The Future Role of Advanced Practice Nurses in Primary Care in the United States

by Sandra Haas Binford, MAEd and
Danielle L. Vazquez, MS

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Summary of the 2011 Institute of Medicine Report on Nursing

Four main points presented in the 2011 Institute of Medicine report brief entitled The Future of Nursing: Leading Change, Advancing Health are discussed here. Nurses comprise the largest portion of health care professionals in the United States, with more than 3 million members. Their numbers highlight the prime candidacy for nurses to help match the goals laid out in the 2010 Affordable Care Act, which will introduce millions of Americans into the existing health care system.(1) Nevertheless, the Institute of Medicine highlights four major barriers preventing nurses from addressing this deficiency of adequate numbers of health care professionals as effectively and efficiently as possible: 1) current legislation; 2) educational opportunities; 3) leadership development; and 4) the need for an improved information infrastructure.(2)

1. Current Legislation. More than 250,000 nurses have both passed the national certification exam and attained either master's or doctoral degrees, thereby qualifying as advanced practice registered nurses (APRNs). However, because rules governing licensing and scope of practice vary by state, the activities that APRNs may perform in practice are limited not by education level or training, but rather by geography. The IOM report recommends that states revise legislation so that APRNs may practice in a manner appropriate to their education and experience, and notes that the federal government "is particularly well suited to promote reform […] by sharing and providing incentives for the adoption of best practices."(2)
2. Educational Opportunities. The nurse's role and responsibilities continue to expand in today's health care system, with requisite competencies ranging from research and evidence-based practice to coordinating multidisciplinary health care teams. In light of this expansion, the IOM report recommends that the current nursing education system be improved, and that all nurses achieve higher levels of education and training "to ensure the delivery of safe, patient-centered care across settings." Specifically, the IOM recommends redesigning education so that nurses can seamlessly transition from regular nursing programs into programs conferring higher-level degrees. Furthermore, nurses should be taught alongside other health care professionals, including physicians, as both students and practitioners.(2)
3. Leadership Development. Nurses must increase their participation in ongoing efforts to redesign the health care system in the United States and become full partners with other professionals. To accomplish this, the IOM recommends that nurses serve on advisory boards responsible for policy decision-making. Nurses must also take "responsibility for identifying problems and areas of system waste, devising and implementing improvement plans, tracking improvement over time, and making necessary adjustments to realize established goals." However, in order for this to happen, nurses must be supported by their institutions and given the authority to supervise and initiate change. A complete nurse's education must also foster leadership capabilities, and nurses at all levels need to have access to leadership development and mentoring programs.(2)
4. Improved Information Infrastructure. The IOM report notes that in order to address the previous three barriers—and, more broadly, the mandates set by the 2010 Affordable Care Act—an improved system of data collection and analysis must be put in place. This point and the others above echo the 2003 IOM report, Health Professions Education: A Bridge to Quality, which states, "All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics."(3) Only after accurate data on the numbers and types of health care professionals in the United States have been acquired can the future demands of the health care system be gauged(2) and the value of nurses be adequately evaluated as assets in the struggle to reduce the shortage of health care professionals.

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Debate on Nursing Education and Precise Scope of Practice Roles

The National Public Radio program Talk of the Nation (TOTN) assembled an expert panel to discuss the appropriateness and value of graduate education for nurses(1): Rosa Gonzalez-Guarda, PhD, MPH, RN, Assistant Professor at the University of Miami School of Nursing and Health Studies; JoAnn Trybulski, PhD, APRN, BC, Associate Dean of the Master's and Doctor of Nursing Practice Programs at the University of Miami's School of Nursing and Health Studies; and J. Fred Ralston, Jr., MD, MACP, President of the American College of Physicians. Dr. Gonzalez-Guarda also served as a member of the IOM committee who issued the report discussed above.(1)

Program discussion developed around six main themes, which are discussed below: 1) graduate education needs and access for nurses; 2) practical education of nurses; 3) licensure and scope of practice differences among states; 4) prescribing practices; 5) public and professional views on the APN's role; 6) team-based education and care.

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Does an Advanced Degree Improve Nursing Knowledge and Skill?

Graduate Education
According to the panel discussion, the relatively new "Doctor of Nursing Practice" (DNP) degree may become a future requirement of nurse practitioners.(1) A TOTN caller from Oregon named "Susan" commented that care from nurse practitioners leads to positive outcomes for patients and responds to increasing demands from patients, and stated that the "IOM is on the right track."(1)

Another TOTN caller named "Katie" said that the graduate education and degree will take the nursing profession forward and will benefit future patient care, but that the access to courses is limited because of the scarcity of programs. She noted that it was very difficult to find a school that offered both the advanced degrees and the flexibility needed for working nurses to enroll. The expert panel responded that many programs are beginning to offer innovative course times, including weekend, executive-style, and intensive sessions, to allow nurses to complete necessary coursework.(1) The IOM report calls for streamlining of the current educational process so that LPNs can become RNs, and so forth,(1,2) but is achieving this simply a matter of offering programs with more built-in flexibility? The TOTN panel did not directly address the number of accredited programs, but the American Association of Colleges of Nursing (AACN) lists DNP programs in most states and the District of Columbia and notes that "more than 100 additional nursing schools are considering starting DNP programs nationwide" as of March 2011.(4)

The AMA Scope of Practice Data Series quoted a 2007 paper(5) that documented online or distance-learning options in NP master's programs: students took courses on-site in 48.3% of the programs, while 46.3% percent of the programs offered some distance learning content. Eight of the 149 that were surveyed conducted programs entirely through distance learning. It further noted that some programs offered online course work and locally convenient clinical training under the supervision of NPs or physicians approved by the school.(6)

Practical Education
In any profession where knowledge must combine with skill and follow-through in performance for excellent practice to be achieved, one finds concerns about relevance of education to practice, such as in the blog comment, "We do not need Ph.D. nurse practitioners. We need nurse practitioners with lots of 'boots on the ground' experience as RN's, who can become NP's. Some of the worst NP graduates I mentored were straight-up academics with little to no practical experience, but they could pass tests with A's."(7) A study provides theoretical support for this comment, discussing the fact that high-level degree programs often do not address the skills professionals consider the most important for APNs, suggesting changes to improve educational preparation for practical nursing at the graduate level.(8)

This concern was also indirectly addressed by TOTN panel member, Dr. Gonzalez-Guarda, who noted that nurse educators now have a "recommendation … to implement a nurse residency program, so that nurses [who] are graduating … have the opportunity to engage in a residency program where they're able to apply a lot of the theory that they learned in the classroom in a real-life setting, with a little bit more support than they would regularly have." She further notes that a nurse residency may be particularly appropriate for nurses changing specialty fields.(1) Accredited NP programs must follow the revised 2008 Criteria for Evaluation of Nurse Practitioner Programs developed by the National Task Force on Quality Nurse Practitioner Education, which requires that any program have "a minimum of 500 supervised clinical hours overall."(9)

Concerns were raised by a TOTN caller named "Sarah" that the unique nature of the nursing model should be respected in this debate. She states, "The Nursing Code of Ethics is pretty clear in distinguishing between collaboration between disciplines, not just cooperating. And in order to preserve nursing's unique contribution to health care, will a model for future health care systems utilizing nursing in a broader scope be a collaborative model or simply back to the medical model with nursing merely cooperating? I mean, does better-trained nurses mean training in the medical model and getting away from our nursing roots?"(1) In short, the answer is no. Panelist Dr. Trybulski says, "We have an excellent way of preparing our nurse practitioners, currently, that grounds them in the nursing discipline and teaches them and models collaboration with all types of health care providers. […] They have gradually graded clinical experiences with … faculty … monitoring their ability to assume an increasingly independent role."(1)

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Licensure and Scope of Practice

Nurse practitioners, nurse anesthetists, nurse midwives, and other kinds of APNs have had special licenses for decades. The discipline of nursing performs many of the same functions as physicians, but nurses work from a different clinical angle and use nursing, not medical, models. A paper published in the Journal of the American Academy of Nurse Practitioners explains of nursing, "We argue that the heart and soul of nursing is in health promotion, both in healthy persons and in those dealing with chronic illness. […] Our vision is for NP care to be consistently 'different,' yet just as essential as physician care."(10)

Limited Licensure
The perception that physicians and APNs are in competition persists. The nursing journal named above published a paper about the divide that stated, "the legal authority for NPs to practice independently is recognized; however, the ability to put that authority into practice is undermined by the historical failure of political, professional, and social entities to recognize NPs as providers capable of providing primary care autonomously."(11) The American Medical Association (AMA) quotes APNs McCabe and Burman, who stated that "the historical roots of NP role development are replete with evidence of pushing the envelope of accepted practice and consistent attempts to expand roles as the potential benefits of APN practice became apparent."(6)

During the panel discussion on TOTN, Dr. Ralston asserted very good relationships and a lack of feelings of threat among doctors and APNs. He notes that one of the key factors or needs bearing on the scope of practice discussion is for people to practice at their level of training, regardless of level or specialty, and to "know when to ask for help" from a professional in a different practice.(1)

Prescribing Authority and Practices
Many of the historic concerns of the scope of practice debate have been cast in terms of prescribing authority.(1) First, documenting some figures is needed: "96.5% of NPs prescribe medications and write an average of 19 prescriptions/day, [and] NPs hold prescriptive privilege in all 50 states, including controlled substances in all but 3."(12) Dr. Ralston said that physicians have no complaints with the idea of APNs writing scripts and ordering tests if a "continuous quality monitoring program" is in place, which he says is needed to "make sure that any individual practice is working well."(1) Research has investigated quality monitoring of nursing practices, for instance:

1. Nurse practitioner prescribing behavior for older adults is scarcely studied in the international literature. While claims data are often used to study physician prescribing, few studies have investigated nurse practitioner prescribing. A Canadian study concluded that data linking patient characteristics and diagnoses to prescriptions written by nurses would be needed to inform quality improvement initiatives.(13)
2. A study considered the site development and implementation of a peer review process for APNs based on an examination of critical incidents that provides meaningful practice evaluation. According to the authors, peer review is central to self-regulation and professional practice for APNs, and has traditionally existed as a component of performance evaluation, practice pattern evaluation, compliance monitoring, and evaluation of quality indicators. A literature review revealed no examples of peer review by APNs of similar rank and clinical expertise participating in evaluating a critical incident.(14)

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A New Practice Doctorate

A relatively newer degree option for practicing nurses wishing to pursue doctoral education is the Doctor of Nursing Practice degree, the subject of the new recommendations from nursing education leadership organizations. Brar and colleagues describe the "availability of the DNP [as having] sparked a debate within the profession."(18) The traditional career path leads to nurses being educated at the Doctor of Philosophy (Ph.D.) level to generate new nursing knowledge and prepare nurses for careers in research, academic education, and health policy; Ph.D. degrees are more research-focused and are required of nursing faculty. Conversely, the DNP is a clinical education option whose purpose is to "educate nurses at the highest level of practice to improve outcomes of patient care, build upon the knowledge and skills obtained through master's programs, and promote the use of evidence-based practice."(19) The DNP emphasizes advanced leadership in clinical practice.(18,19)

Historically, academic preparation required of APNs has varied. The AMA comments on academic preparation of NPs, stating, "Although most NPs are now trained through some form of master's degree program […], not all currently licensed NPs have completed such programs. States' professional practice acts typically include grandfather clauses …."(6). There has indeed been change over time: In 2003, 90.5% of AANP member NPs had attained a graduate degree of at least a master's. But among those who reported entering practice before 1988, 53% had not attained a bachelor's degree or higher.(6) Now, one paper argues that doctoral-level nurses must "better conduct and evaluate research in the clinical setting, and meet evidence-based goals."(20) Another cites evidence for "the relationship between nurse education and improved patient outcomes."(21)

The AACN recommends that all APN programs be at the Doctor of Nursing Practice (DNP) level by 2015.(18) The requirements of that degree for clinical practice expertise and leadership match the recommendations in the 2010 IOM report discussed above and revisit those in the IOM Bridge to Quality (2003) report.(3) The experts interviewed on the TOTN program and many of the health care professionals who called in echoed the IOM report's suggestions.(1) It would seem, then, that many major parties are in agreement, yet fervent debate regarding the DNP continues in the United States.(18)

Some voices in nursing prefer to maintain the rigor and grounding in nursing theory afforded by the Ph.D. degree, and advise that nursing programs not work to implement the DNP, a recommendation meant to preserve the value of the current master's degree.(22) Yet, the AACN anticipates that the master's will be the new standard, stating, "As the education of the generalist nurse is elevated to the master's degree level, it is reasonable to assume that specialty education and the education of those individuals prepared for the highest level of nursing practice would occur at the practice doctoral level."(23) It further cites data that reveal several rationales for doctoral preparation, including(23):

• "Master's prepared advanced practice nurses identify additional knowledge that is needed for a higher level of advanced practice," specifically, "practice management, health policy, use of information technology, risk management, evaluation of evidence, and advanced diagnosis and management." (p. 7)
• "The time spent in master's level nursing education is not congruent with the degree earned," citing that "the didactic and supervised clinical practice hours increased by 72 and 36 clock hours, respectively …. Many NP master's programs now exceed 60 credits and cannot be completed in less than three years." (p. 7)
• "Recent management decisions in our nation's health care organizations have expanded the responsibilities of chief nursing executives to encompass other patient care services, in addition to nursing." The statement further cites the 2003 IOM report, stating that "the loss of mid-level nurse managers and increased responsibility of those remaining have decreased the direct management support to patient care staff" and that these management changes have "resulted in a need for increased knowledge and skills for clinical and administrative leadership across services and sites of healthcare delivery." (p. 2)

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Will We Have Enough APNs for Primary Care?

The introduction of this article described the anticipated entry of 32 million currently unserved Americans entering the health care system.(1) We must consider, then, whether higher graduation rates can increase the number of APN-patient encounters over time. According to the American Academy of Nurse Practitioners (AANP), over 135,000 NPs are practicing in United States, and 88% of NPs have graduate degrees.(12) Some quoted figures about NPs may inform our considerations about training enough APNs to satisfy demand for primary care(12):

• Approximately 8,000 new NPs were prepared in 2008
• 62% of NPs see 3 - 4 patients per hour
• 12% of NPs see > 5 patients per hour
• 20% of NPs practice in rural or frontier settings
• 66% of NPs practice in at least one primary care site
• 31% practice in at least one nonprimary care site (such as inpatient, emergency, surgical, or specialty practice). [An interesting chart displaying NP distribution, mean years of practice, and mean age by specialty may be downloaded at www.aanp.org/AANPCMS2/AboutAANP/NPFactSheet.htm.(12)]

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Clinical Connections

• Advanced practice nurses (APNs) can contribute more knowledge and skills to health care teams than they currently do, partly because of geographical barriers to consistent licensing and scope-of-practice definitions.
• Nurses can contribute professional, competent primary care to millions of currently unserved American patients now entering the health care system.
• Many clinicians believe that a conflict over scope of practice exists between APNs and MDs, yet the President of the American College of Physicians asserted very good relationships and a lack of feelings of threat among doctors and APNs.(1)
• Particular assets of the "consistently 'different,' yet just as essential" nursing model(10) lie in health promotion; care of those with chronic illness; health care leadership and practice management; and directing and providing patient- and family-centered care.
• The Doctor of Nursing Practice (DNP) degree for APNs teaches practice management, deeper clinical knowledge and ability, and nursing leadership that practicing nurses say they lack after completing master's degrees in nursing. The DNP leads to a career path in clinical practice, whereas the nursing Ph.D. degree leads to nursing education.
• The DNP's recommended 2015 implementation by nursing schools is controversial among nurses and other clinicians. The DNP degree raises concern that too few nursing graduates will enter primary care at the rate needed to increase clinician numbers in primary care, a concern compounded by the current shortage of doctoral-prepared nursing faculty to teach new nurses.

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Further Reading

[Note to readers: Some of these sources are repeated in the reference list below.]

• Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. http://iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Report-Brief.aspx. Accessed January 20, 2011.
• American Association of Colleges of Nursing [AACN]. AACN Position Statement on the Practice Doctorate in Nursing, October 2004. AACN Website. http://www.aacn.nche.edu/dnp/pdf/DNP.pdf. Published 2004. Accessed June 27, 2011.
• American Medical Association [AMA] Advocacy Resource Center. Scope of Practice Data Series: Nurse Practitioners. Chicago, IL: American Medical Association; 2009. http://www.aanp.org/AANPCMS2/publicpages/08-0424%20SOP%20Nurse%20Revised%2010-09.pdf. Accessed June 17, 2011.
• West MM, Borden C, Bermudez M, Hanson-Zalot M, Amorim F, Marmion R. Enhancing the clinical adjunct role to benefit students. J Contin Educ Nurs. 2009;40(7):305-310. PMID: 19639851.
• Mullinix C, Bucholtz DP. Role and quality of nurse practitioner practice: a policy issue. Nurs Outlook. 2009;57(2):93-98. PMID: 19318168.
• McInnis LA, Parsons LC. Thoughtful nursing practice: reflections on nurse delegation decision-making. Nurs Clin North Am. 2009;44(4):461-470. PMID: 19850182.
• Hodges ME. Preserving advanced practice nurse role integrity: One hospital's journey. Clin Nurse Spec. 2009;23(3):156-160. PMID: 19395893.
• McCabe S, Burman ME. A tale of two APNs: addressing blurred practice boundaries in APN practice. Perspect Psychiatr Care. 2006;42(1):3-12. PMID: 16480412.

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References

1. Conan N. Role of Nurses in Primary Care May Expand. National Public Radio's Talk of the Nation Website. http://www.npr.org/2010/11/16/131361359/role-of-nurses-in-primary-care-may-expand. Published November 16, 2010. Accessed June 7, 2011.
2. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. http://www.npr.org/2010/11/16/131361359/role-of-nurses-in-primary-care-may-expand. Accessed January 20, 2011.
3. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
4. American Association of Colleges of Nursing [AACN]. Doctor of Nursing Practice (DNP) Programs. Doc. AACN Website. http://www.aacn.nche.edu/DNP/DNPProgramList.htm. Published March 2011. Accessed June 27, 2011.
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12. American Academy of Nurse Practitioners [AANP]. Nurse Practitioner Facts. Washington, DC: AANP; 2010.
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