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Nurse practitioners.

"That was the best physical exam I've ever had!" Nurse practitioner Donna Pachota often hears praise from clients who appreciate her thoroughness during routine checkups. But Pachota does more than perform physical examinations. She is a highly trained health professional responsible for her clients' total care.

Nurse practitioners are registered nurses with advanced education and clinical experience. They provide health care to people of all ages in both urban and rural areas throughout the country. From emphasizing wellness to treating common problems, nurse practitioners help clients understand why their health is important--not only to themselves but to their families as well.

There were about 30,000 nurse practitioners in the United States in 1992, the most recent year for which complete data are available. That number will increase, say nurse practitioners, as they become a more visible part of the American health care system. "The role of the nurse practitioner is going to become broader," says nurse practitioner Melanie Harris. "We're very involved in becoming primary care providers because we're cost effective."

This article describes what nurse practitioners do, where they work, some benefits and drawbacks of their jobs, and the educational requirements for joining the profession. Addresses for more information are in the last section.

What They Do

As Harris says, nurse practitioners are cost effective in providing primary care. Primary care is treatment that helps people stay healthy or get better. And because they perform many of the routine tasks physicians do but at a lower cost, nurse practitioners help keep health care expenses down. "I think we really provide the type of care people are looking for," says nurse practitioner Peter Coggiola. "When lawmakers talk about affordable health care and health maintenance with a strong emphasis on health education, they are describing the work of nurse practitioners."

Focusing on health maintenance, the steps people take to stay well, is a big part of nurse practitioners' work. In routine physical examinations, such as the ones Donna Pachota gives, the nurse practitioner takes a client's vital signs--temperature, blood pressure, and pulse--and notes them on the client's medical record, along with height and weight. She evaluates the client from head to toe and might sign forms necessary for ordering routine analysis of the client's blood or urine. At the end of the exam, she talks with the client about his or her medical history, any problems discovered during the exam, and other health concerns the client may have.

Some other health maintenance activities offered by nurse practitioners include health education, vaccination clinics, and diagnostic screenings for disorders such as high blood pressure and diabetes.

Clients who come to nurse practitioners with minor ailments receive a physical exam, diagnosis, and treatment instructions. During an exam, the nurse practitioner assesses the problem based on the client's physical condition and responses to certain questions. While taking the vital signs of a client complaining of chest pain, for example, the nurse practitioner asks when the pain started, what aggravates or relieves it, and whether the pain is recurring. The client responds that she felt the pain after exercising and notices it hurts more when she raises her arm. The nurse practitioner, after ruling out a serious condition such as heart attack or stroke, determines that she suffers from a pulled muscle. Additional tests might be ordered as a precaution, depending on factors such as the patient's age and weight, but most likely the nurse practitioner would instruct her to put ice on the muscle and rest it a few days.

An important aspect of the nurse practitioner's approach to health care is patient education. The nurse practitioner helps clients recognize the effects poor health can have on themselves and their families. After pointing out how a mother's poor health affects herself and her children, for example, the nurse practitioner would help the woman understand the links between health, diet, and exercise. Then, the nurse practitioner might offer suggestions for improving her diet and making other lifestyle changes, which in turn could positively affect her health and that of her children.

By establishing a relationship with the client, nurse practitioners enable clients to better care for themselves, thus requiring [fewer medical visits due to illness. "Too often in hurried physician visits, people don't understand what to do when they leave the office," says Coggiola. "But if you cover that with them when they're in, they won't have to wonder what to do when they're away from the office."

In almost every State, nurse practitioners have the authority to write some prescriptions. But laws in about half those States require a physician's signature for the prescription to be valid. For treating serious injuries or illnesses, nurse practitioners must consult physicians or specialists. State laws vary regarding the extent of physician consultation required.

Like most health professionals, nurse practitioners are trained to treat minor injuries, such as stitching cuts. Some nurse practitioners specialize in such treatment, known as critical care, but most focus on primary care. Clinical nurse specialists--registered nurses who also have advanced training--more often work in critical care. Although there have been discussions about merging the two occupations, they currently remain separate.

Nurse practitioners usually specialize. Among the kinds of nurse practitioners are the following.

* Neonatal nurse practitioners work with newborns;

* Pediatric nurse practitioners treat children from infancy through adolescence;

* School nurse practitioners serve students in elementary and secondary schools and colleges and universities;

* Adult and family nurse practitioners work with adults and their families;

* Occupational health nurse practitioners provide on-the-job care;

* Psychiatric nurse practitioners aid people with mental and emotional problems;

* Geriatric nurse practitioners care for the elderly. Duties vary within each specialty, depending on the nurse practitioner's specialization and health care needs of the clients he or she treats.

Where They Work

Nurse practitioner duties also vary based on the type of facility in which the practice is located. Those who work in hospitals are more likely to care for clients recovering from surgery or illness, for example, than those whose practice is in employee health clinics. Other facilities where nurse practitioners work include health maintenance organizations, physician offices, clinics, public health departments, nursing homes, student health centers, hospices, and schools of nursing. In States that allow them to practice independently, nurse practitioners may be self-employed or have an office with one or more partners.

Some nurse practitioners work in more than one setting. Coggiola is on the faculty at the University of Rochester's Community Nursing Center, an arm of the university's nursing school. In addition to his clinical duties there, he performs occupational health exams, staffs a mobile health unit, and provides health care to county jail inmates, county hospital clients, and schoolchildren.

Although other nurse practitioners may have similar variety in their duties, such diversity is not the norm for nurse practitioners who teach. Coggiola says, "My situation is unique because the University of Rochester allows nurse practitioners to be entrepreneurial. Most schools don't allow the faculty to have a practice outside of teaching."

Nurse practitioners' specialties often determine their work setting. Almost all neonatal nurse practitioners are employed in hospitals, for example, while most school nurse practitioners work in campus-based student health services. But location also means specialties can become more generalized. For example, necessity dictates that Donna Torrisi's family practice, located in the community health centers of two public housing complexes, covers "just about everything."

Not surprisingly, most nurse practitioners work in States with laws granting them the most autonomy, or authority to act independently of a physician, in writing prescriptions. Those practicing in rural areas--the minority of nurse practitioners--are the most autonomous. They also are most likely to spend some time on the road, visiting clients who are unable to come to their offices. Harris's clinic in rural Oregon is 130 miles from the nearest medical center. "Some people travel 2 hours to get here," she says. "And I do make house calls, usually for the elderly who find it too difficult to get out. They're often not good candidates for being exposed to illnesses in the office."

Benefits and Drawbacks

Despite its geographic complications, rural practice offers advantages to the nurse practitioners who opt out of big city work. "In a rural area," says Harris, "you get to work with generations. You get to know their histories. You become a part of their lives."

Becoming part of their clients' lives is one of the things nurse practitioners--in both rural and urban areas--most enjoy about their jobs. "What I like best is developing and maintaining that relationship with my patients," says Coggiola. Nurse practitioners' duties encompass more than evaluating a client's physical health; relationships develop through the communicative, counseling, and educational focus of their work. "I like participating in the whole care of the patient," says Pachota. "And I like the ability to have hands-on care."

Nurse practitioners are part of a health care team that includes physicians, specialists, nurses, and assistants. But their advanced training allows them to be more independent in their work than some other health care occupations. That makes their jobs appealing, too. "I had been a registered nurse and felt I had a lot of abilities that weren't being utilized," says Harris. "Then I learned about becoming a nurse practitioner and thought that was a niche I could fill. It's really nice to be able to help people."

The American Academy of Nurse Practitioners estimates that the current median salary for nurse practitioners nationwide is in the upper $40,000's to low $50,000's annually, with a range from the low $40,000's to over $70,000. Beginning salaries of 1995 graduates as reported to the Academy are above $50,000; offers of lower starting salaries have resulted in vacancies. Other monetary benefits include vacation and sick pay plus health, dental, and life insurance.

However, annual salaries do not necessarily reflect hourly pay. Few nurse practitioners work a standard 9-to-5, Monday through Friday workweek. Like most health professionals, nurse practitioners often have irregular schedules--including nights, evenings, weekends, and holidays--and cannot always leave promptly at the end of their shifts. And, especially in rural areas, where they might be the only source of health care for miles, nurse practitioners are always on call. As Harris puts it, "If you want to go on vacation, you have to leave town."

In addition to the long hours, nurse practitioners spend much of their time walking and standing. Those who make house calls or attend to clients in several locations must travel often. Nurse practitioners also risk exposure to the diseases their clients have, ranging from the common cold to AIDS, and must take precautions to guard against contracting them. They face other hazards as well, such as radiation, chemicals used for instrument sterilization, and anesthetics.

Most nurse practitioners accept those risks as part of their chosen field. What they dislike more is the lack of understanding or respect--by the public, other health professionals, and the health care industry--for the service they provide. "I don't like the animosity that is sometimes directed toward nurse practitioners or when we're misunderstood," says Pachota. "I get frustrated when it's considered we provide lesser care, because that's not true." But Pachota says the public's misconception of their role has decreased as nurse practitioners have taken a more active, visible role in health care. "We've come a long way in terms of patient acceptance," she says.

The obstacles that remain, say nurse practitioners, stem from continued resistance to their role by other health professionals and the health care industry, especially insurers. Without recognition from other health professionals, nurse practitioners are limited in the duties they can provide without a physician's approval. Often, restrictions apply in urban areas but not in rural ones. "It's such a dichotomy: We can go to a nursing home to practice without a physician onsite, but not in an urban office," says Pachota. "It shouldn't matter where you are geographically. Your skills don't change."

Insurance companies do not pay nurse practitioners directly without prior approval; instead, the insurer pays their employer, who in turn reimburses them. "Our biggest struggle is to be recognized as primary care providers with the insurance industry," says Coggiola. "Without that, my hands are tied and I still have to be subservient to physicians." Nurse practitioners and nurse practitioner organizations continue lobbying efforts to change laws regarding autonomy and reimbursement issues.

Qualifications and Training

Nurse practitioners must enjoy working with people, be patient and sympathetic, and should care about their clients. Because they and other advanced practitioner nurses--certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists--often work independently, they should be able to accept responsibility. However, they also must be willing to consult a physician or refer a client to experts if the situation warrants.

Advanced practice nurses are registered nurses with advanced education and experience. Registered nurses must complete 2 to 5 years of posthigh school training leading to a diploma or associate's or bachelor's degree and pass a national licensing examination. Advanced training for nurse practitioners includes an additional 1 to 2 years of training, usually leading to a master's degree, and passage of a national examination.

To encourage registered nurses to pursue advanced practice, some scholarship, student loan repayment, and externship programs have existed in the past. However, funding varies from year to year. Contact organizations listed at the end of this article for more information about monetary assistance for nurse practitioner study.

Even though you need education beyond college to be a nurse practitioner, preparation begins as early as high school. Build a science framework with courses such as biology, chemistry, anatomy, and physics. But don't overlook subjects like math, history, communications, psychology and social sciences, languages, and fine arts. "You need a well-rounded education with a solid science background," says Coggiola. "The liberal arts part really helps in being able to relate to people."

To get hands-on experience in their field, nurse practitioners supplement their education with clinical training. You should get some exposure to the nurse practitioner profession now to find out if you might like doing the work they do. After all, reading or watching television shows and movies about a trauma victim is much different from actually seeing--and having to deal with--one.

Nurse practitioners suggest doing volunteer community service in a hospital or clinic. You might also want to shadow a few nurse practitioners to observe them in their jobs. If you do not know any nurse practitioners, contact one of the organizations below and ask for a referral.

For More Information

To learn more about registered nurses, consult the Occupational Outlook Handbook or check your local library for books about nursing and health care occupations.

The American College of Nurse Practitioners provides information about nurse practitioners and works to improve the nurse practitioner's role in changing health care delivery. The College has legislative and practice updates available in newsletters, factsheets, and other educational materials. It also acts as a clearing-house for information about the occupation, specialties, and scholarships or other financial assistance. For more information, contact

American College of Nurse

Practitioners

1090 Vermont Avenue NW.

Suite 800

Washington, DC 20005

(202) 408-7050

E-mail: ACNP@aol.com

Nurse practitioner Support Services provides information on nurse practitioners including employment opportunities, publications, boards of nursing, and continuing education offerings. Its Internet home page includes electronic mailing lists, an online directory, links to other nurse practitioner organizations, and employment services such as interviewing tips, resume preparation, and job postings. For more information, contact

Nurse Practitioner Support Services

220 Railroad Avenue N

Kent, WA 98032

(206) 852-9042

E-mail: NPSS@npl.com

Internet: http://www.nurse.net/npss/

Informational brochures about nurse practitioners are available from the National Alliance of Nurse Practitioners and the American Academy of Nurse Practitioners. Contact these organizations at the following addresses.

National Alliance of Nurse

Practitioners

325 Pennsylvania Avenue SE.

Washington, DC 20003

(202) 675-6350

American Academy of Nurse

Practitioners Capitol Station,

LBJ Building P.O. Box 12846

Austin, TX 78711 (512)

442-4262.

The National Organization of Nurse Practitioner Faculties publishes the National Directory of Nurse Practitioner Programs, listing all programs by State and specialty. The winter 1994 edition, which includes a 1996 addendum, is available for $28 from

The National Organization of Nurse

Practitioner Faculties

One Dupont Circle NW.

Suite 530

Washington, DC 20036

(202) 452-1405.
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Title Annotation:employment outlook
Author:Green, Kathleen
Publication:Occupational Outlook Quarterly
Date:Sep 22, 1996
Words:2713
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