05-3425. Final Nurse Practitioner and Nurse-Midwifery Education Program Guidelines

AGENCY:

Health Resources and Services Administration, HHS.

ACTION:

Final Nurse Practitioner and Nurse-Midwifery Education Program Guidelines.

SUMMARY:

On November 3, 2003, the Health Resources and Services Administration (HRSA) published for comment proposed revisions to the Nurse Practitioner and Nurse-Midwifery Education Program Guidelines (Guidelines) for use in the Advanced Education Nursing Grant Program. HRSA has considered the comments received and is publishing the final Guidelines with responses to the comments.

DATES:

These Guidelines are effective immediately.

FOR FURTHER INFORMATION CONTACT:

Irene Sandvold, Division of Nursing, Bureau of Health Professions (BHPr), HRSA, Room 9-36, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, telephone [phone].

SUPPLEMENTARY INFORMATION:

On November 3, 2003, HRSA published in the Federal Register (68 FR 62299) for comment proposed revisions to the Nurse Practitioner (NP) and Nurse-Midwifery Education Program Guidelines for use in the Advanced Education Nursing Grant Program under sec. 811 of the Public Health Service Act. The public comment period on the proposed guidelines closed on December 3, 2003. The Department received comments from four professional nursing associations. These comments, HRSA's responses to the comments, and the final Guidelines are set forth below, according to the applicable headings of the Guidelines. Copies of the final Guidelines are available at http://www.bhpr.hrsa.gov/​nursing and from the Division of Nursing at the above address.

Summary of the Comments and Response to the Comments Overview—Nurse Practitioner Education Program

Core Competencies and Specialty Competencies

One commenter stated that the Guidelines should require all NP graduates to meet the core competencies, as well as the national specialty competencies in an area of specialty preparation. Another commenter suggested that the Guidelines should be revised to clearly require NP graduates in specialty areas, such as psychiatric-mental health NP and acute care NP, to meet any applicable national specialty competencies, in addition to meeting the national NP core competencies.

We agree with these comments and have revised this section to clarify that all NP graduates are expected to meet the national core competencies (Advanced Nursing Practice: Curriculum Guidelines and Program Standards for Nurse Practitioner Education; and, the Criteria for Evaluation of Nurse Practitioner Programs, A Report of the National Task Force on Quality Nurse Practitioner Education), in addition to meeting any applicable national specialty competencies, such as those established in Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, and Women's Health.

Consistency With Master's Education Guidelines

One commenter requested that the Guidelines add the expectation that Nurse Practitioner programs be consistent with the American Association of Colleges of Nursing's (AACN) Essentials of Master's Education for Advanced Practice Nursing. This document provides a framework for educators in designing and assessing masters' nursing education programs for advanced practice nurses.

We believe that the provision in the Advanced Education Nursing Program application guidance requiring documentation that the program for which financial support is requested meets national standards and guidelines available for the specialty sufficiently addresses this requirement. However, for clarity, we revised the Overview section to address this point.

Applicability of the Guidelines to Primary Care Nurse Practitioner and Specialties related to Acute Care Nurse Practitioner Education

Two commenters recommended that the Guidelines address and be made applicable to all NP training programs, whatever their specialty focus, rather than applying just to programs preparing NPs solely in primary health care. They pointed out that programs must prepare NPs to deliver both primary care and acute care services within a variety of health care settings and that NP education programs need the flexibility to respond to the rapidly changing health care system.

We agree with these comments stating that the Guidelines should address NP education programs that prepare NPs to practice across a continuum of settings and to care for individuals in various stages of health and illness. Since the Guidelines were originally published in 1977, the health system has gone through tremendous change. Formerly, the Guidelines only applied to programs preparing NPs in primary health care delivered in a variety of settings to various segments of the population. NP education programs that focus on specialties other than primary health care were supported under the Advanced Education Nursing authority but were not required to meet the Guidelines.

We agree that all NP programs funded under sec. 811 should meet the Guidelines and have revised the Guidelines accordingly. The Guidelines now apply to all programs funded under sec. 811 for the education of NPs and nurse-midwives. This includes programs that prepare NPs to:

• Practice in a wide range of settings, such as acute care hospitals, long term care facilities, and community-based clinics;
• Serve various segments of the population, such as adult, family, gerontological, pediatric, and women; and
• Focus on specialties in addition to primary care, such as acute care and psychiatric mental health.

Length of the Program

One commenter requested the deletion of the minimum length of the program requirement. Since this funding is not available for short continuing education programs, we have retained the minimum length requirement to notify potential applicants of this eligibility requirement. However, this requirement should not hinder innovative programs. Although the program, itself, must meet the minimum length requirement, the individual participants of the program have the flexibility to complete the program in a shorter time using strategies such as entering with some prerequisites or requirements already completed or by achieving competency in a shorter time frame.

Student Enrollment

One commenter suggested that the student eligibility requirement for Nurse-Midwifery programs be revised to delete the requirement of a registered nurse license to make eligible students who study nursing after receiving a baccalaureate degree in another field in accelerated intensive second degree nursing programs. Deletion of a registered nurse license requirement is not necessary to meet these concerns because these accelerated, intensive second degree nursing programs with a graduate specialty in nurse-midwifery are already eligible. The section entitled “Student Enrollment” includes as eligible a program leading to a graduate degree in nursing, in which the students are licensed to practice nursing “at or prior to the time of completion of a program.”

Faculty Qualifications

One commenter requested that HRSA add a “nurse practitioner” to the list of educators contained in the first sentence in the Faculty Qualifications section. Another commenter suggested that faculty with particular experience in the same specialty focus as the track should lead curriculum development.

These comments express the intent of the Guidelines as originally issued and as proposed. We concur with these comments and, for improved clarity, we have revised this section as requested.

Definition of Nurse Practitioner

One commenter stated that the definition of a nurse practitioner is inconsistent with the definition of “nurse practitioner or nurse-midwifery program” due to the omission of the role of the NP in the acute care setting. The commenter suggested revising the definition of NP to include the role of the nurse practitioner in the specialty practice of acute care in the acute care setting.

We believe that all NPs need the orientation to primary health care and health promotion that is included in the nurse practitioner core competencies, including NPs who are prepared for specialty practice in areas such as acute care and psychiatric mental health. Therefore, we revised the definition of NP to clarify this point.

One commenter recommended that the definition of NP include specifically the performance and supervision of laboratory tests.

We concur with this comment and have revised the definition of NP accordingly.

Definition of Post-Master's Nurse Practitioner or Nurse-Midwifery Education Program

One commenter emphasized the importance of documentation of the academic credits and certificate of completion for a post-master's nurse practitioner or nurse-midwifery education program on the academic transcript. We concur with this comment and have revised the definition of post-master's program to address this point.

Definition of Primary Care

One commenter suggested that to reflect the evolving education and practice of NPs, the definition of primary care be clarified to reference the delivery of primary care in a variety of settings, including homes and ambulatory facilities, long-term care facilities, acute care and other health care settings. The commenter interpreted the lack of reference to specialty areas of NP practice, such as acute care, palliative care, rehabilitation, and psychiatric mental health, in the definition of primary care as limiting the programs eligible for grant support under this authority.

The definition of primary care in the Guidelines is universal in application. Since it applies to the delivery of primary care in every setting, it is unnecessary to specify any particular settings. In addition, the reference to any specific settings could be confusing by implying a limitation in application. We understand that due to changing demands in the health care delivery system, increasing numbers of nurse practitioners are providing specialty health care services in acute, critical and long-term care settings. Innovative programs that prepare NPs in specialty areas to meet these emerging population needs are eligible for support; however, these programs must now be consistent with the Guidelines and meet the core competencies.

Accordingly, HRSA has revised the proposed Guidelines to read as follows:

Federal Nurse Practitioner and Nurse-Midwifery Education Program Guidelines

Background

The Federal Nurse Practitioner and Nurse-Midwifery Education Program Guidelines (the Guidelines) promote the quality of nurse practitioner and nurse-midwifery programs funded by the Health Resources and Services Administration (HRSA) and implement section 811(c) of the PHS Act, which states that:

Nurse Practitioner and nurse-midwifery programs eligible for support under this section are educational programs for registered nurses (irrespective of the type of school of nursing in which the nurses received their training) that—

(1) Meet guidelines prescribed by the Secretary, and

(2) Have as their objective the education of nurses who will upon completion of their studies in such programs be qualified to effectively provide primary health care, including primary health care in homes and in ambulatory care facilities, long-term care facilities, acute care, and other healthcare settings.

The Guidelines were originally issued in 1977 as an appendix to regulations implementing the corresponding grant programs. In 2001, as an effort to simplify government procedures, HRSA issued a final rule (66 FR 44981) that rescinded and removed most of the Bureau of Health Professions (BHPr) regulations, including the Guidelines. In the November 3, 2003, Federal Register, HRSA published revised Guidelines for comment. In 2005, February 23, 2005, HRSA published in the Federal Register final revised Guidelines that include appropriate changes.

Overview

Master's nurse practitioner and nurse-midwifery education programs are expected to be consistent with the most current editions of the American Association of Colleges of Nursing's (AACN's) Essentials of Master's Education for Advanced Practice Nursing (available from AACN at http://www.aacn.nche.edu.

Nurse practitioner education programs funded under this authority are graduate level programs that can provide evidence of accreditation from a recognized body or by a State agency, approved for such purpose by the U.S. Department of Education. In addition, programs are expected to be consistent with the most current editions or most current sections of Advanced Nursing Practice: Curriculum Guidelines & Program Standards for Nurse Practitioner Education; and, Criteria for Evaluation of Nurse Practitioner Programs, A Report of the National Task Force on Quality Nurse Practitioner Education (available from the National Organization of Nurse Practitioner Faculties (NONPF) at http://www.nonpf.com). Nurse practitioner graduates, at a minimum, must meet the national core competencies established in the most current editions or updated sections (such as “Domains and Competencies of Nurse Practitioner Practice—2002” ) of Advanced Nursing Practice: Curriculum Guidelines and Program Standards for Nurse Practitioner Education; and Criteria for Evaluation of Nurse Practitioner Programs; and any applicable national specialty competencies such as those established in the most current Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, and Women's Health or most current relevant sections of these documents. This document is available online at http://www.nonpf.com and http://www.aacn.nche.edu.

Nurse-Midwifery education programs must provide evidence of pre-accreditation or accreditation from the Division of Accreditation (DOA) of the American College of Nurse-Midwives (ACNM), recognized for this purpose by the U.S. Department of Education, prior to Notice of Grant Award. All programs must comply with the following criteria, as applicable:

(a) The current Criteria for Pre-accreditation of Education Programs in Nurse-Midwifery and Midwifery with Guidelines for Elaboration and Documentation of Pre-accreditation Criteria; or

(b) The current Criteria for Accreditation of Education Programs in Nurse-Midwifery and Midwifery with Guidelines for Elaboration and Documentation of Accreditation Criteria.

At a minimum, graduates of these programs must be prepared to meet national competencies established in The Core Competencies for Basic Midwifery Practice. The above three documents are available from the Division of Accreditation of the ACNM at http://www.acnm.org.

Organization and Administration

A nurse practitioner or nurse-midwifery education program should actively collaborate with nurses and other health professionals who have expertise relevant to nurse practitioner or nurse-midwifery practice and primary health care, to assist in the initial and ongoing planning, implementation, and evaluation of the program.

Student Enrollment

All students enrolled in a nurse practitioner or nurse-midwifery education program should be licensed to practice nursing—

(a) At the time of enrollment, or

(b) In the case of a program leading to a graduate degree in nursing, at or prior to the time of completion of a program.

The policies for the recruitment, selection and progression of students should be consistent with the requirements of the sponsoring institution and developed in cooperation with the faculty responsible for conducting the nurse practitioner and/or nurse-midwifery program. Programs should develop, implement, and evaluate specific plans to achieve recruitment, retention, timely progression and graduation of a diverse student body.

Length of Program

A nurse practitioner or nurse-midwifery education program is a formal program of study of a minimum of 1 academic year (9 months) in length and should include at least 4 months in the aggregate of full-time didactic instruction. Post-master's programs must also meet this requirement. Individual students may be able to complete the program within a shorter time frame.

Curriculum

A nurse practitioner or nurse-midwifery education program should be a distinct program of study consisting of didactic instruction and supervised clinical practice designed to teach registered nurses the knowledge and competencies needed to perform the functions and scope of practice of a nurse practitioner or nurse-midwife. The faculty has the ultimate responsibility for evaluation of student clinical performance and achievement of competence. The nurse practitioner and nurse-midwifery specialty portion of the graduate curriculum should be developed and implemented cooperatively by nurse practitioner and/or nurse-midwife educators, other graduate nursing faculty, and appropriate representatives of other health disciplines. Interdisciplinary academic and practice learning experiences are recommended to prepare graduates to serve underserved populations in complex health systems. The program content, both didactic and clinical portions, should prepare the nurse practitioner or nurse-midwife to provide primary health care within a community perspective. The nurse practitioner and nurse-midwife should be knowledgeable about the cultural factors that affect the health status of the populations served and how to assist the community make decisions about its priorities and health services. The curriculum must include student preceptorships and/or other clinical learning experiences. Faculty should develop and assess clinical learning sites through site visits and prepare clinical faculty and preceptors for teaching, evaluating, and problem solving with nurse practitioner and nurse-midwifery students. Nurse practitioner or nurse-midwifery program faculty should retain full responsibility for assuring the quality and effectiveness of each practicum site for student learning. Specific criteria used for the selection of clinical learning sites should be documented in the application.

Faculty Qualifications

A nurse practitioner or nurse-midwifery education program should have a sufficient number of qualified nurse practitioner or nurse-midwifery, nursing, medical and other related health professional faculty with academic preparation and clinical expertise relevant to their areas of teaching responsibility and with demonstrated ability in the development and implementation of educational programs. The program director should be a nationally certified nurse practitioner or nurse-midwife with appropriate academic preparation, clinical expertise and experience as an educator. The lead faculty for a specialty track must be certified in the specialty. Nurse practitioner and nurse-midwife clinical faculty and preceptors must have national and/or State certification as appropriate for their specialty and must have at least one year of practice experience as a nurse practitioner or certified nurse-midwife. Other clinicians serving as clinical preceptors must be authorized by the State licensing entity to practice in their specific scope of practice. Faculty qualifications should be consistent with the requirements of their academic institution. The faculty must participate in maintenance of competency and clinical practice.

Resources

A nurse practitioner or nurse-midwifery education program must have available sufficient educational and clinical resources in a variety of practice settings with adequate space and equipment, number, age and type of clients needed for the students enrolled in the program. Where the institution or organization conducting the program does not provide the clinical practice settings itself, it should provide for such settings through written agreements with other appropriate institutions or organizations.

Definitions

The following terms are defined for purposes of the Nurse Practitioner and Nurse-Midwifery Program.

Culturally and Linguistically Appropriate Services means health care services that are respectful of and responsive to cultural and linguistic needs.

Full-time Student means a student enrolled in at least the number of credits defined as full-time by the institution.

Full-time educational program means an educational program that provides for a full-time program of study as defined by the institution. Students progressing through the program are able to enroll on a full-time basis to complete the program in a timely manner. Students in such a program may be part-time or full-time.

Nurse-Midwife means a registered nurse educated in the two disciplines of nursing and midwifery who has successfully completed a nurse-midwifery education program accredited by the Division of Accreditation of the American College of Nurse-Midwives (ACNM). Following ACNM Certification Council (ACC) certification, the nurse-midwife has ability to provide independent management of primary health care for women in the context of family-centered care focusing particularly on pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and gynecological needs of women within a health care system that provides for consultation, collaborative management or referral as indicated by the health status of the client. This ability includes the:

• Assessment of the health status of women and infants, through health and medical history taking, physical examination, ordering, performing, supervising and interpreting diagnostic tests and making diagnoses;
• Institution and provision of continuity of primary health care to women and referral to other health care providers as appropriate;
• Prescription of pharmacological and non-pharmacological therapeutics, consistent with current standards of care;
• Provision of instruction and counseling to individuals, families, and groups in the areas of promotion and maintenance of health and disease prevention by actively involving these individuals in the decision making and planning for their own health care; and
• Collaboration with other health care providers and agencies to provide and coordinate services to individual women, children, and families.

Nurse Practitioner means a registered nurse who has successfully completed a Nurse Practitioner Program, as defined below, who can deliver primary and acute care services in a variety of settings, such as homes, ambulatory care facilities, long-term care facilities, and acute care facilities, using independent and interdependent decision making with direct accountability for clinical judgment. The health care services to be provided include:

• Assessment of the health status of individuals and families through health and medical history taking, physical examination, ordering, performing, supervising, and interpreting diagnostic tests and making diagnoses;
• Management of acute episodic and chronic illnesses;
• Institution and provision of continuity of primary health care to individuals and families and referral to other health care providers when appropriate;
• Prescription of treatments including pharmacological and non-pharmacological therapeutics, consistent with current standards of care;
• Provision of instruction and counseling to individuals, families, and groups in the areas of promotion and maintenance of health and disease prevention, by actively involving these individuals in the decision making and planning for their own health care; and
• Collaboration with other health care providers and agencies to provide, and where appropriate, coordinate services to individuals and families.

Nurse Practitioner or Nurse-Midwifery Program means a full-time educational program of study, as defined by the institution, (although students may be progressing through the program on a full-time or part-time basis), which meets the Guidelines prescribed herein. The program's objective is the education of nurses who will, upon completion of their studies in the program, be qualified to effectively provide primary care in a variety of settings, including in homes, ambulatory care facilities, long-term care facilities, acute care, and other health care settings.

Post-Nursing Master's Certificate Program means a formal, post-graduate program for Registered Nurses with master's degrees that awards a certificate and academic credit that is documented on a graduate transcript from the school for completion of the program of study as a Nurse Practitioner or Nurse-Midwife.

Preceptorship means a clinical learning experience in which the student is assigned to a faculty member or with oversight by program faculty to a designated preceptor who is a nurse practitioner or nurse-midwife or other health professional for specific aspects of the clinical learning experience. The preceptorship provides the student with practice experiences conducive to meeting the defined goals and objectives of the particular clinical course. The preceptor is responsible for the daily teaching and assignment of individuals to be cared for, supervision, and participation in the evaluation of the nurse practitioner or nurse-midwifery student. The preceptor teaches, supervises, and evaluates the student and provides the student with an environment that permits observation, active participation, and management of primary health care. Before and during this preceptorship, the program faculty visit and assess the clinical learning sites and prepare the clinical faculty/preceptors for teaching their students.

Primary Care means the provision of integrated, accessible health care services by clinicians, including nurse practitioners and nurse-midwives, who are accountable for addressing a large majority of personal health care needs within their scopes of practice, developing a sustained partnership with clients, and practicing in the context of family and communities. Critical elements also include accountability of clinicians and systems for quality of care, consumer satisfaction, efficient use of resources, and ethical behavior. Clients have direct access to an appropriate source of care, which continues over time for a variety of problems and includes needs for preventive services. The Guidelines use “Primary Care” and “Primary Health Care” interchangeably. (Definition adapted from Barbara Starfield, Primary Care Concept, Evaluation, and Policy, Oxford University Press, New York, 1992 p. 4 and Institute of Medicine: Moila S. Donaldson, Karl D. Yordy, Kathleen N., and Neal A. Vanselow, Editors, Committee on the Future of Primary Care, Division of Health Care Services, Primary Care: America's Health in a New Era, Summary, National Academy Press, Washington, DC, 1996, p. 23.)

Dated: February 15, 2005.

Elizabeth M. Duke,

Administrator.