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Practice Settings for NPs

Practice Settings for NPs: Community Health and Urgent Care Centers

The community health clinic and urgent care setting includes a diverse patient population. Nurse practitioners can expect to see patients ranging from pediatrics to adult and elderly. This setting requires a much more narrow set of practice skills than what NPs are prepared for. The advanced training nursing practitioners gain in their education programs prepares them for a variety of settings, including when to refer a patient to the emergency room. They may choose to practice in this type of setting for a variety of particular reasons. Some will clearly like the flexibility as well as the limited hours. There is also the benefit of independence in this role, and this can enhance their expertise because of the limited number of conditions that are usually seen. The typical patient has one of 10 conditions: upper respiratory infections, sinusitis, bronchitis, pharyngitis, otitis media, otitis externa, conjunctivitis, urinary tract infections, immunizations and screening tests or blood pressure checks. The other perks that some NPs enjoy, is the rapid pace of urgent care centers. They will find fewer obstacles when they are practicing in this type of setting. The education that they can pass onto their patients is extremely rewarding, and in this setting there is also greater time to dedicate themselves to health teaching and wellness promotion.

The health clinic and urgent care setting have strict guidelines and protocols in place so that if something falls outside of the written protocols then the patient should be referred to the emergency department or hospital. The NPs have provide services with the goal of caring for the non-urgent care concerns of patients, and in carrying this out they have decreased the pressure and influx on the emergency departments that would otherwise see many of this patient population. This has a two-fold benefit for the patient and the physician practice setting. If the patient is seen after-hours in one of the urgent care centers, the facility will send a report to the patient’s regular physician office to let them know of the patient’s condition and what treatment was given.

These clinics, often times, serve a patient population that would not otherwise seek treatment. The nurse practitioners are able to assist this population in seeking and receiving the much-needed medical treatment that they would not receive without these clinics. The clinic setting is a non-threatening setting that offers the patient the ability to have an open conversation and offers care to this population and others for urgent care needs that may not be met without this service.

When deciding what area or clinic to choose to work in, nurse practitioners have many options. There are currently private practice clinics expanding their hours to offer after-hours care as well, as they are also seeing the demand for this type of care. Also, urgent care centers (or retail health clinics) have opened up in almost every local pharmacy across the country. For private practices that do not offer after-hours care, their patients are forced to go elsewhere for urgent care, which benefits neither the patient nor the practice. Keep in mind that the ultimate goal of nurse practitioners is to provide medical care and teaching to their patients and the clinic setting offers that choice for both patient and practitioner.

Practice Settings for NPs: Home Health and Nurse Practitioning

The home health care field is another area or setting that a nurse practitioner can choose to practice in. The skills and advanced training that is necessary for this setting is taught during the schooling process and offers NPs the opportunity to assist the home health industry in modeling and assisting with operations. Home health nurse practitioners are able to assess in-home patients, administer care, order testing if necessary, perform physical examinations and prescribe medications. This provides them with similar duties to that of a physician. This will all change when the institution of the new doctorate level education requirements takes effect in 2015.

Home health nurse practitioners can offer greater flexibility with teaching patients and families and also promote health maintenance programs. They are able to manage the health care team of professionals that will take care of the patient in the home setting. The team provides ongoing evaluations and the nurse practitioner takes the lead role in the multidisciplinary approach to the patient’s well being.

The educational background that is necessary for home health care will help advance them in their clinical knowledge of chronic diseases as well as post-surgical management. One of the most beneficial skills that NPs bring to the home health field is their nursing perspective. They are trained as nurses first, and the training, skills and areas they can offer to the patient are often areas that a physician may overlook. For example, the patient may feel more comfortable talking about certain things with their NP instead of their physician. Home health NPs will often times assess skin conditions more thoroughly than physicians, since this was an area of primary concern when the was a practicing registered nurse.

Nurse practitioners have ever-changing roles, and currently there is a bill that was introduced for legislation on Jan. 31, 2011. The Home Health Care Planning and Improvement Act allows payment for home health services to Medicare beneficiaries by: (1) a Nurse Practitioner, (2) a clinical nurse specialist working in collaboration with a physician in accordance with state law, (3) a certified nurse-midwife, or (4) qualified graduates of physician assistant programs working under a physician's supervision. The introduction of this bill can offer greater flexibility to nurse practitioners, as they can offer the patient additional care with coverage payment from Medicare where appropriate.

NPs should take into consideration that his or her role in home health would be a unique area. To work in home health, the NP should desire to help patients in their home environment. Sometimes this can be a difficult situation, since entering a patient’s home places the practitioner on a different level from that of the typical office settings. The NP must respect the patient’s wishes and involve the family in the care, since they will most likely be assisting with activities of daily living and hands-on care for the patient. The well being of the whole family can benefit from the nurse practitioner and the teaching that takes place in the home. To choose home health as the setting to work in will be a diverse and fulfilling career option for many nurse practitioners.

Practice Settings for NPs: Hospice

It takes a special individual to specialize and practice as a nurse practitioner in the hospice setting. It requires providing compassionate care to the patient and family members as a unit. Hospice patients are at the final stages of life and the primary concern is comfort. The terminally ill can have hours or days to live and the family is at the bedside along with the nurses to care for the unit as a whole. This type of care will be provided to a patient for six months. The physician must certify that patient is in end-of-life condition. The nurse practitioner can follow the patient and can certify the patient as end of life, only if he or she is considered the “attending physician.” The nurse practitioner has experience with dying patients and caring for them in a clinical practice, but the hospice setting is different. The NP is responsible for making sure all of the needs of the patient are met, be it physical, emotional, psychosocial and spiritual.

Hospice care is a practice setting in which patients receive care for many conditions such as heart disease, dementia, Alzheimer’s, lung disease and end stage renal disease. Nurse practitioners in this role are essential in providing the preparation for the end-of-life needs. This person needs to have assurance that the other medical professionals involved have the same goal for the final days of care. NPs are easily able to provide this because they are nurses first and medical prescribers second. They can offer a unique approach to that of a general physician and this is second nature to them.

There are several hospice care settings that nurse practitioners can practice in. Each is different and addresses the patient’s needs in a different way. First, the hospital setting that treats the seriously ill patient can often offer a hospice program. This can allow the patient and family to have additional support system and health care professionals. Nurse practitioners can practice in this setting and care for his or her patient through the continuum of care. The end-of-life concerns can be addressed and there is a medical pharmacy on site to provide pain medications, anxiety medications and address all the needs of the patient and family. Next, many nursing homes and long-term care facilities have a small hospice unit available. They have specially trained nursing staff and individuals who can make arrangements to have hospice provide the care. The patient’s physician would follow them in this setting and the nurse practitioner would assist in the delivery of care and management of the end-of-life needs. Finally, there are freestanding, independently owned hospice facilities that have a building as well as home care hospice to offer the patient. This can be beneficial for the person who does not have primary caregivers available at home. They can assist the family in making the decision and if they feel this is a viable option the NP can follow the patient through to their final stages of life.

Nurse practitioners are able to offer the diverse background as a nurse as well as the prescriptive authority of a physician in the hospice setting. This is beneficial for the patient and the caregivers. They are able to relate to the NP in a unique way that may not be found with just a physician. Consider the option of hospice as a diverse and challenging specialty that rewards you with the many lives one can touch and help in their end-of-life decisions. This alone is one reason why it takes a special nurse practitioner to practice in this setting.

Practice Settings for NPs: Private Medical Practice

Practicing in a private medical practice is often the first choice for a new nurse practitioner. This can offer the practitioner the support system and familiarity of the medical practice setting while still having the independence one needs to develop clinical practice skills. In the medical practice settings across country, nurse practitioners have the opportunity to work with together in practices where their skills complement one another. Some physicians feel that they’re unavailable to consult, the nurse practitioner might order unnecessary testing and studies that will drive up the cost of health care, while making the patient wonder why the tests are being performed. This is an ongoing debate in the health care community.

The private medical practice setting offers NPs the choice to see patients on a daily scheduled routine. It can provide them the ability to collaborate with the physicians on staff to ensure all treatments, testing and clinical care is provided to the patient. These nurse practitioners have a diverse background and advanced clinical, pharmacology and physiology. The private practice setting can offer a diversity of hospital rounds as well. The NPs will see patients in the office setting as well as the hospital setting for continuity of care. This offers them the chance to follow their patients through an acute or chronic disease state. Then get to follow up with their patients at the private practice after discharged from the hospital.

With the new and coming education requirements for nurse practitioning, NPs will be required to achieve their doctorate prior to certification and licensing. There will be additional opportunities to assist the primary care community with the shortages that are currently rising. This change in the role for the NP will benefit the private practice setting with the diversity of skills and additional independence the NP will hold. This change will take place by 2015 and is being implemented in the Advanced Practice Registered Nurse consensus model. More information can be found about this model at www.ncsbn.org/aprn.htm. The scope of practice barriers that hinder nurses from practicing to the full extent of their education and training can be changed one step at a time with the implementation of this model.

The health care industry needs to be sure that they are using all the skills that the NP has acquired to tap into the shortages and voids where primary care and private practice settings are concerned. With the shortage of primary care physicians and the new changes in health care laws, the influx of newly insured patients will increase exponentially. This will only compound an already taxed system, so employment for nurse practitioners will only increase when these changes take place. Think of the benefits for the patient who doesn’t have to wait weeks to obtain an appointment. Since the employment of nurse practitioners, available openings for scheduled appointments and greater and can thus accommodate additional office visits, which improves patient flow.

As an NP, if this is an area of interest for you then the advanced clinical training and knowledge can offer open up this door for you. Nurse practitioners can provide the skills, patience, teaching and health education and maintenance that the modern day patient of today needs. This is just the right fit for a nurse who wants to practice independently in a private practice setting, but still has the collaboration of the health care team environment to fall back on. Take a look and see what you think when you are at your next private practice appointment. Who sees you the most, the physician or the nurse practitioner. I bet you will see the changes already coming into play.

Practice Settings for NPs: Public or Private Schools

Nurse practitioners who select the setting of public or private school can provide care and instruction to children and teens throughout the school year. There are many public and private schools as well that offer routine health care, where a child can be treated when they are ill. You can also choose to talk to counseling and social support services as well. These centers do not replace the child’s regularly scheduled pediatrician visits, but enhance and provide primary care, health education as well as mental health services as needed. Health education can be provided on an individual basis or the nurse practitioner can choose to provide classroom instruction and select the topics for classes according to age and appropriateness of the subjects that are needed.

In the medical health centers if the child is under 18 years of age, and if the child will need counseling it is also offered around adolescent health issues because basing your decisions on reliable information can help you lead a healthier life. The nurse practitioner will assist students in understanding the health issues that concern adolescents. The practitioner is able to provide treatments, specific medication per agreements and consent from parents and guardians. The main role, however, is teaching and support of the ancillary staff when necessary.

To prepare for this role as a nurse practitioner there is extensive training and advanced clinical classes in pediatric and also teen health issues. The issues that they will see in this practice setting can range from a common cold to a teen who is questioning pregnancy concerns. This is a dynamic setting to tackle and takes a special practitioner; one who desires to help children, teens and families with the daily challenges that children face today in public and private schools. Often there are clinics set up to assist the students with obtaining information on specific areas of concern from relationships and student interaction, to common hygiene and puberty changes that happen at this age. Each school is different in the information that will be offered to students and their peers. The information is often voted on at the school board meetings and presented to parents prior to having exposure to children if it is a sensitive topic. All teaching done by the nurse practitioner is age specific for the needs according to the class level. This can be the most challenging part of the public school practitioner.

Think of the possibilities and the many children who will benefit from a nurse practitioner in this setting. They have individualized clinic care that they can offer to the children, and any special needs can be referred to the child’s pediatrician for follow-up. This type of health clinic can provide the necessary go-between that a child needs in-between their check ups and well visits to the pediatrician. By having an onsite advanced practitioner in the school, problems that may not get cared for regularly can be exposed and the nurse practitioner can address the areas they can take care of and then other physical or mental problems can be taken care of by specialists of that particular area.

Consider this setting if you are the kind of person who reaches out to children and sees the need in your public or private school district. This position offers rewards for the practitioner, child, parents and school alike. There will be numerous changes that take place within a school that can offer care for a child’s health and well being. This is definitely a change from the schools that only offer an onsite nurse, because with an advanced nurse practitioner on hand the medical needs can be met on a daily basis instead of waiting for the child to see their pediatrician. This can benefit the students in getting timely treatment when necessary and further decrease missed days of school and missed opportunities for promoting health education and maintenance.

Practice Settings for NPs: Public Health Department

In the public health department, nurse practitioners work with a physician to provide primary care to patients. Their advanced training permits NPs to care for the physically ill and also provide preventive health program teaching to patients and their families. These programs are monitored by the Department of Health and are regulated by local, state and federal program guidelines, policies and regulations. Funding is provided accordingly through the budget process under the health department’s particular state.

When working in this setting, nurse practitioner focus their care on preventive care vs. actual treatment. The NPs promote healthy lifestyles and safe work and home environments to assist their patients, which will potentially lead to needing fewer visits to a health care facility. The main goal for public health nurses is to educate patients with diverse community programs. This helps the community unite to assist one another in times of need. Some of the programs that nurse practitioners focus on are diet, infectious diseases, substance abuse, teen pregnancy and parenting and social interactions. Nurse practitioners working in this setting will learn the needs of their community and will then focus on meeting those needs.

Nurse practitioners should be aware of any cultural sensitivities within the community. The public health practitioner has to be aware of the cultural differences within the community and also have the ability to keep an open mind and understand the culture and environment of the community. Public health nurse practitioners must be able to focus on public health needs and develop programs that can assist the people of the community.

When a practitioner chooses to be a public health nurse, he or she will normally provide access to health care for many underprivileged populations within the community. This patient population may include poor and underinsured patients as well as patients from many different cultural backgrounds. These patients often come to a community health clinic for counseling and other services that may not be offered to the patient in another setting. The treatments or services can range from simple immunizations to connecting the individual or family with the necessary support system to find adequate housing, job placement, food services as well as health support and maintenance.

The public health practitioner should be willing to discuss the issues and concerns that might otherwise not be addressed at a physician office visit. The nurse has the potential to lead his or her career into many various work environments within the public health setting. This can include health clinics, community centers and also patients’ homes. There are also outreach positions available for nurse practitioners to practice in and offer their services within government agencies such as disaster relief and support services.

As public health practitioners help build the steps and paths in a communities there will be new relationships formed, existing relationships strengthened, and weak relationships rebuilt. The community will be strengthened and be able to provide its members with greater stability to face future challenges

Public health practitioners play an important role in collecting data on the disparities in the community. The goal is to track the progress of disparities and possibly eliminate them in the future. Accurate data collection is essential to this process. By interviewing patients, community members and collecting data with a comprehensive assessment tool that the practitioner creates, he or she can plan and prioritize the changes that need to take place to provide early intervention and promote healthy changes.

The responsibilities of public health nurse practitioners include the assessment and history of the patient and performing physical examinations. If testing is necessary, lab tests and diagnostic tests may be ordered. There may be referrals needed or a consultation requested if the practitioner feels it is required. Prescriptions and medical appliances can be ordered if they are needed for the patient’s treatment plan. Education and counseling is provided and also follow-up appointments will be scheduled to evaluate the ongoing treatment plan. Documentation is essential and the governmental agency will dictate the required summaries and reports necessary.

This is an overall summary of the areas and essential duties of public health nurse practitioners. If a nurse practitioner chooses this work setting, it can be a rewarding and challenging opportunity to grow and work within their community.

Practice Settings for NPs: Nursing Homes

With the ever-changing roles of nurse practitioners, nursing homes can offer a diverse and creative environment for NPs to utilize their advanced skills. The use of a nurse practitioner in this setting can improve the quality of care that patients in the nursing home receive. The full range of primary care services that NPs can offer can help meet the needs of the facility and the professional standards of care. In addition to a full range of patient care services, NPs also provide medication and non-pharmacologic therapeutic modalities throughout the facility.

The practitioner is an expansion of the clinical care that can usually be provided by a physician. NPs expand the care and nursing services the facility offers and identify goals to create a more holistic approach to the nursing model. Their views are validated and supported by the nursing staff and the director of nursing.

The nursing home patient population can vary from gerontological to adult and sometimes even young adult population. The accessibility of nurse practitioners provides great assistance in meeting the needs of the patients. This can be beneficial in establishing communication and assisting the nursing and support staff with go-between person to discuss the patient’s issues and concerns. Nurse practitioners decrease cost by minimizing physician visits and patient transfers to the hospital. If the NP increases staff education this can provide a clear procedure about when to transfer a patient to the hospital and when to notify the physician or nurse practitioner about an issue or concern.

NPs are an excellent fit in the nursing home setting. They are able to provide advanced clinical care with extensive training as well as being available to teach residents and families about their health status. By incorporating health strategies and activities of daily living management, nurse practitioners can help empower patients to take an active role in their daily care. The nursing support staff also plays an important role in this process and the NP can teach them the knowledge and skills needed to carry on the job for continuity of patient care.

When deciding what setting to work in after certification, the nursing home setting can provide fulfillment to nurse practitioners who offer diverse and creative care for this population. The advanced training in pharmacology, acute and chronic disease states, as well as their extensive teaching and health maintenance perspective provides ongoing support to this aging population. The unique needs of nursing home patients can be challenging and offers nurse practitioners a chance to utilize all the skills learned in their clinical practice as well as management of ethical and moral issues concerning end-of-life issues.

To take on the challenges and changes that occur in the nursing home today, nurse practitioners need to maintain all aspects of professional patient care. To be able to provide the care of a physician and prescribe, monitor, and maintain the patient throughout the continuum of care is essential for the well-being and life maintenance of this population.

Practice Settings for NPs: Hospitals

In the hospital setting a nurse practitioner takes on a completely different role as the physician liaison. They treat the general patient population by taking care of their health needs. They also assist in developing the treatment plan for the patient and have their own caseload of patients who they follow from admission to discharge. They make daily rounds on each patient and assess, evaluate and modify any treatments currently ordered for the patient. They talk with the health care team to adjust or write additional orders that the patient may require to help assist in the care process. Nurse practitioners play an essential role in teaching patients and families about their health status and how the treatments, tests and medications will benefit and assist with the diagnosis and healing process. This is an ongoing process from the time the patient is admitted and continues through to discharge, when the patient will follow up in the physician’s office post-discharge. NPs offer a broad range of services to patients of all ages when hospitalized.

In order to offer care in a hospital setting, nurse practitioners must take a few required steps.. Hospital privileges ensure the continuity of care for patients and this permits the practitioner to actively take part in the inpatient care process. If this is to take place they must obtain credentialing first. The credentialing process takes place and the hospital has a review board of physicians that will review qualifications and decide whether to grant privileges. If privileges are granted this also gives the nurse practitioner negotiation benefits to obtain a higher base salary or a certain percentage of the collected hospital revenue.

This credentialing process takes time and there are bylaws and state laws that have to be followed. These laws will dictate the scope of practice and many states require the physicians to monitor or co-admit the patients. Each state varies and will be taken into consideration when the nurse practitioner submits his or her application, which is generally 10 to 20 pages in length. The verification process will start with license, photo identification, child abuse clearances, and criminal background checks. They will also need a copy of the applicant’s resume, DEA certificate, malpractice certificate and CPR/ACLS documents. A negative Mantoux test within one year as well or a negative chest X-ray report if the Mantoux was positive will need to be obtained. This must all be provided in order to be considered for admitting privileges.

Some facilities will require a physician to sponsor the applicant. This document will be signed by one or two select physicians who work with the nurse practitioner in the physician practice. They are taking ultimate responsibility for supervising the care that the NP will provide within the hospital setting. There is usually a policy included on the co-signature of orders that needs to take place within 24 hours after the NP writes a new order on the patient’s chart.

This process can take time and it varies from facility from three months up to one year after all documentation has been received. Then once granted privileges the nurse practitioner will have full privileges or ancillary privileges. The full privileges permit admission, rounds and discharge without supervision or a co-signature being required. The ancillary privileges offer collaboration with the supervising physician when performing these duties.

The last area that should be considered when applying to a hospital setting is whether to even apply for credentialing. In some states nurse practitioners are recognized by managed care organizations as a primary care provider. This would be essential in receiving privileges to admit to the hospital setting. Other settings do not support the management of hospital patients and in this case privileges might not be necessary to obtain.

Some of the additional responsibilities for the role will include overnight taking call, which requires additional work hours. These hours are often at the beginning or end of the day’s work and there may need to be additional rounding or a second round on a patient that presented some concerns and changes in their treatment plan that day. This situation needs followed up on prior to signing off for your shift to the covering physician or another NP within the practice.

These are all areas to take into consideration when selecting whether to work in a hospital-based setting. The challenges are great, but the rewards are even greater. To collaborate with the health care team and assist a patient in the health care process can offer a great sense of satisfaction at the end of the day


Last Updated: 05/19/2014

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