Role of Nurse Practitioners (NP) in primary health care and the rationale for formal graduate education
Continuous shortage of primary care physicians prompted the development of nurse practitioners (NPs) as an alternative strategy to increase access to primary health care. Standardization of preparation, certification, and licensing of advanced nurses began only recently because state legislatures mandated safeguarding the public from unsafe practices. Rapid advancements in the healthcare system and demand for quality of care offer exciting career prospects and challenges to advanced nurse practitioners (ANPs), and graduate education grooms ANPs to become efficient managers and effective healthcare providers. There is increased world attention to the contributions of nurse practitioners, but it is argued that cost-benefit effectiveness and tangible and intangible benefits of advanced nurse practice education are not percolating to nurse practitioners.
A “registered professional nurse with advanced education and clinical training to provide health care to individuals across the lifespan and their families”, and who is “an expert health care provider who practices under the rules and regulations of Nursing Practice Act” may be classified as a Family Nurse practitioner (FNP). (Family nurse practitioner (FNP), 2007). American Association of Colleges of Nursing (AACN) broadly defines the advanced nursing practice as: “any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy.” (The essential of doctoral education for advanced nursing practice, 2006, p. 4).
The professional role of the nurse practitioner, according to ‘the American Academy of Nurse Practitioners,’ is described as “a provider of nursing and medical services to individuals, families, and groups; a manager of acute and chronic illnesses; and a promoter of health and disease prevention in ambulatory, acute, and long-term care settings.” (Shams, 2006).
Advanced practice nurses (APNs) “denotes nurses with formal post-baccalaureate preparation in one of four roles: nurse midwives, nurse anesthetists, nurse practitioners, and clinical nurse specialists” (Zwygart-Stauffacher & Mirr, 2005) American Nurses Association (ANA) defines advanced practice nurses (APNs) as “having advanced specialized clinical knowledge and skills through masters or doctoral education that prepares them for specialization, expansion, and advancement of practice. The nurse practitioners are expected to “assess health status, diagnose, develop and implement treatment plans, and follow up on and evaluates patient status” (Shams, 2006). Advanced nursing pathway (ANP) is a career pathway in nursing, and it describes an “advanced level of nursing practice that maximizes the use of in-depth nursing knowledge and skill in meeting the health needs of clients.” (MacDonald, Schreiber & Davis, 2005, p. 1).
Development of nurse practitioners (NPs)
Continuous shortage of primary care physicians prompted the development of nurse practitioners (NPs) as an alternative strategy to increase access to primary health care and the “first successful program to prepare NPs was developed at the University of Colorado in 1965 under the co-direction of a nurse, Loretta Ford, and a physician, Henry Silver” (Sherwood et al, 1997). “Anticipated and actual shortages of primary care physicians have led policymakers to consider the role of nurse practitioners (NPs) in improving access to primary health care services.” (Nurse practitioners in primary care, 2009).
The nurse practitioner role in the United States was established in 1965, and the MSN degree became the required degree for NP certification in the 1980s. In response to the clarion call of the Institute of Medicine (IOM) in 2003 for “increased preparation for health care professionals in general” the American Association of Colleges of Nursing (AACN) recommended that “all nurses seeking to be credentialed as nurse practitioners earn a doctorate of nursing science (DNS) degree. The phase-in date is 2015.” (Nurse Practitioners, 2009). The recommendation that nurses practicing at the highest level should receive doctoral-level preparation emerged from multiple factors including the “expansion of scientific knowledge required for safe nursing practice and growing concerns regarding the quality of patient care delivery and outcomes.” (The essential of doctoral education for advanced nursing practice, 2006).
Educational requirement of NPs
Educational requirements of nurse practitioners in the United States are:
- Four years of college with a B.Sc in nursing or related field; and
- approximately two years of graduate school to obtain a master’s degree as a nurse practitioner
A registered nurse who has undertaken a specific advanced nursing education of honors-level study can assume the role of an advanced nurse practitioner. Nurse practitioner education is envisaged to “prepare graduates to provide safe, high quality, cost-effective, coordinated, and comprehensive clinical care grounded in evidence-based practice. Strategies of care include support for individuals and groups, decision-making related to personal health, mobilization of resources, therapeutics (pharmacologic/ nonpharmacologic), health education and counseling, coordination of services, and evaluation of treatment outcomes.” (Nurse practitioner DNP education, certification and titling: A unified statement, (n.d)).
It is presumed that the DNP degree is compatible with the changing health care system that trains nurse practitioners clinically more competent. The professional knowledge and skills of nurse practitioners are evaluated through certification. On successful completion of a specific course of study an individual is accredited with PhD, DNSc, or DNP, and the certification examinations test the professional competencies of handling the role as an advanced nurse practitioner that is evaluated “through rigorous and psychometrically sound examination processes.” (Nurse practitioner DNP education, certification, and titling: A unified statement, (n.d)). Even though criticism abounds about the nature and extent of training of physicians and NPs and the scope of their practice, the American college of physicians acknowledges that “NPs are health care professionals with the capability to provide important and critical access to primary care.” (Nurse Practitioners, 2009).
Role of advanced nurse practitioners in primary health care
There is increased world attention to the contributions of nurse practitioners and recent findings by the International Council of Nurses (ICN) confirm that “nurse practitioners provide quality health services in a range of settings.” (Role of the nurse practitioners around the world, n.d). Universally accepted common characteristics of nurse practitioners are educational preparation at an advanced level; legislative recognition with licensure, registration certification, and credentialing; scope of practice for prescribing medication, treatment, referral to other professionals, and authority for hospital admission; and to function as a point of contact for clients, case management, diagnostic care, treatment care, preventive care, and palliative care.
Various studies conducted in the U.S indicate that the number of nurse practitioners increased from 30,000 to 65,000 over the past 10 years; about 85 percent work in ambulatory settings and the majority are in primary care; nurse practitioners are projected to double more than 100,000 by 2005 despite the emerging shortage of nurses, and nurse practitioners have presence in 50 states. (Role of the nurse practitioners around the world, (n.d).
A trained NP is expected to possess capabilities equivalent to that of a primary care physician. NPs can diagnose and treat common acute illnesses and injuries, manage general maladies and chronic problems, prescribe drugs, order and interpret clinical and laboratory tests, and guide patients on disease prevention. The role and responsibilities of physician assistants (PAs) are akin to NPs and their services are interchangeable, though there is a difference in educational standards. “PAs are mostly graduates of two-year medical training programs” and are not nurses. (Dueker, Michael J et al, 2005, p. 4). Physician assistants generally work in the family practice which is in the primary care area, whereas NPs are more specialized in primary health care delivery.
Quality nursing care and barriers to the competent workforce
Statistics show that the U.S public health workforce, which is to provide essential public health services to communities, consists of “approximately 500,000 individuals” and nurses comprise 89% of the workforce. (CDC/ATSDR strategic plan for public health workforce development, (n.d), p. 3). Key environmental factors that contribute to quality nursing care identified by Kramer and Schmalenberg (2001, cited by Doloresco, 2004) are: “working with other nurses who are clinically competent; good nurse-physician relationships and communication; nurse autonomy and accountability; supportive nurse manager-supervisor; control over nursing practice and practice environment; adequate nurse staffing; and concern for patient.” (Doloresco, 2004). Among these eight factors ‘competent co-workers’ is considered as the most influencing factor for job satisfaction among nurses, and only through advanced knowledge and skills, it will be possible to develop competence.
The Task Force Report (n.d)on public health workforce development opines that “The public health workforce needs a well-rounded realm of knowledge, skills, and abilities in response to the expanding scope and functions of public health practice” and “a competent workforce capable of performing the essential services are necessary for long-term success” (p.3). Whereas, it is pointed out that a majority of public health workers are untrained to handle the future challenges the gap between ‘current capabilities and future needs continues to widen.’ The Task Force Report (n.d) highlights that the public health workforce is unevenly trained in the basic tenets of public health and the “recent estimates of the gap range from 66% to 93% depending upon the scope of the study.”
Many major barriers to achieving a competent 21st-century public health workforce have been identified by Task Force. Among other things, it is pointed out that: “significant gaps still exist in the availability/accessibility of needed job-related training and continuing education; an integrated delivery system for life-long learning does not exist; inadequate incentives and nonexistence of national competency standards for public health workers obstruct training and continuing education” (Task Force, n.d). However, the Canadian Nurses Association acclaims that a consensus exists in the United States regarding advanced practice and educational requirement for nurse practitioner(NP) role, as NP preparation in the U.S is at the graduate level and “all NP programs in the US now culminate in a master’s degree” (Canadian Nurses Association, 2005, p.1). The health profession education programs under Title VII and VIII of the Public Health Services Act, which is supporting the training and education needs of health care providers in the U.S have to be acclaimed for this success.
Financial allocation for improving health professional’s education in the U.S
Health professions education programs are the only federal program designed to train and educate health care providers authorized under Titles VII and VIII of the Public Health Services Act administered through the Health Resources and Services Administration (HRSA). The Title VII and VIII health professions and nursing programs support the training and education of health care providers to enhance the supply, diversity, and distribution of the health care workforce so that the gap in the supply chain of health care providers is filled. The provisions under Title VII and VIII programs provide “loans, loan guarantees, and scholarships to students, and grants and contracts to academic institutions and non-profit organizations” to “train providers in interdisciplinary settings to meet the needs of special and underserved population, as well as increase minority representation in the health care workforce” (Cheng, 2009). Among the seven major program categories of the Health Professions Education Partnership Act of 1998, the Nursing Workforce Development programs under Title VIII provide training for entry-level and advanced degree nurses to improve the access to, and quality of, health care in underserved areas. During FY 2008 funding and programmatic support were given to 51,667 nursing students and nurses for pursuing nursing education. It implies that adequate financial provisions are made for continuing education of nurses in the US.
Cost-benefit analysis of graduate nursing education
Return on investment in education extends over a lifetime, and “an individual will invest in his or her human capital … as long as the marginal gain from that investment exceeds its added cost.” (Jimenez & Patrinos, 2008). Since investment in education has implications for development economics, a cost-benefit analysis (CBA) is a well-established tool in deciding the amount and type of investment in education. Jimenez & Patrinos (2008) argue that “the private benefit (B) of investing in another year of education is the gain in earnings for the rest of a person’s working life. The private cost (C) will include any fees or direct costs that the individual pays plus the opportunity cost in terms of foregone income. The net present value (NPV) is the difference between discounted values of the net present streams of benefits and costs.” To understand the relationship between costs and benefits of graduate nurse practice education it is essential to narrate the nature of economic costs.
Studies indicate that there was no improvement in nursing wages since 1992, as registered nurses (RNs) “saw no increase in the purchasing power of their annual earnings” after adjustment for inflation (Harrington, 2004, p.206). It is also reported that “wages of RNs who did not seek additional education or promotion to higher positions received wages that rose at decreasing rates with experience; wages paid to hospital staff nurses who graduated twenty years earlier were only 10% higher than wages paid to those who came into nursing ten years later.” (Harrington, 2004). It has to be construed that there were less job flexibility and career advancement opportunities for RNs and the best alternative for salary gains is to pursue higher education.
Based on the 2005 National Sample Survey of Nurse Practitioners, analysts observe that nurse practitioners are getting paid closer to their worth as “the average annual full-time salary has reached $74,812” with an 8.1% increase over the past two year average, and average part-time wage increased “by 8.6%, to $ 36.80 an hour.” (Tumolo & Rollet, 2005). On review of median salary by years concerning the experience of nurse practitioners (NPs) in the United States the marginal increase during the first year of enrolment and 1-4 years, as well as next 5-9 years is around $3,000 each. Based on employer type for salary structure, private practice earning is lower ($71,525) compared to earning from hospitals ($74,412) and government ($75,805). On state-wise comparison it may be seen that highest median salary is paid in New York ($86,751). (Salary survey report for job: Family nurse practitioner (NP), n.d). While making a cost-benefit analysis of earnings by NPs the total cost of tuition fees and other overhead expenses to become a qualified NP is estimated at approximately $11,264. On analyzing the median salary of FNP and RN during the first year of enrolment it may be seen that the difference in their earning is $21,451. Admitting that it takes two years or more to become an FNP, on simple arithmetic terms it may be seen that return on investment is available for NPs within less than a year of becoming a licensed nurse practitioner
Data from national salary surveys show that as compared to those professionals with master’s degrees nurse practitioners are earning comfortably. Earning of the individual is dependent on his or her efficiency and the needs of stakeholders, and there may be some nonmonetary factors that may generate indirect revenue, which is generally not accounted for as earning. Even though some NPs may feel that they are not getting paid adequately in tune with their hard-earned qualification and expertise as compared to RNs they may be ignorant of the worth of their autonomy and tangible and intangible advantages of working in an advanced role.
Barriers to tangible and intangible benefits of graduate nursing education
Like every human nurse practitioners also expect tangible and intangible rewards, besides salary and incentives. While considering the tangible and intangible benefits of graduate nurse education it has to be construed that intangible benefits overpower tangible benefits because the outcomes of nursing practice are beyond estimation. It is well established that in the case of aged and chronic health care scenarios NPs can support the patients as well as families to adopt the best strategies for self-management in their daily life and contribute to maintaining continuity of care, which the physicians may not be able to sustain. The reason is that generally nurses act as intermediaries between physicians and patients and their family members and have more affinity than physicians, who are held in high admiration by patients and their families. Contributions of appropriately trained NPs in primary and ambulatory health care are found to produce high-quality health outcomes for patients and patient satisfaction. In the case of patient-oriented outcomes studies, it is shown that nurse practitioner-led in-patient units are better prepared for discharge. These performance outcomes are not measurable and only appreciations and acknowledgments of good work done by NPs will help boost their morale.
However, increased workload, lower pay and remunerations, and reduced work satisfaction is found to promote dissatisfaction among NPs. In addition, the productivity of the available nurse workforce is obstructed by inefficient human resource management that exacerbates the problem. The absence of a healthy and stable working environment emanating from inefficient human resource management is considered as the main problem in growing nurse dissatisfaction. Lack of respect, both personal and professional, “by physicians who are abusive and pay scant heed to what nurses think, administrators who control nurses’ lives but know little about patient care, financial managers who cut budgets at the expense of patient care, patients who are violent against nurses” and a feeling of being undervalued make nurses more frustrated (Health care system 2004). In these circumstances, intangible benefits act as intermediaries and help defuse tension. Intangible rewards include acknowledgment and appreciation of their work, status and identity, a sense of belonging, emotional reward, and trust and reciprocity from their employers and society where they perform their duty. Non-monetary compensations, such as time off, income incentives, and sign-on bonuses are found to reduce the dissatisfaction of nurse practitioners.
Nurse practitioners still seek recognition both within and outside nursing, even though NP practice “have progressed toward more independent clinical decision making” (Phillips et al, 2002). Research evidence suggests that there is continued conflict between physicians and nurse practitioners because the effort of NPs to expand ‘practice autonomy and get independent reimbursement’ is controlled by physicians “through mandatory supervisory relationships, keeping responsibility for patients, and limiting direct reimbursement of NPs” (Phillip et al). Limited prescribing rights and ‘variability in scope of practice’ are other contentious areas in NP practice.
However, ‘policy collaborations’ and ‘interprofessional efforts’ have provided more autonomy to nurse practitioners and increased collaboration between physicians and NPs. State practice laws for NPs also provided avenues for NPs to move away from physician supervision and protocols and the “Balance Budget Act (BBA), of 1997” enabled NPs in all settings “eligible for direct Medicare reimbursement at 85 percent of the physician are when they collaborate with physicians” (Phillips et al). Research evidence suggests that “nurse practitioners offer an appropriate solution to the difficulties doctors face in providing high-quality services to their patient population.” (Wilson, Pearson, & Hassey, 2008).
Limited studies conducted to assess the effectiveness of collaboration between physicians and NPs show that there is improved patient satisfaction and outcomes, and cost and quality-of-care improvements in different settings. (Phillips, et al 2002). suggests that ‘evolution of NP autonomy’ and innovations in health care, along with the collaboration of physicians, NP organizations, and other health care professions will ‘reinvigorate public trust and strengthen the roles of both NPs and physicians as patient advocates.”
Since there are web-based classes and a multitude of institutions are introducing graduate nurse practitioner and DNP programs it will not be a burden for the enthusiastic RNs to pursue higher studies and fructify career advancement dreams. In addition, Nursing Workforce Development programs under Title VIII provide training for entry-level and advanced degree nurses to improve the access to, and quality of, health care in underserved areas. Federal programs providing financial support for pursuing higher studies is a boon for talented and hard-working nurse practitioners and their investment in education will be more economical in their long earning careers. Master’s and higher degree nurse practitioner programs, based on scientific knowledge across disciplines and best-evidenced practices, prepare nurse practitioners capable of providing quality primary and specialty care to diverse patient populations and empower nurse practitioners to be fully accountable for the services provided by them. The transition of a registered nurse to the role of Family Nurse Practitioner transcends knowledge and ability in health promotion, diagnosis, and management of common illnesses in primary health care that is supported with theoretical and research-based advanced nursing practices.
- CDC/ATSDR strategic plan for public health workforce development. (n.d), p. 3.
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