Professional nurses in the advanced practice role of nurse practitioner (NP) face ongoing issues of importance to the health of their professional role as well as the health of the people they serve. NPs are ethically obliged to identify and engage in opportunities that promote the nation's health. We, as guest editors for this issue of JAANP, are pleased to highlight five relevant topics that fulfill such obligations. The collection of articles in this themed issue identify opportunities for professional growth that have implications for health on a national level and address societal needs. Through this issue, we spotlight novel works that convey the importance of NP engagement to improve science, practice, preceptors, collaboration, workforce analyses, and regulations. The implications simply are too serious to discount.

Care coordination as part of practice

A long-standing component of the NP role has always included care coordination activities. Such activities began long before the formal name and national recognition of care coordination. In the first article featured, Ruggerio and colleagues undertook a novel approach to demonstrate the value of NPs in meeting the care coordination needs of medically complex children. Through pilot work and following the principles of quality improvement, the authors identified a problem, developed a solution, implemented the proposed solution, and evaluated the effects in terms of patient and organizational outcomes. Findings from this project demonstrate the added value that NPs can bring to an organization. This team identified the value of NP-led care coordination, which resulted in a reduction in delays in treatment, resolution of discrepancies within the treatment plan, fewer missed appointments, and reduced emergency department utilization, all while maintaining family centeredness. Another notable aspect of this work was the time involved in nonreimbursable activities; nearly one-quarter of the coordinating activities required 10-19 additional minutes of the provider's time to implement. Such findings demonstrate the hidden financial value of NPs and help to justify the use of NPs in settings that rely on relative value units and productivity measures. These findings also have direct implications for today's educational programs. Ruggerio et al.'s work underscores an urgent need for NPs to receive formal care coordination education during academic preparation. We envision a day when such content will be equally important on national certification examinations to further provide evidence to the public and health care organizations that NPs provide essential services beyond direct patient care.

Preceptors

In terms of NP education, the need for preceptors is a long-standing issue in the search of a permanent solution. From the work of Carelli and others, a national discussion can emerge on how health policy changes, in the form of tax incentives, can become a sustaining solution. These authors provide a current review of the issue and how a limited number of states have begun to implement tax reform that addresses clinical education needs. The impetus behind tax incentives is to provide some compensation for clinicians who precept, thus addressing one of the identified barriers. It is important that tax incentives may have the potential for encouraging clinicians in rural communities to precept students who may choose to either stay in a rural home community or to relocate from an urban to rural environment. Further research is needed to definitively assess the effectiveness of tax incentives to encourage clinicians to precept students, and the idea is appealing and worthy of investigation. Either way, we believe any encouragement that provides education to students in rural areas is a step toward addressing the problem of lack of health care access due to provider shortages in underserved areas.

Nurse practitioners as clinical scholars

Nurse practitioners are clinical scholars who, as both clinicians and scholars, encounter opportunities for clinical inquiry on a regular basis. Nurse practitioners often neglect clinical inquiry due to other competing priorities. Yet, the need for clinical inquiry will grow only through the changing patient demographics as well as changes in the expectations for health care delivery. Falkenberg-Olson approaches clinical inquiry as a professional responsibility. She posits that collaboration is the optimal approach for doctorally prepared NPs to become engaged members of the inquiry team. Today, opportunities for collaboration are more evident through the growth in doctoral education for nurses, be it Doctor of Philosophy (PhD), Doctor of Nursing Practice (DNP), or other doctoral degrees. The Institute of Medicine (IOM) (2010) report on The Future of Nursing spurred the commitment of NPs to seek function at the highest level of licensure and practice consistent with the scope of role preparation. The variance between the educational pathways NPs select provides great opportunities to blend research, evidence-based practice, and clinical care to address issues within the health care system. Nurse practitioner participation on diverse health care teams should bring expanded growth of NP-driven research and improvement science. Nurse practitioners must be flexible in their ability to generate knowledge through either the knowledge of discovery or the translation of evidence to practice.

Supply and demand

Another current trend is the growth of NP graduates. The current growth is the result of new NP programs and expansion of existing programs. While such a growth is professionally advantageous in positioning more NPs to care for more patients, there is a need to address workforce trends and job markets. Faraz and Salsberg have established a methodology that could be useful in future forecast models. An important aspect of any forecast model is the ability to obtain the right inputs to project the right outputs. Researchers will need to overcome the barriers to sampling recent NP graduates. Sampling must be of sufficient size and geographical distribution for maximum value. We offer caution to readers in interpreting the results from a distribution perspective and a true supply and demand model. However, the establishment of a method to do a larger, more impactful study is highly recognized. An important finding from this study was that one-third of the respondents were not familiar with the legal requirements for practice. This disclosure signals that some educational institutions are missing opportunities to educate students in alignment with the goals established by the IOM's Future of Nursing's report. Additional information is needed if such deficits are found within online programs, on ground programs, or both. This study also led us to question how well any graduating health professional student truly understands the scope of practice issues.

Regulation of practice

Given the findings from the Faraz and Salsberg article, we approached two national leaders with regulatory expertise to provide insights into the regulatory arena. The APRN Consensus Model (2008) for APRN regulation is now more than 10 years old. Drs. Hudspeth and Klein have indicated that clarifying and understanding scope of practice are essential for NPs. The experts highlight the lack of a national scope of practice and uniform language to guide NPs. Such work also has implications for nursing education and the level of jurisprudence knowledge expected of today's graduates. This work also has important implications for helping all NPs become stewards of the profession. Such a stewardship is needed in helping leaders from organizational systems and clinical sites understand the scope of practice boundaries and where NPs can be effectively and legally utilized. Finally, we believe that it would be important for more NPs to engage with every sponsoring organization of the Consensus Model to drive changes in practice acts across the nation.

We hope you find the articles in this issue to be thought provoking and useful-useful as a patient advocate, a protector of the health system, a tool for engaging with policy makers, and a host of other opportunities. Using the information here helps NPs ethically meet the needs of the patients, families, and communities we serve. As we always do, we encourage all NPs to be familiar with our professional issues and engage in scholarly discussions followed by deliberate actions.

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