April 16, 2008

Latest Developments in Advanced Nursing Practice

By Clinton, Patricia

Ask the Expert provides research-based answers to practice questions submitted by JSPN readers. Question: What are the most compelUng issues in role development for the pediatric nurse practitioner?

Patricia Clinton responds: The more things change, the more they stay the same. Pediatric nurse practitioners (PNPs) are practicing in a much different world than they did 15-20 years ago. Prescribing privileges are granted to almost all PNPs, reimbursement is expected for services (even though we may disagree about the level of reimbursement), and more people are familiar with the nurse practitioner (NP) role. Yet we find ourselves protecting our practice and role today, as we did 30 years ago, despite many of the opportunities and privileges that we now accept as commonplace.

Three issues have immediate and far-reaching significance for professional practice for PNPs and other NPs: (a) education, (b) role recognition, and (c) scope of practice. Who are we? What do we do? How do we learn to do it? These three issues impact the everyday lives of most NPs because they are at the core of advanced practice.

What Are the Current Trends in Education for PNPs?

Education for advanced practice is undergoing a major transformation. Sparked by documents by the Institute of Medicine (2001; Greiner & Knebel, 2003), the American Association of Colleges of Nursing (AACN) moved to raise the bar for NP education and require that, as of 2015, NP education will be at the practice doctorate level (AACN, 2004). Rationale for this action included the complexity of health care in the 21st century, length of master's programs that approached credits more common in doctoral programs, and parity with other healthcare providers with practice doctorate preparation.

Titting and accreditation standards continue to be developed through a series of task forces and symposia. In the past 3 years the number of programs has grown exponentially. There are currently 52 programs listed as enrolling Doctor of Nursing Practice (DNP) students and 140 more programs in development listed on the AACN Web site (www.aacn.nche.edu/ DNP/DNPProgramList.htm). The DNP is intended for new NPs or those NPs who choose to acquire the additional education. It is not mandated that current master's- prepared NPs return to school and complete the DNP degree.

DNP education is built on the curricula and competencies of master's programs. Additional knowledge of evidence-based practice, leadership, policy, and advocacy differentiate DNP programs from their master's level counterparts. The additional leadership, evidence-based practice, and policy content equip practitioners with a new skill set that enables them to more fully account for their own practice outcomes, lead projects to improve quality of care for patients, and contribute to reforming healthcare delivery systems.

How Has Role Recognition Changed?

According to the American Academy of Nurse Practitioners (2007), there are an estimated 120,000 practicing NPs and approximately 6,000 new NPs graduating annually in the United States. In both primary, acute, and chronic care settings, NPs provide competent quality care. PNPs and their counterparts in other specialties are known in every state legislature and on Capital Hill. NPs are more familiar than ever to the general public, with the rapid rise of retail-based clinics that make NPs more visible and accessible. Educating the public, colleagues, legislators, and others about who we are is easier because of our numbers and because we have been carrying the message for 40 years.

The advent of clinical doctorate preparation for NPs has raised concern about titling. The American Medical Association (2007) has campaigned vigorously to prevent NPs from referring to themselves as doctors, even though the degree they carry is titled Doctor of Nursing Practice. In 2006, a bill known as the Healthcare Truth and Transparency Act was introduced in Congress by Rep. John Sullivan (Oklahoma). The language of the bill claimed evidence that patients have been deliberately misled to believe that the NP is a doctor and, further, that this can put the patients' health at risk. Of course this is unfounded. However, as nursing moves forward to strengthen educational programs to meet the demands of today's complex healthcare system, NPs should and must be accountable for representing themselves accurately.

This, then, is our new educational directive: to accurately identify our professional title and our role. For example, PNPs might introduce themselves to a family as "Dr. Smith, your nurse practitioner" or "Jane, I am your nurse practitioner."

Our role as healthcare providers is an important component of health care in the United States, and NPs are key to any attempts at healthcare reform. Pennsylvania Governor Ed Rendell recognized the advantage of NPs as an important part of his healthcare initiative. Legislation, that he pushed, resulted in opening up practice and removing barriers so that NPs could practice to their full capacity (Rollet, 2007). This could be a template for all states, but it will take the continued effort of PNPs and their colleagues to make the Pennsylvania practice environment a reality for all.

Have There Been Changes in the Permissible Scope of Practice?

Scope of practice is defined by the Pew Commission (Reforming Healthcare Workforce Regulation: Policy Considerations for the 21st Century, 1995) as:

... the rules, the regulations, and the boundaries within which a fully qualified practitioner with substantial and appropriate training, knowledge, and experience may practice in a field of medicine or surgery, or other specifically defined field. Such practice is also governed by requirements for continuing education and professional accountability. (p. ix)

States have the authority to regulate the scope of practice for healthcare professionals within their borders. A scope of practice is an assurance to the public that a provider has the education and training to practice safely. From time to time, scopes of practice are reviewed and updated to reflect changes and advancements within the respective professions.

It is the responsibility of professionals to define for themselves their knowledge and skills and to define to the public a scope of practice. The regulatory responsibility of boards of the various healthcare providers is to establish the practice acts for each profession within their jurisdiction. Boards will rely on experts in those professions to craft practice acts that accurately reflect practice roles.

The National Association of Pediatric Nurse Practitioners and the Society of Pediatric Nurses have come together and created a joint Scope and Standards of Practice that addresses pediatric nursing at all levels, from basic to advanced practice. The document is currently under final review and editing after being open for public review and comments. Pediatric Nursing: Scope and Standards of Practice will be available late spring of 2008 as a finished document. More information is available in this issue's editorial (Foster, 2008).

As PNPs have expanded the knowledge and skills necessary to practice in today's complex healthcare arena, so has the scope of practice been compelled to change. That, in turn, has created discomfort for other providers who feel threatened by an NP who is comfortable in the independent role described above. The focal point of a landmark, yet little known, document, Changes in Healthcare Professions' Scope of Practice: legislative Considerations (n.d.), is that changes in scope of practice are inevitable given the educational preparation of providers, healthcare needs of the public, and expectations of accessible quality care by legislators. Furthermore, this document recognizes that overlap of knowledge and skills among providers is common and expected, and that the true measure of safe practice is the assurance that the provider is sufficiently educated and competent to provide the service. Input into Changes in Healthcare Professions' Scope of Practice was provided by representatives from medicine, nursing, occupational health, pharmacy, physical therapy, and social work. This representation recognizes the importance of collaboration and cooperation in the spirit of the interdisciplinary team called for by the Institute of Medicine (2001; Greiner & Knebel, 2003).


There are opportunities all around to truly impact the care NPs provide to children and their families. As in the past, NPs will be prepared to take advantage of new educational initiatives and will have the freedom to practice to the fullest extent of their preparation. As NPs, we know who we are, we know what we do and we have the education to provide quality health care to children and families. It is an exciting time to be a part of the healthcare field.


American Academy of Nurse Practitioners. (2007). Frequently asked questions: Why choose a nurse practitioner as your healthcare provider? Retrieved December 7, 2007, from http://npfinder.eom/ faq:pdf

American Association of Colleges of Nursing. (2004). Position statement on the practice doctorate in nursing. Retrieved December 7, 2007, from http://www.aacn.nche.edu/DNP/DNPPositionStatement.htm

American Medical Association. (2007). Need to expose and counter nurse doctoral programs (NDP) misrepresentation (Policy No. D- 35.992). Retrieved December 7, 2007, from http://www.ama-assn.org/ apps /pf_new/pf_online?f_n=browse&doc=policy files/DIR/D-35.992.HTM Changes in healthcare professions' scope of practice: Legislative considerations (n.d.). Retrieved December 6, 2007, from https:// www.ncsbn.org/ScopeofPractice.pdf

Foster, R. (2008). One voice on the scope and standards for pediatric nursing practice. Journal for Specialists in Pediatric Nursing, 13, 61-62.

Greiner, C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st Century. Washington, DC: National Academies Press.

Reforming Healthcare Workforce Regulation: Policy Considerations for the 21st Century. (1995, December). Report of the Pew Health Professions Commission's Taskforce on Healthcare Workforce Regulation. San Francisco, CA, p. ix.

Rollet, J. (2007). Special report: Pennsylvania unleashes NPs. Advance for nurse practitioners. Retrieved December 7, 2007, from http://nurse-practitioners.advanceweb.com/Editorial/Content/ Editorial.aspx?CC=99618

Patricia Clinton

Column Editor: Ann M. Rhodes

Patricia Clinton, PhD, RN, CPNP, FAANP

Immediate Past President, National Association of Pediatric

Nurse Practitioners

Director, Master's and DNP Programs

College of Nursing, University of Iowa

Iowa City, IA

Author contact: [email protected], with a copy to the Editor: [email protected]

Search terms: Education, pediatric nurse practitioner, role recognition, scope of practice

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