Women s Health Nurse Practitioner

The Women s Health Nurse Practitioner Evolutionof a Powerful Role

Linda Curran, RN, BSN Today s women s health nurse practitioner (WHNP) role is the product of more than three decades of growth and change. As the role has evolved, both professional and public perceptions have not always kept up with the latest developments in the nature and scope of the role. Some are confused as to how the WHNP role varies from other nurse practitioner roles, such as family planning nurse practitioner or OB/GYN nurse practitioner, or even by general practice roles, such as family nurse practitioner. The Association of Women s Health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Nurse Practitioners in Women s Health (NPWH) (2000) refined the scope of nursing practice specific to the WHNP. As defined, WHNPs practice within a dynamic and highly autonomous role that requires expert knowledge in order to provide assessment, diagnosis, and treatment of the complex human responses of individual, families, or communities to actual or potential health problems (AWHONN & NPWH, 2000) (see Box 1). The American Nurses Association developed standards of advanced practice nursing. In addition to basic nursing standards for all registered nurses, advanced practice nurses must also adhere to standards that reflect the increased level of education, autonomy and responsibility. To fully explore the modern role of WHNP, it s important to see from where it has come, particularly its history, description, scope, standards of practice, educational requirements and certification guidelines. It s important for nurses today to understand the differences in these advanced practice roles and how these advanced practice nurses will continue to shape future trends in health care delivery.

Looking Back Although the first defined nurse practitioner began in 1965, WHNPs trace the roots of that role to the family nurse practitioner (FPNP) model developed in 1972 by the Planned Parenthood Federation of America (PPFA) (Andrist, 1998; National Certification Corporation [NCC], 2000; PPFA, 1998). The FPNP role was an outgrowth of Title X of the Public Health Service Act that was signed into law in 1992, making family planning services available to women who could otherwise have not afforded them (Allen Guttmacher Institute, 2001). The FPNP role was developed because there was an emerging need to increase the number of clinicians available to provide high-quality, low-cost reproductive health care to low income women living in underserved areas (PPFA, 1998). With the aid of both private and Title X funding, PPFA created the first certificate program to educate nurse practitioners. Graduates were employed primarily in state-run Title X funded clinics, but also in other public and private health care settings. FPNPs focused exclusively on reproductive health, particularly contraception and screening for and treating sexually transmitted diseases. In 1979, the PPFA nurse practitioner program was expanded and redesigned to meet outcomes consistent with OB/GYN nurse practitioner programs (PPFA, 1998). This role offered an expanded scope of reproductive care, and added prenatal and midlife care. In the late 1970s, many universities began certificate and master s level OB/GYN nurse practitioner programs (Andrist, 1998). The evolution of the female-focused nurse practitioner role reflected the increasingly powerful and vocal force of the women s health movement of the 1960s and 1970s. Feminist activists argued that women s health and wellness issues were not adequately addressed in what was then a predominantly male-centered health care system (Geary, 1995; Taylor & Woods, 1996). These activists also called attention to the fact that most research supporting clinical practice was based on studies of male subjects and inappropriately extrapolated to the care of women. This activism sparked changes in public health policy and research and demonstrated the need for primary care that addressed the unique needs of women (Andrist, 1998, Geary, 1995; Taylor & Woods, 1996). As it was, health care for women was both fragmented and medicalized (Andrist, 1998). Medical care was addressing Linda Curran, RN, BSN, is currently a master s candidate at the University of Miami in Coral Gables, FL. Box 1. Women's Health Nurse Practitioners WHNP guidelines are broken down into six basic areas (AWHONN & NPWH, 2000): client care nurse-client relationship health education and counseling professional role managing health care delivery quality of care health concerns in discreet body systems, such as reproduction, dermatology and psychiatry, but neglecting the woman as a whole human being. This led to the expansion of the OB/GYN nurse practitioner role into the more holistic primary care role of the WHNP (Geary, 1995). Today, the role is not limited to the reproductive health care needs of women; rather, it focuses on the primary health care needs experienced by women in relation to their age, environment and personal definitions of health and illness (Star, Lommel, & Shannon, 1995). As the role progressed toward a more holistic view of women s care, a more comprehensive educational curriculum was instituted to prepare new WHNPs. Nurse Practitioners The overall nurse practitioner role is set apart from other health care provider roles because care is provided to women using concepts and practices unique to nursing. The focus, then, is on wellness and the promotion of optimal stages of health, rather than on illness. Nurses are educated to consider the client and her health status within the context of her environment, family, friends, school, job, community and culture, juxtaposed against a framework of economic and social conditions. Additionally, nurses use highly developed communication skills to enhance interactions. This client-focused, holistic approach with its emphasis is especially important to the WHNP role. AWHONN and NPWH (2000) jointly define the WHNP roles as follows: The women s health nurse practitioner provides primary health care to women across the lifespan, with an emphasis on reproductive-gynecologic health. The practitioner uses the processes of assessment, diagnosis, management and evaluation to provide care that integrates the psychosocial and physical needs of women (p. 2) (see Box 2). 334 AWHONN Lifelines Volume 6 Issue 4

WHNPs are also expected to contribute to the advancement of the profession, which may be accomplished by serving as a role model and mentor to individuals considering a career as a WHNP, precepting nurse practitioner students, educating other health care professionals and the public about the professional role and participating in professional organizations and legislative activities. WHNPs should demonstrate leadership in achieving improved health care outcomes for all clients and evidence accountability through continuous quality assessment (AWHONN and NPWH, 2000). Educational Preparation Some may ask how the educational preparation for a WHNP differs from an FNP when it comes to women s care, and how those differences may affect the quality of care provided. A WHNP s preparation is based on a core premise that women s health needs are unique from men s. As such, WHNPs are educated within a completely female-focused paradigm. All health and social issues are studied in the context of how they affect women. In contrast, FNPs are educated to care for men, women and children, and as a result, educational preparation for FNPs is more generalized. This broad focus sparks FNPs to concentrate on issues as they affect the general population, and less on the unique needs of women. Traditionally, the general Box 2. WHNP Competencies AWHONN and NPWH (2000) further identify primary competencies, some of which include, establishing a therapeutic relationship with the client obtaining a health history and psychosocial database performing a physical assessment initiating and interpreting screening, diagnostic procedures and tests managing selected episodic conditions prescribing medication (as regulated by individual state nursing practice acts) providing health education in response to needs evaluating client outcomes making referrals as needed collaborating with other health professionals using research to enhance outcomes population approach to determining health care needs is biased toward men s health care because the majority of the research and clinical studies are male-focused (American Academy of Nursing, 1997). Although FNPs are useful women s health providers, WHNPs provide care that is more carefully tailored to the unique primary care needs of women. The National Certification Corporation (NCC) certifies WHNPs. While the NCC doesn t currently require that applicants have a master s degree in order to qualify to take the exam, in 2007 educational training at the master s level will become a requirement, and all WHNPs certified prior to the new requirement will be grandmothered in (Andrist, 1998). Currently, many individual states and third-party reimbursers require that WHNPs be prepared at the master s level (NCC, 2000). Universities are making efforts to assist practicing nurse practitioners prepared by certificate programs to acquire the education and skills to meet current demand for a full range of primary care services. These programs are being designed to help certificate-prepared WHNPs acquire the coursework necessary to complete the advanced degree, thereby enhancing the nurses job security and mobility (NCC, 2000). Currently, the NCC requires that nurses complete programs that meet the following criteria (NCC, 2000): The program must be at least one year in length (nine months) The program curricula must reflect the content of the WHNP examination, which includes the following: 8-12 percent primary care; 35-45 percent gynecology; 30-40 percent obstetrics; 10-15 percent pharmacology; and less than 5 percent professional issues At least 200 hours of the program s OB/GYN content must be didactic and 600 hours must be clinical The move toward master s level education as the entrypoint to practice has come about for a number of reasons (Ninger, 2000): Need for in-depth knowledge: The expanding role of the WHNP as the provider of comprehensive primary care requires that the nurse have an in-depth knowledge of women s health issues, achievable through the rigorous and comprehensive course of study offered in master s level programs Licensing requirements: Many states now have licensing requirements that include a graduate degree in the WHNP specialty area Reimbursement issues: Graduate education will be necessary for the WHNP to obtain third-party reimbursement (Ninger, 2000) Role identity: The new standardized education and certification requirements will assist in decreasing confusion about the role by the lay public and fellow health care professionals August September 2002 AWHONN Lifelines 335

Comparable educational preparation: The heightened educational requirements will bring the WHNP to an educational level similar to other professionals in the multidisciplinary health care team and will assist in reducing intraprofessional tension Women s Health Nurse Practitioner Guidelines (AWHONN & NPWH, 2000) discuss the WHNP s role within the interdisciplinary team in three ways: collaborates with other health care providers to achieve optimal outcomes recognizes the value of each provider s contribution to the comprehensive health care of women uses these collaborative relationships with health care professionals to strengthen the role of the WHNP Like advanced practice registered nurses, WHNPs partner their unique skills with medical specialists, other health care colleagues and support staff in providing care. These relationships are critically important to the effectiveness of WHNPs and should be nurtured and highly regarded. These collaborative relationships are also used to strengthen the WHNP role. When the WHNP works with other members of the interdisciplinary team, those members gain a better understanding and increased awareness of the WHNP s abilities and actions. The recognition of the value and importance of the role of the WHNP by other health professionals gives it further validation. The WHNP is responsible for mentoring future WHNPs by guiding and educating nurses and support staff about the profession and encouraging those who demonstrate interest and ability to pursue the necessary education. WHNPs have also affected interdisciplinary health care. Although the nurse practitioner role has at times met with some resistance from the medical community, medicine has been quick to appreciate the importance of the holistic approach of the WHNP role and has begun to adopt a similar approach in medical school programs (Taylor & Woods, 1996). Looking Ahead Three major trends affecting WHNPs are related to adaptation of care to the needs of an aging female population heightened and standardized requirements in WHNP education current oversupply of WHNPs in some areas of the country As the female population ages, fertility rates decline and life expectancy continues to increase, a demographic shift is taking place in the United States. Female baby-boomers women born in the postwar period of 1946 to 1964 are the largest segment of the population by age, consisting of approximately 38 million females. According to the Agency for Health Care Research and Quality (2001), the age composition of the American female population is changing. In 2025, there will be roughly the same number of women in every age group, from birth to seventy years old. This is a dramatic change from the pyramid-shaped population graphs of the past. To reflect the needs of this new American female population group, WHNPs will need to focus on preventive care throughout the life span. For example, the WHNP may shift emphasis from topics such as contraception, sexually transmitted diseases and perinatal care issues of adolescence and young adulthood to midlife concerns such as surveillance of breast health, cardiovascular health, diabetes, continence, reproductive cancers, osteoporosis and estrogen loss. WHNPs will also most likely be caring for more elderly women with chronic illnesses and helping them adapt to aging and caregiver The overall nurse practitioner role is set apart from other health care provider roles because care is provided to women using concepts and practices unique to nursing. The focus, then, is on wellness and the promotion of optimal stages of health, rather than on illness. support (American Academy of Nursing, 1997). The clients needs will, in effect, drive the WHNP scope of practice. Another major issue currently facing the role is the transition away from certificate programs to master s programs as the minimum standard of educational preparation for new practitioners. Women s health nurse practitioners have been slow to embrace preparation at the master s level. While the majority of nurse practitioner education currently occurs in master s programs, in 1996, however, it was noted that 66 percent of the candidates who took the NCC WHNP certification exams were certificate prepared and only 34 percent were master s prepared (NCC, 2000). Though articulation programs are available, many nurses still have not completed the education necessary to meet the heightened standards and recommendations endorsed by the NCC, AWHONN and NPWH. In failing to augment their education, these nurse practitioners may be effectively making themselves obsolete to third-party reimbursers. Looking ahead, this mandate may affect the profession in a number of significant ways: Professional Conflict There may be increased tension between master s and non-masters prepared WHNPs in the 336 AWHONN Lifelines Volume 6 Issue 4

practitioner programs if certificate-prepared nurses fail to pursue the additional education. It s also possible that the scope of practice of the WHNP may prove to be too narrow to make them attractive to employers in this age of financial constraints within managed care. Box 3. Getting All the Facts Association of Women s Health, Obstetric and Neonatal Nurses: www.awhonn.org National Association of Nurse Practitioners in Women s Health: www.npwh.org National Certification Corp: www.nccnet.org workplace as differences in educational background, scope of practice and reimbursibility surface Loss of Expert Practitioners If certificate-prepared nurse practitioners fail to meet heightened educational requirements, their value in the workplace may diminish because they lack the credentials necessary for third-party reimbursement. They may become less valuable to the employers and have difficulty securing employment. If this happens, the profession will lose the benefit of their experience and skills and the clients will lose a valuable partner in their health Public Perception In time, as the educational backgrounds of the WHNPs become standardized, public confusion about the role should diminish. Although heightened educational requirements may be difficult, costly and timeconsuming, they are a critical step to ensure the professional growth needed to meet today s sophisticated health care consumer Nurse practitioners may be reaching and exceeding a critical mass in our health care system (Leccese, 2000). With an increased number of university-level nurse practitioner programs, there is an unprecedented number of NPs coming into the workforce. This is especially true in areas such as the Northeast that currently have multiple programs producing master s-prepared nurse practitioners. For example, an apparent oversupply of WHNPs in New England may just be a regional phenomenon related to the concentration of graduate nursing programs in a small area or it may be the sign of an emerging trend. Predicting employment trends for NPs is difficult at best. The heightened educational requirements may create employment opportunities for new graduates of master s-level nurse References Agency for Health Care Research and Quality. (2001). Women s Health Highlights. Retrieved September 3, 2001, from http://www.ahrq.gov/research/womenh1.htm Allen Guttmacher Institute. (2001). Fulfilling the promise: Public policy and U.S. family planning clinics. Retrieved September 5, 2001, from http://www.agi-usa.org/pubs/ fulfill.pdf American Academy of Nursing. (1997). Women s health and women s health care: Recommendations of the 1996 AAN expert panel of women s health. Nursing Outlook, 45(1), 7-14. Andrist, L. C. (1998). Women s health: Where are nurse practitioner programs headed? Clinical Excellence for Nurse Practitioners, 2, 286-292. Association of Women s Health, Obstetric and Neonatal Nurses & National Association of Nurse Practitioners in Women s Health. (2000). The women s health nurse practitioner: Guidelines for practice and education [brochure]. Washington, DC: Author. Geary, M. A. S. (1995). An analysis of the women s health movement and its impact on the delivery of the health care within the United States. Nurse Practitioner, 20(11), 24-35. Leccese, C. (2000). What a difference two years makes: Results of the Advance 1999 national salary survey of nurse practitioners. Advance for Nurse Practitioners. Retrieved November 1, 2000, from http://www.advancefornp. com/npsalsurv99.html National Certification Corporation. (2000) Guidelines for NP articulation agreements. Retrieved November 1, 2000, from http://nccnd.org/certify/articulatevhtm Ninger, L. (2000). Consensus statement promotes nurse practitioner graduate education. The Nurse Practitioner, 4(suppl)(1), 8. Planned Parenthood Federation of America. (1998). OB/GYN nurse practitioner program: History. Retrieved September, 2, 2001, from http://www.plannedparenthood.org/about/nurse/hold/np_history.html Star, W. L., Lommel, L. L., & Shannon, M. T. (1995). Women s primary health care. Washington, DC: American Nurses Publishing. Taylor, D. L., & Woods, N. F. (1996). Changing women s health, changing women s practice. The Journal of Obstetric, Gynecologic and Neonatal Nursing, 25(9), 791-802. August September 2002 AWHONN Lifelines 337