Klein T. Scope of practice and the nurse practitioner: regulation, competency, expansion, and evolution. Medscape. Topics in Advanced Practice Nursing eJournal. 2007;7(3). Retrieved December 13, 2007. 25. In contrast, an acute care physician, hospitalist or emergency medicine physician would be well prepared from his or her medical school education and internal medicine residency training to assume a primary care practice position. 26. McCabe S, Burnam M. A tale of two APNs: addressing blurred practice boundaries in APN Practice. Perspectives in Psychiatric Care. February 2006, Vol. 42, No. 1. 27. Oncology Nursing Society. 2003. Statement on the scope and standards of advanced practice nursing in oncology, 3rd Ed. p. 12. Scope of Practice Data Series: Nurse practitioners • III. Nurse practitioner profession 9 Return to table of contents Most states now allow NPs fairly broad prescribing associations and U.S. government agencies as “primary authority. (See Figure 2.) Despite this broad authority, care.” These primary care specialties were among the early questions are arising in the nursing and medical com- specialty tracks offered by nursing school NP programs.32 munities about NPs’ prescribing patterns. A study on antibiotic prescribing published in the American Journal From the 1970s onward, NPs gradually began to take of Medicine in 2005 found that non-physician clinicians on specialties beyond those classified as primary care were more likely to prescribe antibiotics than were specialties. The Oncology Nursing Society, for example, practicing physicians (26.3 percent and 16.2 percent, was founded in 1975 for RNs working in cancer wards. respectively) in outpatient settings.28 Another study In 1990 it published its first edition of Standards for suggested that many NPs had not received enough edu- Advanced Practice in Oncology Nursing and began to cer- cation in microbiology,29 knowledge integral to effective tify NPs who wanted specialty recognition as advanced treatment for bacterial, fungal as well as viral disease. oncology certified nurses (AOCN®).33 Advanced prac- And mentioned earlier in this document was the study tice in nephrology nursing was also a practice option questioning why rural NPs wrote more prescriptions for NPs by the mid-1990s. The American Nephrology than their urban counterparts.30 Nurses Association published an advanced practice scope-and-standards book in 1999,34 and the American Nurses Association (ANA) approved the nephrology Specialization NP specialty designation in 2005.35 An NP specializes in a certain practice area by complet- ing a master’s degree in nursing with a focus, or major, Today NPs specialize in such areas as acute care pediatrics, in that specialty, and subsequently sitting for a certifica- cardiology, critical care, diabetes management, dermatol- tion examination in that specialty. Notably, NPs who ogy, emergency medicine, home health, holistic nursing, have already obtained master’s degrees in nursing may gastroenterology, long-term care, neonatology, nephrol- qualify for certain specialty certification exams by sim- ogy, neuroscience, occupational health, oncology, psy- ply obtaining a post-master’s certificate in that specialty. chiatrics and mental health, school health, surgery, and The post-master’s certificate recognizes the master’s- wound, ostomy and continence care.36 Despite this list, level content of formal education previously obtained the American Board of Nursing Specialties (ABNS), by the NP, and supplements it only with specialty which was founded in 1991 “to create uniformity in content and any core courses required by the specialty nursing certification and to increase public awareness certification organization’s accrediting standards. of the value of certification,”37 recognizes only the fol- lowing NP titles: The U.S. Department of Labor’s Bureau of Labor Statistics • Acute care nurse practitioner determined that for 2006–2007, NPs most commonly • Adult nurse practitioner specialized in family practice, adult practice, women’s • Family nurse practitioner health, pediatrics, acute care and gerontology.31 Except • Gerontological nurse practitioner for acute care, these specialties are classified by NP • Pediatric nurse practitioner 28. Roumie C. and Halasa N. Differences in antibiotic prescribing among residents, physicians and non-physician clinicians. American Journal of Medicine. June 2005, Vol. 118, No. 6, pp. 641–648. 29. Sym D. et al. Characteristics of nurse practitioner curricula in the United States related to antimicrobial prescribing and resistance. Journal of the American Academy of Nurse Practitioners. September 2007, Vol. 19, No. 9, p. 477–485. 30. Cipher D. and Hooker R. Prescribing trends by nurse practitioners and physician assistants in the United States. Journal of the American Academy of Nurse Practitioners. June 2006, Vol. 18, No. 6, p. 6. 31. Web. U.S. Department of Labor. Bureau of Labor Statistics. Occupational outlook handbook 2006–2007 edition. www.stats.bls.gov/oco/ocos083.htm. Retrieved December 7, 2007. 32. Web. AANP. Announcement (2008). NP primary care competencies in specialty areas: adult, family, gerontological, pediatric and women’s health. This announcement refers to a collaboration of AANP, HHS, HRSA, NONPF and AACN. www.aanp.org. 33. Oncology Nursing Society. 2003. Statement on the scope and standards of advanced practice nursing in oncology, 3rd ed. 34. Web. Larson J. New nephrology advanced practice guidelines released. Nursing News, March 29, 2002. Retrieved March 25, 2008. 35. VanBuskirk S. The American Nurses Association designates nephrology nursing as a recognized nursing specialty! Nephrology Nursing Journal, Nov–Dec 2005, 589. 36. Approved specialties are cited on the Web sites of the AANP and American Board of Nursing Specialty (ABNS). See www.aanp.org and www.nursingcertification.org. 37. Web. American Board of Nursing Specialties (ABNS). Fact Sheet (2004). www.nursingcertification.org. Retrieved March 25, 2008. Scope of Practice Data Series: Nurse practitioners • III. Nurse practitioner profession 10