The nurse practitioner role is such a critical piece of healthcare today that it is hard to imagine it as a groundbreaking career path back in 1965 at the time of its inception. Today, nurse practitioners work everywhere, treating patients in every imaginable medical scenario, from cancer treatment centers to pediatric hospitals to private dermatology practices.
The primary care nurse practitioner role is extremely popular in primary care settings and specialty areas. We will review the similarities between family nurse practitioners (FNPs) and Acute Care Nurse Practitioners (ACNPs) in this article, but first, we will highlight the history of how the NP role came into existence and what it takes for a nurse to transition into this role.
History of the Nurse Practitioner
The story of nurse practitioners (NPs) is a story of supply and demand. Back in 1965, Medicare and Medicaid were expanded in a significant way. Their coverage would now be extended to low-income women and children as well as elderly patients and disabled individuals. Suddenly, the US had significant population groups seeking primary health care, and there simply were not enough primary care physicians to keep up with the demand.
Enter the nurse practitioner, a position created to assist with patients’ treatment, giving nurses additional training and certifications to enable them to perform many of primary care physicians’ duties. The first NP program was established at the University of Colorado, initially as a certificate program. It would go on to become a master’s program in the early 1970s.
In fact, by 1973, there were more than 65 NP programs across the country, bringing new NPs into the healthcare workforce to continue to meet the patient demands of a growing population.
An important step in cementing the legitimacy of the position occurred in 1974 when the American Nurses Association established the Council of Primary Nurse Care Practitioners. By 1977 the ANA was also offering certification exams for nurse practitioners.
As the 1970s came to a close, approximately 15,000 NPs were working in the United States. Flash forward to today, and there are almost 300,000 licensed nurse practitioners caring for patients all across the country and making significant contributions to patient advocacy, innovations in healthcare treatments, and overall quality of care.
The road from 1965 to today has not always been a smooth one for the development of the nurse practitioner job, and there are still efforts underway to legitimize the role and increase funding for NP programs.
Still, growth continues with no signs of slowing. NPs are still in demand as more Americans received health care coverage under the Affordable Care Act, and we also need more health care workers to keep up with the demands of an elderly population that is living longer.
What is a Nurse Practitioner?
A nurse practitioner (NP) designation is given to those registered nurses. They have gone on to earn advanced degrees and work as Advanced Practice Registered Nurses (APRN) with either a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP). The NP’s role carries with it more authority than that of an RN, and the duties and responsibilities of an NP have some overlap with that of physicians.
While NPs and physicians both assess patients and diagnose various conditions, there are some restrictions placed on NPs depending upon the state in which they are practicing. For example, while many NPs can prescribe medication, they can only do so with collaborative agreements and/or oversight from physicians in some areas. They do not have the same autonomy level as those who have earned degrees and certifications as Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
Nurse practitioners commonly work in family and primary care settings. In contrast, MDs and DOs will be found everywhere from oncology to obstetrics, in private practices, hospitals, group practices, or academic institutions. As time goes on, it is expected that nurse practitioners will be found in many more specialized healthcare settings as the demand for them continues to rise. Growing evidence supports the fact that they provide cost-effective and high-quality healthcare.
One of the most significant differences between NPs and physicians is the time spent in education and training. To work as a nurse practitioner, most individuals will spend 6 to 8 years in postsecondary education and training. Most individuals will spend 11 years in postsecondary education and training to work as an MD or DO.
We should note here that becoming an Advanced Practice Registered Nurse (APRN) is not only linked to nurse practitioners. The NP role is just one of the four advanced practice nursing roles. APRNs are also at work in the healthcare system as nurse midwives, nurse anesthetists, and clinical nurse specialists.
Advanced nursing is needed in every area of health care. As our guidelines and regulations related to NPs continue to evolve, patients will see more and more NPs to address their medical needs, including preventative measures, symptom management, medications and therapies, and overall wellness initiatives.
Nursing students thinking about the path of the NP role and registered nurses considering advanced degrees often consider the choice between becoming a Family Nurse Practitioner (FNP) and an Acute Care Nurse Practitioner (ACNP) will explore those specific NP roles next.
Family Nurse Practitioners
A family nurse practitioner (FNP) is a type of advanced practice nurse who looks after patients of all ages in a primary care setting. FNPs have filled a void created by a shortage of primary care physicians. Many MDs and DOs are now entering specialty fields where there are simply not enough “general” doctors to treat the basic needs of a large percentage of the population.
We need and indeed value expert care in specialty areas; an experienced oncologist is your best ally in fighting cancer, just like a cardiologist will be best equipped to treat a complicated heart issue. However, we face the day-to-day health concerns that need the care and attention of a general physician, be it a lingering sinus infection, the flu, unexplained fatigue, or any number of problems.
Family practice doctors also act as a sort of anchor in your medical history, monitoring changes at your annual physical and keeping records of changes in your health. They are the primary source of your overall medical information, and they would be a natural part of your care team even after referring you to an oncologist, cardiologist, or other specialists. In this way, the FNP mirrors the physician’s role closely.
FNPs work to provide health services for a lifetime, treating patients of all ages and backgrounds. The development of longstanding relationships between FNPs and their patients is one of the most rewarding aspects of the job.
If you transition from RN to APRN role as a family nurse practitioner, you will continue to build upon the skills you have developed in patient care as an RN and dd some new ones along with new levels of authority.
The FNP duties will typically include:
- Assessing and diagnosing patients’ overall health
- Performing annual or routine physical examinations
- Developing patient treatment plans for chronic illness
- Providing preventative care services
- Making referrals to specialists when needed
- Prescribing medication for patients
- Ordering lab and diagnostic tests and assessing results
- Assisting physicians with minor surgical procedures
FNPs are most often found in primary health care clinics and other outpatient settings, which is one of the main ways they differ from acute care nurse practitioners.
Acute Care Nurse Practitioners
An acute care nurse practitioner (ACNP) is an APRN who works specifically with patients battling acute conditions that may be life-threatening. You may see these nurse practitioners working in emergency rooms, intensive care units, and inpatient hospitals.
The ACNP role includes treating patients 13 and older with complex medical conditions, diseases, or injuries. ACNPs manage patient care and also perform procedures such as intubations. They admit and discharge patients in many states, and they work closely with physicians as part of a care team in these hospital settings.
Whereas the rewarding aspect of the FNP role—the development of longstanding patient relationships—may be missing from the daily routine of an ACNP, there are still many rewarding aspects of this challenging work. ACNPs perform lifesaving medical interventions in very serious and complex crises. Those RNs truly passionate about healthcare in emergency settings are the ideal candidates to consider pursuing this advanced degree path.
Educational Requirements and Certifications for FNPs vs. ACNPs
To understand the educational and certification requirements for FNPs and ACNPs, we need to start at the beginning with a basic overview of what it first takes to become a registered nurse.
The RN path leads to nurse practitioner roles, so we will explore those requirements, but we should mention here that there are indeed other nursing roles available for those who want to serve in health care but cannot commit to the degree that takes several years to complete.
Certified nursing assistants (CNAs), licensed practical nurses (LPNs), and licensed vocational nurses (LVNs) are roles in the nursing field you can train for in a year or less. These important health care jobs offer valuable experience, and these employees make valuable contributions to patient care; however, they are not necessarily “stepping stones” to an eventual nurse practitioner role without becoming a registered nurse, and ultimately an APRN, first.
Registered Nurses with Associate Degrees
Two-year programs offer an Associate Degree in Nursing (AND) or Associate of Science in Nursing (ASN) degree, and these enable an individual to work as a Registered Nurse (RN) once they pass a state licensing exam. The challenge with an associate degree is that many employers will ultimately prefer to hire RNs with a four-year degree, which is something to keep in mind if you are starting your nursing education.
Registered Nurse with Bachelor’s Degrees (RN BSN)
The Bachelor of Science in Nursing degree is a much more intensive program of nurse training that prepares RNs for the possibility of eventual leadership roles. Typically, RNs with a BSN degree are paid more than RNs with associate degrees, and the next step from this role is enrolling in a master’s degree program.
Registered Nurses with Master’s Degrees (APRN MSN)
The advanced practice registered nurse (APRN) designation comes once an RN has earned a Master of Science in Nursing (MSN) degree. This is the stage where the RN becomes a nurse practitioner with completion of a degree and passage of a certification exam.
Doctoral Degrees in Nursing
The Doctor of Nursing Practice (DNP) or Doctor of Philosophy in Nursing (Ph.D.) degrees also enable nurse practitioners to advance in their roles. These degrees are also sought by RNs who want to transition to academic settings to teach other nurses.
With each new degree described above, a nurse’s earning potential increases, as does the opportunity to take on senior leadership positions.
Now that we have highlighted the basic path of RN degrees and advanced degrees, we will outline exactly what you need to do to become an FNP or an ACNP.
Family Nurse Practitioner: Education and Certification
To work as an FNP, an individual must be a registered nurse who earns a Master of Science in Nursing (MSN), Doctor of Nursing Practice (DNP), or post-master’s certificate with a nurse practitioner population focus.
The NP population focus describes the patient population the APRN is specializing in, which may include one or more of the following:
- Families and individuals for lifetime care
- Women’s Health
- Mental Health
Focus on specific patient populations is one way the NP roles have evolved since their 1965 inception, and the certification exams now reflect that as well.
Acute Care Nurse Practitioner: Education and Certification
To work as an ACNP, an individual must be a registered nurse who earns a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP), with emphasis on specializations in acute care (such as pediatric acute care or adult gerontology acute care).
The certifications for acute care nurse practitioners include:
- ACNP-AG: the acute care nurse practitioner certification for adult-gerontology may be obtained from the American Association of Critical-Care Nurses.
- CPNP-AC: The certified pediatric nurse practitioner-acute care may be obtained from the Pediatric Nursing Certification Board.
- AGACNP-BC: The adult-gerontology acute care nurse practitioner may be obtained from the American Nursing Credentialing Center.
In both the case of an FNP and the acute care specialties, the nurse practitioner also needs to pass state licensing requirements.
Salaries for FNPs vs ACNPs
Nurse practitioners are already in demand, and this trend is expected to continue. The shortfalls in primary care and specialty physician areas mean that more NPs will be needed to fill that gap.
Therefore, in terms of overall job security and opportunity, it is wise to invest in the advanced degrees needed for this job. Even if this requires taking in student loan debt, NPs should be able to pay it off as their salaries increase.
A registered nurse looking to earn more money can be assured that the NP role will get him past the $100k mark in time, and there is only a slight difference between the different types of NPs we have highlighted.
As you may have guessed, the acute care roles pay slightly more than the family care roles in nurse practitioner jobs, just as you would expect an ICU or ER doctor earns more than your family care physician.
Figures from the US Department of Labor Bureau of Labor Statistics in 2016 included:
- An average salary for NPs of $104,610
- The top 10% of nurse practitioners earning $140,930
- NPs in acute care settings earning average salaries from $109,000 to $117,000
- NPs in primary or family care earning average salaries from $103,000 to $107,000
States Where Nurse Practitioners Can Practice with Autonomy
When you consider a career as an NP, either in family care or acute care, you will want to consider the restrictions on autonomy (or lack thereof) where you will practice. Part of the decision-making process when it comes to pursuing advanced degrees will relate to geography. Certain states have more jobs available for NPs and offer more authority and/or autonomy in treating patients.
Because regulations related to nurse practitioners often change, check with each state’s nursing board for the most up-to-date information, especially before deciding where to apply for jobs. As of now, these states allow APRNs to practice with autonomy.
Full practice autonomy (or FPA) is granted to all nurse practitioners in Alaska. In addition, NPs in Alaska can apply for the authority to write prescriptions for controlled substances (Schedule II to V).
The Arizona Board of Nursing offers NPs a license with full prescriptive authority, with these conditions: the NP has to apply via a Controlled Substance Prescription Monitoring Program and register with the Drug Enforcement Agency (DEA) before they are allowed to write prescriptions for patients.
In the Centennial State, nurse practitioners have full practice authority. After 1,000 practice hours, the NP will have provisional prescriptive authority. This provisional authority to write prescriptions may shift to full after a period of physician oversight and/or a mentoring nurse practitioner.
NPs in Connecticut must also spend a period of time under physician oversight before they are granted FPA.
If working in a tropical island paradise with an annual mean wage of $117,000 and full practice authority sounds like your dream job as a nurse practitioner, Hawaii may be the best place for your employment applications.
Advanced practice nursing compact legislation allows APRNs in Idaho to also practice in Wyoming. FPA is granted to nurse practitioners in Idaho, and after 30 hours of qualifying continuing education courses, they are allowed to write prescriptions for patient medications.
Nurse practitioners in Iowa may lead their own practices with an advanced registered nurse practitioner (ARNP) license. That same license allows them to prescribe medication.
Full practice authority is granted to nurse practitioners in Maine. The APRN license also grants authority to write prescriptions in Maine.
To prescribe medications in Maryland, NPs must have the APRN license and register with the state’s Prescription Drug Monitoring Program. Licensed NPs can also treat patients in Maryland without physician oversight.
FPA is granted to nurse practitioners in Minnesota by the state’s board of nursing, and APRNs can also prescribe medications.
In order to prescribe medication in Montana, APRNs must submit an application to the Prescriptive Authority. While NPs here do not have to work with physician oversight, they are required to complete courses in disease management as well as pharmacology.
A 30-hour pharmacology requirement is needed before a nurse practitioner can write prescriptions in Nebraska. Once that requirement is met, they have full prescriptive authority.
If you want to roll the dice and try your luck as an NP in Nevada, you will have an FPA as well as a Nevada Board of Pharmacy license. NPs in Nevada must register with the DEA to write prescriptions for controlled substances.
An APRN license in New Hampshire allows for full practice authority and the ability to prescribe medications to patients.
NPs working in New Mexico can register with the DEA and seek state certification to write prescriptions for Schedule II through V-controlled substances.
A nurse practitioner working in North Dakota must complete 30 hours of pharmacology coursework before writing patient prescriptions, and they can also treat patients independently without oversight.
Oregon is a popular state for NPs thanks to competitive salaries. Full prescriptive authority is granted here with APRN licensure.
Across the country in Rhode Island, NPs can gain full prescriptive authority after completing a Controlled Substances Act Registration. This earns the NP global signature authority (meaning no physician oversight is needed on prescriptions for patients).
In February 2017, South Dakota joined the list of states granting FPA to NPs. This was a significant development in a state with rural populations often lacking in family practice health care choices.
A nurse practitioner working in Vermont can gain full practice authority after completing 1,600 practice hours under the oversight of a physician. These NPs are also allowed to write prescriptions if they are registered with the state’s Prescription Monitoring System.
Treating patients without physician oversight is afforded to the NPs working in Washington, as well as the ability to write prescriptions for Schedule V controlled substances and other medicines.
As mentioned previously, APN compact legislation allows NPs in Wyoming to practice in Idaho and vice versa. Nurse practitioners in Wyoming also have full practice authority.
NPs in our nation’s capital have FPA as soon as they earn their licenses.
In Utah, NPs can treat patients without formal oversight.
Finally, this group of states allows NPs to have FPA after working under physician oversight for a set amount of hours/time:
- Delaware: two years and 4,000 hours
- Illinois: 4,000 hours
- Kentucky: four years
- Virginia: Five years and 9,000 hours
- West Virginia: Three years
FNP vs ACNP: Which is the Right Career Path for You?
When it comes to advanced practice nursing, the distinguishing factors between roles will often be about the settings and hours NPs work. Salaries for all NPs generally exceed $100,000, so the money associated with the job is less of a deciding factor than the work itself.
A family nurse practitioner typically has the stability of set hours in a primary care location. In contrast, an acute care nurse practitioner is typically going to work “hospital shifts,” with less certainty about work schedules. ACNPs may have to work night shifts, holidays, and weekends, in a role that is already physically (and emotionally) quite demanding.
FNPs may occasionally have to manage an emergency, after-hours situation, but for the most part, it is a career path geared toward those who prefer set schedules.
Both roles bring with them challenges and benefits, and both roles are incredibly important in health care today. NP roles will only expand more in the coming years, so either type we have outlined here is a “safe bet” in terms of jobs available.