Improving healthcare outcomes and accessibility in the USA : the advanced practice nurse

http://dx.doi.org/10.14528/snr.2015.49.2.64 In the United States (US), there is emerging a need for more healthcare providers and advanced practice nurses (APNs) are an important group in filling that need. The Centers for Disease Control and Prevention (2015) report that life expectancy in US is approximately 78.8 years with males living approximately 76.2 years and females 81 years. With a longer life expectancy, additional healthcare services are needed, as many of these individuals have complex chronic diseases and need more accessibility to cost-effective quality healthcare. The demand for healthcare providers for this expanding aging population as well as for all other age groups is increasing while the numbers of medical physicians are decreasing. According to the Association of American Medical Colleges (2015), there is currently a shortage of physicians that will only worsen. Physicians are aging as well and will be retiring in the next ten years. It is estimated that by 2025, 12,500 to 31,100 additional primary care medical doctors will be needed, along with a need for approximately 63,000 specialty physicians. These physicians will not be easily replaced by younger doctors, as fewer students study medicine due to the high cost of medical training. In the US, the average medical school tuition is $50,000 per year along with additional laboratory fees and living expenses that may exceed $30,000. Therefore, many medical students complete their education with a debt of at least $200,000 that must be repaid. With statistics as these, it is evident that the healthcare needs of the US population will not be adequately met by physicians alone. Addressing the decreasing accessibility to quality healthcare, the Institute of Medicine (IOM, now known as the National Academy of Medicine), a nonprofit, independent, and multidisciplinary organization providing information to decision makers in US as well as globally to inform or change policies to improve health outcomes, speaks of a need to transform healthcare. The IOM put forth a report entitled The Future of Nursing, stating that the healthcare system is in need of a transformation from a provider system that is currently focused only on what is most suitable for the healthcare provider, to one that focuses on the individual needs of patients (Institute of Medicine, 2010, p. 85). This information delineates the need for qualified healthcare providers with the knowledge and skills to care for all populations, who do not necessarily need to be physicians, but can be nurses with advanced practice education and skills. The report specifically addresses the use of APNs in caring for those with complex chronic illnesses and also providing primary health care in the communities they live. Over 100 studies conducted on the quality of APN healthcare outcomes and delivery, patient satisfaction and the cost-effectiveness of APN care demonstrate equal quality of outcomes, better patient satisfaction and decreased cost compared to medical physicians (Bauer, 2010). APN is a term used for 4 practice roles: certified nurse midwife (CNM), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA) and nurse practitioner (NP). APNs who are nurse practitioners (NPs) focus on specific populations; for example, family nurse practitioners (FNPs) who provide primary care across the life span, adult acute care nurse practitioners (ACNPs) who provide care in complex exacerbations of illness, primary care pediatric nurse practitioners (PCPNPs), acute care pediatric nurse practitioners (ACPNPs) and psychiatric-mental health nurse practitioners (PMHNPs). In order to practice, all NPs must pass a national certification exam specific to the population they will care for. The role of the NP was developed in 1965 by Loretta Ford (Ed.D) and Henry Silver (M.D) at the University of Colorado to provide primary care to underserved children through an educational certificate program (Aleshire & Wheeler, 2012; Denisco & Barker, 2015). The NP certificate programs at that time, which combined Leading article/Uvodnik

In the United States (US), there is emerging a need for more healthcare providers and advanced practice nurses (APNs) are an important group in filling that need.The Centers for Disease Control and Prevention (2015) report that life expectancy in US is approximately 78.8 years with males living approximately 76.2 years and females 81 years.With a longer life expectancy, additional healthcare services are needed, as many of these individuals have complex chronic diseases and need more accessibility to cost-effective quality healthcare.
The demand for healthcare providers for this expanding aging population as well as for all other age groups is increasing while the numbers of medical physicians are decreasing.According to the Association of American Medical Colleges (2015), there is currently a shortage of physicians that will only worsen.Physicians are aging as well and will be retiring in the next ten years.It is estimated that by 2025, 12,500 to 31,100 additional primary care medical doctors will be needed, along with a need for approximately 63,000 specialty physicians.These physicians will not be easily replaced by younger doctors, as fewer students study medicine due to the high cost of medical training.In the US, the average medical school tuition is $50,000 per year along with additional laboratory fees and living expenses that may exceed $30,000.Therefore, many medical students complete their education with a debt of at least $200,000 that must be repaid.With statistics as these, it is evident that the healthcare needs of the US population will not be adequately met by physicians alone.
Addressing the decreasing accessibility to quality healthcare, the Institute of Medicine (IOM, now known as the National Academy of Medicine), a nonprofit, independent, and multidisciplinary organization providing information to decision makers in US as well as globally to inform or change policies to improve health outcomes, speaks of a need to transform healthcare.The IOM put forth a report entitled The Future of Nursing, stating that the healthcare system is in need of a transformation from a provider system that is currently focused only on what is most suitable for the healthcare provider, to one that focuses on the individual needs of patients (Institute of Medicine, 2010, p. 85).This information delineates the need for qualified healthcare providers with the knowledge and skills to care for all populations, who do not necessarily need to be physicians, but can be nurses with advanced practice education and skills.The report specifically addresses the use of APNs in caring for those with complex chronic illnesses and also providing primary health care in the communities they live.Over 100 studies conducted on the quality of APN healthcare outcomes and delivery, patient satisfaction and the cost-effectiveness of APN care demonstrate equal quality of outcomes, better patient satisfaction and decreased cost compared to medical physicians (Bauer, 2010).
APN is a term used for 4 practice roles: certified nurse midwife (CNM), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA) and nurse practitioner (NP).APNs who are nurse practitioners (NPs) focus on specific populations; for example, family nurse practitioners (FNPs) who provide primary care across the life span, adult acute care nurse practitioners (ACNPs) who provide care in complex exacerbations of illness, primary care pediatric nurse practitioners (PC-PNPs), acute care pediatric nurse practitioners (AC-PNPs) and psychiatric-mental health nurse practitioners (PMHNPs).In order to practice, all NPs must pass a national certification exam specific to the population they will care for.
The role of the NP was developed in 1965 by Loretta Ford (Ed.D) and Henry Silver (M.D) at the University of Colorado to provide primary care to underserved children through an educational certificate program (Aleshire & Wheeler, 2012;Denisco & Barker, 2015).The NP certificate programs at that time, which combined

Leading article/Uvodnik
Improving healthcare outcomes and accessibility in the USA: the advanced practice nurse Izboljševanje izidov in dostopnosti zdravstvene oskrbe v ZDA: diplomirana medicinska sestra/diplomirani zdravstvenik z naprednimi znanji nursing and medical concepts of diagnosis and treatment, grew in number as the need for access to healthcare for all ages became apparent in rural, medically underserved areas.In the 1970s, the education for NPs was elevated to master's levels in nursing as NPs needed additional skills in clinical decision-making, leadership and policy making (Aleshire & Wheeler, 2012).

Why Utilize Advanced Practice Nurses (APNs)
Although there are educational differences between physicians and APNs, the American Academy of Nurse Practitioners AANP, (2013) published a position paper stating there is no evidence to suggest one is superior to the other in terms of patient outcomes, safety and quality of care.In fact, nurses attending APN programs have more experience in clinical situations that graduating medical students.Students enrolled in APN programs are already practicing registered nurses, while beginning medical students do not need to have any clinical experience with patients prior to entering medical school.Bauer (2010) cites numerous studies demonstrating that APNs provide quality of care equal to that of physicians.Patients also professed more satisfaction with APNs as their healthcare provider because they believe their concerns were listened to, they felt they were partners in the decisions for their care, they received more education on their conditions, as well as more timely follow up (Gadkari, 2013).
APNs provide excellent quality of care as they are required to maintain national certification to practice.Depending on the focus population and the credentialing board, every year or every five years, APNs must provide proof that they are keeping up with evidence based guidelines, through continuing education units or conferences.
''The cost-effectiveness of APNs begins with their academic preparation'' (American Academy of Nurse Practitioners AANP, Position Paper, 2013).The cost of an entire APN program is approximately $24,000 to $34,000 compared to $240,000 for physicians.The total tuition for APN education is less than 1 year of tuition for a physician.APN students are considered adult learners, and they are actively working as nurses while they are enrolled in APN studies.Therefore, quality of care and safety of patients in hospital settings is not being jeopardized as these nurses continue in to be employed as they are advancing their education.
APNs are cost-effective in terms of their salaries.Physicians in general practice receive a salary of approximately $180,000 per year, which can range up to $250,000 per year in a specialty such as cardiology (Association of American Medical Colleges, 2013).These salaries are even higher for other specialties and do not include any bonuses many physicians receive for productivity, which means seeing more patients/day or seeing more complex patients than another physician.
According to a national survey conducted by The Advance Healthcare Network for NPs (2013) the mean full-time NP's total salary was $97,345, across all types of practice.
According to American Academy of Nurse Practitioners (2013), ninety percent of the 192,000 NPs certified to practice are actively practicing, with 89 % working in primary care settings.For the purposes of this article, only the family nurse practitioner (FNP) role will be discussed as this role has been shown to positively affect the largest number of individuals requiring healthcare access.

The Family Nurse Practitioner (FNP)
The FNP is a master's prepared nurse who focuses on primary care across the lifespan.As defined by the Johns Hopkins Primary Care Policy Center (2015), primary care ''provides person-focused (not disease-oriented) care over time … for all but very uncommon or unusual conditions, and coordinates…preventative, curative, and rehabilitative care''.Therefore, FNPs are involved in health promotion and maintenance, disease prevention, diagnosis and management of acute and chronic illnesses, pharmacologic and non-pharmacologic treatments, patient/family education, and patient advocacy.
Application and subsequent admission to a FNP program is a rigorous process.Prospective students must provide evidence of a baccalaureate degree in nursing (BSN) with superior grades in basic courses such as pathophysiology, pharmacology, health assessment, as well as all the nursing courses required for a BSN.It is strongly recommended that an applicant have clinical bedside nursing experience for at least 2 years before entering the FNP program.
Once admitted to the program, the student begins the basic master's of science in nursing (MSN) courses on Role of the Advance Practice Nurse, Nursing Theory, Research and Evidence-Based Practice, and Informatics (use of technology for outcomes in patient care).Once these are successfully passed, students then begin their NP specialization courses: Advanced Pathophysiology (which has a strong medical focus), Advanced Pharmacology (which focuses on when to prescribe medications for treatment and ongoing management), Advanced Health Assessment (which includes differential diagnoses and advanced assessment skills), Primary Care of the Adult Patient, Primary Care of Children and their Families, Primary Care of Women, Behavioral and Mental Health, and Practicum (which is the integration of all the specialization courses).All of these specialization courses are a requirement for national certification.There is a clinical component to all the primary care courses as well as the practicum.A minimum of 500 clinical hours are required for the national certification exam.Most FNP programs have clinical hours that range from 500 to 640 hours.
A national certification exam must be taken at the conclusion of the FNP program.FNPs work in a variety of clinical settings in order to improve outcomes and access to health care.These NPs can be found working in government clinics, private clinics, physician offices, urgent care settings, emergency rooms, community health care settings, hospices, and settings specific for geriatric individuals-settings across the lifespan.

APN Issues
Although 50 years have passed since the first nurse practitioner program was developed, there are still issues surrounding APNs in the US.There is a question which has not been resolved as yet as to whether the basic education for an APN should be at a master's level or a Doctor of Nursing Practice (DNP) level.A student graduating from either of these levels may be nationally certified.Currently, the US has APNs who only have a master's degree and there are some APNs who have a DNP degree.
There are four organizations which offer national certification exams for APNs: The American Nurses Credentialing Center, the American Association of Nurse Practitioners, the Pediatric Nurse Certification Board, and the American Association of Critical Care Nurses.APN students and sometime faculty are often confused as to which certifying exam they should take.
Individual US states license APNs and dictate the scope of practice and regulatory oversight for APNs.In some US states, an APN may practice independently with no physician oversight, in other states, the physician must have a supervisory role over the APN, and still in other states, there is a required collaborative agreement between the physician and the APN, delineating the type of patients that an APN may see as well as a list of medications an APN can prescribe.All the states, with the exception of Florida, permit APNs to prescribe drugs from Schedule II-V (sedatives, narcotics and stimulants), if their patients require it.
Other countries throughout the world have also embraced the role of the APN as a cost-effective way to provide quality care that is evidence based (Aleshire & Wheeler, 2012;Christiansen, et al., 2012;Flagerstrom & Glasberg, 2011;Matthews, 2012;Nardi & Diallo, 2014).It is interesting to note that APNs in other countries are experiencing many of the same issues that US APNs are experiencing; issues of education requirements, role of the APN, licensing, scope of practice, and acceptance by the medical community as well as by the public.While studies have been conducted on the safety, quality and costeffectiveness of APN practice in the US, additional research needs to be done as APN practice roles are expanding in the US as well as globally.To best address these common issues, the International Council of Nurses (ICN) along with the American Academy of Nurse Practitioners (AANP) meet as a group to assist APNs navigate these common issues (Aleshire & Wheeler, 2012).This is a major step towards improving global healthcare outcomes and access through standardization of education, licensure and practice.