Advanced Nursing Practice

Traditionally, nurses are viewed as support staff for physicians. They provide most of the
'frontline' care, from drawing blood to ensuring the patient is comfortable, but all medical
decisions must be made by a doctor. As a result, nurses cannot be primary caregivers.
But the truth is, many nurses do have sufficient training to provide primary care. There are
multiple levels of nursing: Licensed vocational nurses (LVNs), registered nurses (RNs)
and advanced practice nurses, or nurse practitioners. Although someone can become an
LVN or RN with just an associate's or bachelor's degree, advanced practice nurses all
have specialized advanced education.
A master's degree is the minimum requirement to become a nurse practitioner.
Furthermore, most graduate nursing programs offer advanced training in a specific area of
care, such as anesthesia, family practice, gerontology, midwifery, psychiatry or public
health. Nurses can even pursue a doctoral degree, known as the Doctor of Nursing
Practice (DNP), that prepares them for the highest level in patient-centered healthcare.
No matter what their area of focus, advanced practice nurses are trained to perform a
number of primary care activities. These include assessing patient needs, deciding to
admit patients to hospitals, making diagnoses, writing prescriptions, ordering tests and
making referrals to specialists.


Expanding the Scope
Organizations such as the Institute
of Medicine (IOM) argue that the
advanced training provided by
graduate nursing programs
prepares nurse practitioners to
provide the same basic primary
care as a general physician. IOM
recently published a study exploring
the future of nursing and offering a
number of recommendations for
how the practice of nursing should
be redefined in the 21st century.
The four key messages from the study are:
Nurses should be allowed to practice to the full extent of their training.
The nursing education system should provide seamless academic progression (much like the pre-med to
medical school system) in order to help more nurses achieve higher levels of education.
Nurses should be equal partners with physicians and other health practitioners in the process of redesigning
the American healthcare system.
Better data collection and a more consistent information infrastructure will be required in order to improve
workforce training and policymaking.

All of these sound like excellent ideas. There will never be a shortage of people in need of
healthcare, and since the passage of the Affordable Care Act last spring, health
professionals expect to see 32 million new people accessing the healthcare system. More
individuals should have access to the education required to care for the population, and
those who have that training should be allowed to do so.
But it's not that simple. Most physicians argue that, no matter how much training nurses
have, it's not the right training. Doctors claim that medical decisions should only be made
by those with an M.D. - period.


Patient-Centered Primary
Care
It's not hard to understand
the position of doctors on
this issue. Making medical
decisions means putting
the health, and possibly
even the life, of a human
being in your hands. That's
why medical school is such
a lengthy, difficult process,
and why physicians are so
defensive of their unique
rights.
But the IOM study suggests that doctors are not, in fact, the only practitioners qualified to
provide primary care. The organization examined several bodies of research that
compared both the quality and outcomes of care provided by doctors and by nurse
practitioners. They found overwhelming evidence that nurses can and do provide
excellent, patient-centered primary care.
As noted above, advanced practice nurses are trained to provide many of the same basic
services as physicians, such as writing prescriptions and ordering tests. Yet in many
states, the scope of their practice is significantly limited by law. Nurse practitioners simply
aren't legally allowed to apply their training.
As it stands, the country is facing a greater need for primary caregivers, and there's a
growing body of nurses who have been shown to be more than able to provide that care,
but the law is standing in the way. So the IOM has recommended that Congress and state
legislatures change laws to expand the scope of legal nursing practice so that it matches
the education and training provided to professionals in the field.



The Education Challenge
Unfortunately, the law isn't the only thing standing in the
way of the growth of contemporary nursing practice. The
country is also facing a shortage of qualified nurse
practitioners because there's a shortage of nurse
educators.
The fact is, nurses with master's and doctoral degrees can
simply earn more working in healthcare or policy.
Teaching therefore doesn't attract as many highly
educated professionals as other parts of nursing practice.
Since there are relatively few advanced practice nurses
(as compared to LVNs and RNs) to begin with, there just
aren't enough qualified educators.
Without enough instructors, schools can't accept enough
students to keep up with the expected shortage. The IOM
reports that thousands of potential nurses are turned away from the education system
each year. Although the report doesn't make specific recommendations for fixing this
problem, the organization does assert that education needs to be a priority.
If more nurses are guided through the pipeline from the undergraduate degree to
advanced training, the pool of potential educators will start to increase. In turn, more
students will have the opportunity to receive graduate nursing education and join the
workforce as primary caregivers. The key is to smooth the transition from RN to nurse
practitioner, creating the same natural step from undergraduate to graduate nursing
school as there is from pre-med to medical school.
With more trained nurses and a wider scope of practice, nursing may become a linchpin of
the 21st century healthcare system.