Nurse practitioners have long been an important component of our nation’s healthcare delivery system, but in recent years the vital importance of skilled clinicians trained in advanced health assessment, pathophysiology and pharmacology has become even more apparent amid a deepening physician shortage. As more people enjoy access to healthcare services under the Affordable Care Act and as the aging Baby Boomer population continues to strain an already-overwhelmed healthcare system, nurse practitioners are recognized as key to helping ease the strain by providing cost-effective, high quality, patient-focused care.
Nurse practitioners are recognized as advanced clinical practitioners in all states. Depending on the way licensing laws are written in a given jurisdiction, they would most often be licensed as advanced practice registered nurses (APRN), or otherwise have an advanced practice endorsement or certification on their RN license. Though each state is responsible for establishing and maintaining licensing standards for nurse practitioners within their jurisdiction, there is a great deal of consistency in the general licensing requirements and processes nationwide. Licensing requirement and processes continue to become more standardized as state boards of nursing seek consensus and move towards aligning their requirements under a common model.
Although each state’s licensing board acts as the final arbiter for qualifying registered nurses to practice as NPs within their jurisdiction, the general requirements are the same: Registered nurses with unrestricted licenses in good standing may become nurse practitioners by earning a master’s or higher degree, becoming nationally certified, and qualifying for advanced practice state licensure through their board of nursing.
As APRNs, nurse practitioners must possess a graduate-level nursing education, national certification and, in most cases, state licensure:
Step 1. Complete a Graduate-Level Nurse Practitioner Program
The minimum educational requirement for becoming a nurse practitioner is the Master of Science in Nursing (MSN). The Commission on Collegiate Nursing Education (CCNE) is the national accrediting agency for MSN programs.
The CCNE currently recognizes more than 400 nurse practitioner programs, which are designed in a number of different ways to accommodate nursing students with different educational backgrounds:
- Traditional MSN Programs: Traditional MSN programs are for BSN-prepared RNs. These standard BSN-MSN programs are by far the most common and ubiquitous type of MSN available and take about two years to complete.
- RN-to-MSN Programs: RN-to-MSN bridge programs are for ADN-prepared RNs looking for an accelerated track toward becoming a nurse practitioner. These bridge programs allow students to complete both their BSN and MSN in one accelerated program that usually takes about three years of full-time study to complete.
- Direct-Entry/Entry-Level MSN Programs: Direct-entry MSN programs, also called entry-level MSN programs, are for non-nursing professionals that possess a bachelor’s degree in an area other than nursing. Designed specifically for bachelor’s-educated career changers looking to enter the field of nursing, direct-entry MSN programs allow students to earn their RN license and MSN degree in preparation to become a nurse practitioner, all in one combined program.
Many programs allow students to complete their MSN program on a part-time basis or in a fully or partially online format. Institutions offering online MSN programs allow students to complete the didactic portion of their program through distance learning, and the clinical portion of their program at partner sites close to home. In many cases, graduate nursing students in online programs can complete clinical sequences at their current place of employment.
Three Components of an MSN Program for NPs: Core Coursework, Patient Population Coursework and Clinical Preceptor Experience
All nurse practitioner MSN programs contain three, major components:
The Direct Care (APRN) Core
- Advanced physiology/pathophysiology, including general principles that apply across the lifespan
- Advanced health assessment, including the assessment of all human systems, concepts and approaches, and advanced assessment techniques
- Advanced pharmacology, including:
- Pharmacotherapeutics of all broad categories of agents
Study in the Nationally Recognized Nurse Practitioner Competencies and in at Least One Population Focus
In addition to study in the recognized nurse practitioner competencies, an MSN nurse practitioner program must include study in at least one population focus:
- Family/Individual Across the Lifespan
- Adult-Gerontology (Acute care/primary care)
- Women’s health/gender-related
- Pediatrics (Acute care/primary care)
- Psychiatric/mental health
Many programs include a combination of two or more population foci, and many more allow students to further focus their nurse practitioner degree by choosing a nursing specialty, such as oncology, nephrology, orthopedics, etc.
Nurse practitioner programs must contain at least 500 hours of direct, clinical experience, designed to provide students with real-world, hands-on experience in a variety of clinical settings.
Nurse Practitioner Program Learned Competencies
CCNE-accredited nurse practitioner programs qualify students to take the appropriate national certification examination and become state licensed as certified nurse practitioners. All accredited programs are designed to teach the National Organization of Nurse Practitioner Faculties’ Nurse Practitioner Core Competencies, which are recognized as essential to all nurse practitioners.
Graduates of nurse practitioner programs are prepared in the following competencies:
- Ethics: Integrates ethical principles into decision-making and evaluates the ethical consequences of decisions
- Health delivery system: Applies knowledge of organizational practices and complex systems to improve the delivery of healthcare
- Leadership: Assumes advanced leadership roles, advocates for improved healthcare access and quality, and provides/demonstrates leadership
- Policy: Demonstrates an understanding of policy and practice and advocates for ethical policies
- Practice inquiry: Provides leadership when translating new knowledge into practice
- Quality: Uses the best available evidence to improve clinical practice; evaluates organizational structure, care processes, financing, and marketing/policy decisions; and anticipates variations in practice
- Scientific foundation: Analyzes data and evidence, translates research, and develops new practice approaches for improving advanced nursing practice
- Technology and information literacy: Integrates technologies for knowledge management, translates technical and scientific health information, and demonstrates information literacy skills in complex decision-making
- Independent practice: Functions as an independent licensed practitioner
Step 2. Earn National Certification as a Certified Nurse Practitioner (CNP) through a Recognized Certification Board
After earning an MSN or higher degree with an emphasis on the nurse practitioner role and patient population focus of choice, graduates must prepare to take a national certification examination to become credentialed as an NP with knowledge and clinical training in the patient population focus that aligns with their graduate education.
Passing a national certification examination indicates that the graduate possesses a level of professional knowledge in their chosen population focus. This is necessary to qualify for APRN licensure as a nurse practitioner through all state boards of nursing.
The following national certification agencies offer certification examinations for the respective nurse practitioner population foci and are recognized by all state boards of nursing:
- Adult nurse practitioner (ANP)
- Family nurse practitioner (FNP)
- Adult-gerontological primary care nurse practitioner (AGPCNP)
The certification examinations of the AANP each consist of 150 multiple-choice questions, including 15 pretest questions. The AANP encourages applicants to being the application process as early as six months before graduation.
Upon completion of the clinical and didactic portions of their nurse practitioner program, candidates can expect to receive a letter in the mail from Professional Examination Services (ProExam) notifying them of their authorized testing window dates.
Candidates would take the appropriate AANP exam through Prometric Testing Services, which has testing centers throughout the U.S.
- Acute care nurse practitioner – Board certified (ACNP-BC)
- Adult nurse practitioner – Board certified (ANP-BC)
- Family nurse practitioner – Board certified (FNP-BC)
- Gerontological nurse practitioner – Board certified (GNP-BC)
- Pediatric primary care nurse practitioner – Board certified (PPCNP-BC)
- Psychiatric-mental health nurse practitioner – Board certified (PMHNP-BC)
- Adult psychiatric- mental health nurse practitioner – Board certified (PMHNP-BC)
- Adult-gerontological acute care nurse practitioner (AGACNP-BC)
- Adult-gerontological primary care nurse practitioner (AGPCNP-BC)
- School nurse practitioner
ANCC exams consist of between 150 and 175 score test items, as well as 25 pilot test questions.
Candidates would take the appropriate ANCC exam through Prometric Testing Services, which has testing centers throughout the U.S.
- Pediatric nurse practitioner primary care (CPNP-PC)
- Pediatric nurse practitioner acute care (CPNPAC)
PNCB exams validate a candidate’s knowledge, skills, and abilities as it relates to primary or acute pediatric care. Upon graduating from a nurse practitioner program in pediatrics, candidates will receive notification of their eligibility to sit for the exam through PNCB. Once they receive this letter, they must schedule the appropriate PNCB exam within 90 days.
Candidates would take the appropriate AANP exam through Prometric Testing Services, which has testing centers throughout the U.S.
- Women’s health nurse practitioner – Board certified (WHNP-BC)
- Neonatal nurse practitioner – Board certified (NNP-BC)
The NCC will notify graduates of nurse practitioner programs in women’s health or neonatology of their eligibility to schedule the appropriate NCC exam. The NCC core examinations are three hours long.
Upon receiving their eligibility letter, candidates must schedule their own exam appointment through AMP. Most AMP Assessment Centers are located in H&R Block offices, and candidates are scheduled on a first-come, first-serve basis.
Step 3. Earn APRN State Licensure as a Certified Nurse Practitioner (CNP)
To qualify for state licensure as an advanced practice registered nurse (APRN), nurse practitioners must possess:
- An MSN or higher degree through an accredited nurse practitioner graduate program
- National certification as a nurse practitioner in a recognized population focus
- A current and unencumbered registered nurse (RN) license
Once candidates have achieved state licensure, they must practice within the professional boundaries set forth by their state board of nursing.
All states allow nurse practitioners to prescribe prescription medications, including controlled substances. Depending on the state, applicants may also need to apply for prescriptive authority. All nurse practitioners who prescribe controlled substances must apply for DEA Registration.
In some states, nurse practitioners are required to establish a collaborative practice agreement with a licensed physician.
Currently, 21 states and the District of Columbia allow nurse practitioners to practice independently, without the need for formal physician oversight of any kind. In these states, nurse practitioners are fully recognized as independent practitioners and are not required to establish a collaborative practice agreement or gain physician consent for any act within their scope of training and education, as defined in their state’s scope of practice laws:
- Washington D.C.
- New Hampshire
- New Mexico
- North Dakota
- Rhode Island
However, all states that do not appear on this list do restrict the practice of nurse practitioners, and generally require NPs to enter into collaborative physician agreements that specify what acts must be delegated through a physician and the parameters for delegating these acts. Depending on a state’s licensing laws, the collaborative agreement may stipulate everything from direct on-site supervision in the most restrictive states, to off-sight phone consultation for the delegation of certain acts and prescribing privileges in the least restrictive states.
The American Association of Nurse Practitioners maintains information on licensure and regulatory requirements for nurse practitioners in each state.
Step 4. Maintain National Certification and State Licensure as a Nurse Practitioner
All nurse practitioners must maintain their national certification and state APRN license by completing a specified number of continuing units/credits and a minimum number of clinical practice hours during each renewal cycle. While some states recognize the maintenance of national certification as meeting the requirements for state licensure renewal, others require additional continuing education credits/units to be completed.
Nurse practitioner certification/licensure is always dependent upon maintaining an RN license.
Some states also require the completion of a specific number of continuing education credits/units in areas such as professional ethics, pharmacology/pharmacotherapeutics and HIV/AIDS education.
National and state professional associations are often valuable sources of continuing education opportunities:
- American Association of Nurse Practitioners
- National Association of Pediatric Nurse Practitioners
- Gerontological Advanced Practice Nurses Association
- National Association of Nurse Practitioners in Women’s Health
- American Academy of Emergency Nurse Practitioners
- Dermatology Nurses Association
- National Association of Neonatal Nurse Practitioners
- Nurse Practitioner Associates for Continuing Education