Advanced Practice Nursing

Karen Dejardins, DNP with a patient

What are advanced practice nurses?

Advanced practice nurses are professional nurses with specialty training, usually at the master's level, in primary or acute care. There are approximately 100,000 advanced practice nurses in the United States.

In recent years, state legislatures have broadened the authority of nurse practitioners to receive direct payment and to write prescriptions. As a result, these practitioners can establish independent practices that parallel those of primary care physicians. Nurse practitioners can also establish collaborative practices in which doctors and nurses share clinical responsibilities.

What is collaborative practice?

In collaborative practice, a nurse practitioner and a physician provide health care to a group of patients, and the two professionals share authority equally for providing care within the scope of their practice. The nurse practitioner is not required to obtain the physician's approval to provide that care. When differences of opinion arise, the provider with the greatest degree of professional competence holds authority; for complex diagnostic and treatment problems involving unstable and critically ill patients, this is the physician; for prevention, access to community-based resources, health education, and counseling, this is the nurse practitioner. When there is a difference of opinion about a patient's direct medical care, the physician has final authority.

Why is collaborative practice important?

Collaborative practice is important because it can bring more and better primary care to the public - no small benefit when the current health system is failing to meet the basic health needs of millions of Americans.

The shortage of primary care providers is decades in the making. For some time, physicians have been gravitating toward the specialties and away from primary care, seeking greater rewards and more manageable practices. This has left us with too many anesthesiologists and radiologists, for example, and too few family practitioners and pediatricians. At the same time, the scope of nursing care has grown. Nurse practitioners in many ways resemble the family doctor of old and are capable of assessing, diagnosing, and treating a wide array of illnesses, from coughs and colds to chronic disease. Numerous studies show that nurse practitioners are indistinguishable from their physician counterparts in making primary care decisions.

Comprehensive, cost-effective care.

Although nurse practitioners can substitute capably for primary care physicians, we believe the public will be best served by collaborative nurse-physician practices that take advantage of each professional's unique strengths and capabilities. While the physician tends to focus on illness, the nurse tends to focus on wellness. Neither approach is better; rather they are complementary and are best combined in a collaborative practice.

Clearly, the physician is superior at managing medically complex cases. The nurse practitioner, on the other hand, is more likely to talk with patients and adapt medical regiments to a patient's preferences, family situation, and environment. Nurses are also more likely to counsel patients about disease prevention and health promotion and to present information about community resources, such as nutrition, partnering, and stress-reduction programs. The end result of a collaborative practice, compared to a nurse-only or physician-only practice, is that the patient receives more comprehensive care and is more likely to get healthy and remain healthy. An added benefit is that a satisfied patient is less likely to be litigious; indeed, counseling and education are the best prescriptions for preventing true negligence and protecting the patient. Another strong argument for collaborative practice is that it may be the most cost-effective model of delivering primary care. In today's competitive health care environment, this is a benefit that cannot be ignored.

This trend raises an intriguing question: Do we need to re-fashion medical training in order to produce more primary care physicians, as many have proposed? A powerful argument can be made for continuing to train the majority of medical graduates in the specialties, albeit in fewer overall numbers. Indeed, the fastest and most cost-effective way to meet the nation's basic health needs may be to produce more nurse practitioners to team with specialist physicians.

The growing role of the nurse practitioner in acute care settings.

Nurse practitioners are also changing the patterns of health care delivery. In acute care facilities around the nation, nurse practioners are demonstrating that they are able to complement and even substitute for physicians in caring for stable inpatients. Because of substantial cuts in reimbursements, teaching hospitals are contemplating significant cuts in residency staffs. But who will provide the care now delivered by these physicians? Many in nursing contend that nurse practitioners are ideal replacements. They can perform most of the first-year resident's tasks under a physician's supervision, while incurring one-half the cost in salary and malpractice insurance.


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