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.