[Federal Register Volume 70, Number 35 (Wednesday, February 23, 2005)]
[Notices]
[Pages 8812-8816]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-3425]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


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.

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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 (301) 
443-6333.

SUPPLEMENTARY INFORMATION: On November 3, 2003, HRSA published in

[[Page 8813]]

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

[[Page 8814]]

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

[[Page 8815]]

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;

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     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.
[FR Doc. 05-3425 Filed 2-22-05; 8:45 am]
BILLING CODE 4165-15-P