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Pediatric nurse practitioners (PNP) care for children across the health continuum.
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PNPs integrate the primary and acute care PNP competencies into practice.
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Schools should consider dual pediatric primary and acute care PNP educational tracks.
Abstract
This survey aimed to evaluate contemporary pediatric nurse practitioner (PNP) practice as it relates to the competencies of both the primary and acute care population focus and settings of practice to guide curriculum revisions. The design of the study was a cross-sectional survey of PNPs certified by the Pediatric Nursing Certification Board. There were 2,265 surveys completed. Regardless of the certification type, PNPs report providing care across settings and integrating the competencies of both the primary and acute care PNP into practice. This warrants further consideration by programs to prepare future PNPs for dual primary and acute care certification.
Pediatric nurse practitioners (PNPs) have been an integral part of the health care team for over 50 years. The pediatric health care landscape has been changing, with shorter hospital stays, increased needs for complex chronic health management, and inadequate access to pediatric specialists (
). These changing circumstances require an adaptable PNP workforce to practice in various settings and with patients of varying acuity. Although health care systems increasingly recognize the value of PNP expertise in the care of children in contrast to other advanced practice providers (e.g., physician assistants and family nurse practitioners) who report limited practice in the care of children (2% to 25%, respectively), there is a predicted shortage of PNPs to meet this demand (
The original role and educational preparation for PNPs was to prepare nurses to provide comprehensive primary care to children in various settings, as reported in a position statement by the National Association of Pediatric Nurse Practitioners (
) on the educational preparation and role parameters of the PNP. The position statement highlighted the role of PNPs as primary care providers focusing on comprehensive, coordinated, and longitudinal care in addition to episodic care (
National Association of Pediatric Nurse Practitioners NAPNAP White Paper on educational preparation and role parameters of pediatric nurse practitioners.
). With the evolving health care system, PNPs practice beyond the primary care focus, caring for a wide variety of pediatric populations, degrees of acuity, and in varied settings (
). Although PNPs were already caring for children with primary and acute care needs, in the 1990s, graduate programs began to prepare nurse practitioner (NP) students for population-focused acute care practice. The acute care PNP role and the development of the certification exam for the acute care PNP was first offered in 2005 through the Pediatric Nursing Certification Board (PNCB).
Currently, the primary care and acute care PNP roles are considered distinct and separate and are guided by the needs of patients and not by the care setting (
Pediatric Nursing Certification Board. (2021a). The acute care certified pediatric nurse practitioner: Role, competencies, settings and ethics. Retrieved from https://www.pncb.org/cpnp-ac-role
). Over time, professional organizations, regulatory bodies, and researchers have worked to differentiate the roles of primary and acute care scope of practice and competencies of PNPs. One of the key elements of the Consensus Model for APRN regulation (2008), the Licensure, Accreditation, Certification, and Education (LACE) model, a collaboration between 48 professional organizations, including accreditors, educators, certifiers, and regulators, clarified their should be alignment between accreditation, education, licensure, and certification and practice to ensure patient safety (APRN Consensus Work Group &
APRN Consensus Work GroupThe National Council of State Boards of Nursing APRN Advisory Committee Consensus model for APRN regulation, licensure, accreditation, certification, & education.
). The scope of practice is determined through state regulatory boards, in which practice and licensure may or may not yet be aligned to education or certification. However, it is expected that the LACE model will incrementally be implemented across states (APRN Consensus Work Group &
APRN Consensus Work GroupThe National Council of State Boards of Nursing APRN Advisory Committee Consensus model for APRN regulation, licensure, accreditation, certification, & education.
Significant work has been done to identify and recognize the overlap and distinctions between the competencies of the primary and acute care PNP that can guide educational programs, PNPs, and employers (
). Each population focus has distinct differences, but some competencies flow across a continuum, making the distinction difficult. The physiological needs of patients vary depending on their illness state, regardless of the care setting. PNPs may find their job functions evolve depending on population needs, employer needs, practice settings, additional training, or personal interests. This can lead to “scope of practice creep,” in which one's job functions surpass the initial intended scope of practice. However, the National Organization of Nurse Practitioner Faculties and the LACE model support the scope of practice of a PNP should be determined by NP educational preparation and certification regardless of demonstrated “on the job” competence (APRN Consensus Work Group &
APRN Consensus Work GroupThe National Council of State Boards of Nursing APRN Advisory Committee Consensus model for APRN regulation, licensure, accreditation, certification, & education.
found 5% to 42% of other advanced practice registered nurses (not PNPs) worked in settings not traditionally aligned with their certification.
COMPETENCIES OF THE PNP
Overlapping Competencies of Primary and Acute Care PNPs
There are several competencies that, depending on the role, setting, changes in patient status, and transitions of care, maybe within the scope of practice of both primary and acute care PNPs (
). This is defined as care for patients with the following: (1) stable, acute episodic conditions (e.g., respiratory illness, otitis media); (2) common, chronic health care conditions (e.g., chronic constipation, atopic dermatitis); (3) consultation on the management of patients with acutely ill or unstable conditions (not providing direct care); (4) longitudinal care of patients with stable, but complex chronic health conditions (e.g., asthma, diabetes); and (5) titration of chronic therapy (e.g., established palliative care patients, maintenance chemotherapy, chronic dialysis) (
Unique Competencies of Primary and Acute Care PNPs
Other population-focused competencies are specific to the role of the primary care PNP that do not overlap with the acute care PNP. These competencies include (1) well-child care/preventive health care maintenance; (2) diagnosis of common mental/behavioral health conditions (e.g., attention deficit hyperactivity disorder, anxiety, depression); and (3) longitudinal care of patients with common mental/behavioral health conditions (e.g., attention deficit hyperactivity disorder, anxiety, depression) (
). Similarly, there are competencies of the acute care PNP that are unique and clearly defined as specific to this role. This includes (1) care of acutely ill, unstable patients with life-threatening illnesses (e.g., requiring ventilatory management, multisystem organ failure, diabetic ketoacidosis); (2) management of patients requiring titration of IV analgesia/sedation (e.g., sedation management); (3) longitudinal care for patients who require the long-term use of technological devices (e.g., home ventilator); (4) peri or postoperative care; and (5) care of patients in the operating room (
Development of Dual Pediatric Primary/Acute Care PNP Programs
Although there is an increased need for PNPs to provide care to children across the continuum of health, most PNP programs continue to educate students in a “siloed” approach, offering either a primary or acute care pediatric population focus. This approach requires PNPs to return to school if their practice aligns better with the other focus. A potential solution for the need to align the educational preparation of students to work across the continuum of pediatric health care without returning to school was proposed in 2010 with the creation of dual primary and acute care PNP (dual PNP) program guidelines (
). These approved dual PNPs programs enable PNPs to practice to the full scope of pediatric practice, meet the competencies of both population foci, and become eligible to sit for both primary care and acute care PNP certification exams (
). The merits of these programs appeared obvious to certifiers, educators, and students. It was argued that these dual PNP programs would benefit patients, increase PNP proficiency across the continuum of care, allow preferential hiring by employers, decrease the need to return to school for additional education, increase PNP program enrollments, and offer flexibility in employment choices (
). More than 10 years have passed since the first dual PNP programs were launched. There are 94 primary care, 47 acute care, and 22 dual PNP programs recognized by PNCB (
). Although the greatest number of PNP programs remain focused on a single population, many universities that sponsor them anecdotally reported interest in dual PNP programs (E. Hawkins-Walsh, personal communication, August 12, 2022).
In further evaluating the need for more dual PNP programs, it is important to study how the contemporary practice of PNPs compares with the overlapping and unique competencies of each population focus and setting of practice. This can provide evidence of whether changes are needed in PNP education to meet workforce demands and align with the realities of PNP practice. This targeted survey aims to evaluate contemporary PNP practice nationally in 2021 to determine whether curriculum revisions might be needed to support recommendations to prepare all PNPs for dual PNP practice.
METHODS
Design
The study was a cross-sectional survey of primary and acute care PNPs certified by the PNCB and accessed by e-mail. PNCB offers both PNP primary and acute care certification. In addition, PNCB is the only certification board for acute care PNPs. The American Nurses Credentialing Center also certifies primary care PNPs but is closed to new certifications as of 2018.
The survey was developed by an expert team of doctorally prepared PNP faculty from four universities across the country using a Delphi method. The group drew items from the population-based competencies set forth by the
matching education and certification to population-focused roles, competencies, and settings. The survey was piloted with 15 PNPs in various settings to assess face validity for relevance and clarity. Feedback was informal. The survey consisted of 38 questions focused on demographics, roles, and competencies.
Survey Platform and Recruitment
Study data were collected and managed using Research Electronic Data Capture electronic data capture tools at the host university. Research Electronic Data Capture is a secure, Web-based software platform designed to support data capture for research studies, providing the following: an intuitive interface for validated data capture; audit trails for tracking data manipulation and export procedures; automated export procedures for seamless data downloads to common statistical packages; and procedures for data integration and interoperability with external sources. The study team was blinded to the linking of survey responses to individuals. The study was acknowledged as exempt under the Department of Health and Human Services Regulations by the host university's Office of Human Subjects Research Institutional Review Boards.
A list of e-mail addresses of all PNPs certified through PNCB in primary and acute care who opted into third-party contact by PNCB was obtained. The database included 17,530 certificants through PNCB as of August 5, 2021. Of these, 14,635 were certified in pediatric primary care (83.4%), and 2,895 were certified in pediatric acute care (16.5%). Exclusion criteria included respondents who indicated additional preparation in a life span population (e.g., family NP or psychiatric mental health practitioner). The survey was distributed to e-mail addresses with a reminder e-mail 1 week later with an additional 10-day response period. Descriptive data were then exported to a comma-separated value format and transferred to the statistician for analysis.
The data were analyzed using R software (version 4.0.3; R Foundation for Statistical Computing, Vienna, Austria). Absolute frequencies and percentages were calculated for categorical data, and a χ2 test was used to assess statistical differences between PNPs with different certifications. Data were tested using the Anderson–Darling, Shapiro-Francia, and Shapiro-Wilk tests and a normal probability plot. Quantitative data were judged to be not normally distributed; therefore, median and interquartile ranges were used as central tendency and dispersion measures. To test for statistical evidence of a difference between ages in those with different certifications, ages were rank transformed.
RESULTS
Demographics
There were 2,265 surveys completed (13% response rate). A description of the study sample is presented in Table 1. Respondents were primarily female (96% to 98%), White (90% to 94%), and non-Hispanic/non-Latino (91% to 93%) across primary, acute care, and dual PNP respondents. Acute care and dual PNPs were younger than primary care PNPs. Thirty-six percent (n = 82) of acute care PNPs, 32% (n = 36) of dual PNPs and 20% (n = 381) of primary care PNPs were aged 25–35 years. Forty-four percent (n = 101) of acute care PNPs, 42% (n = 47) of dual PNPs and 32% (n = 620) of primary care PNPs were aged 35–45 years. Twenty-one percent (n = 395) of primary care PNPs, and 14% of acute and dual PNPs (n = 33 and n = 16, respectively) were aged 45–55 years.
Responses were broadly distributed across the country (Table 2). Texas was the state with the greatest percentage (30%) of respondents. Twelve percent (n = 13) of dual PNPs, 9% (n = 175) of primary care PNPs, and 9% (n = 21) of acute care PNPs were from Texas. Most PNPs reported working in urban, metropolitan, and large metropolitan settings. Proportionally, more primary care PNPs (15%, n = 278) worked in rural or small towns compared with dual (10%, n = 11) or acute care (2%, n = 4) PNPs.
Participants were asked how much time they spent caring for patients of various ages. The results reflected that PNPs care for patients from birth into adulthood. For nearly half of the respondents (45%), patients aged from birth to 17 years encompass 25% to 50% of their practice, with < 25% of their practice time with patients aged 19–20. Fifty-eight percent (n = 130) of acute care PNPs, 42% (n = 46) of dual PNPs, and 32% (n = 634) of primary care PNPs reported spending at least some of their time (0% to 75%) providing care for patients aged 21–26 years. Twenty-nine percent (n = 67) of acute care, 15% of dual, and 6% (n = 32) of primary care PNPs reported caring for patients ages 27 and older in their practice.
Practice setting and specialty
Respondents were asked to report their practice setting, focus, and specialty. Respondents could select more than one answer if they had more than one specialty (e.g., PNP practicing in a high acuity emergency department and an urgent care setting). Over three-quarters (76%, n = 1,451) of primary care PNPs practiced in an outpatient setting, 14% (n = 259) practiced in both inpatient and outpatient settings, and 10% (n = 198) practiced exclusively in an inpatient setting (Figure 1). Fifteen (< 1%) of primary care PNPs practiced in the patient's home. More than half (53%, n = 121) of acute care PNPs practiced in an inpatient setting, 31% (n = 71) practiced in both inpatient and outpatient settings, and 15% (n = 35) practiced in an outpatient setting only. Similarly, only two acute care PNPs practiced in a patient's home. Forty percent (n = 44) of dual PNPs practiced in an inpatient setting, 31% (n = 34) practiced in both inpatient and outpatient settings, and 30% (n = 33) practiced in outpatient settings only. No dual PNPs practiced in the homes of patients.
Sixty percent (n = 1,147) of primary care PNPs practiced in outpatient general pediatrics and 27% (n = 511) practiced in speciality care. To a lesser degree, primary care PNPs practiced in surgical services (5%, n = 88), inpatient general pediatrics (5%, n = 105), urgent care (4%, n = 79), critical care (2%, n = 45) or in progressive care units (e.g., step-down, intermediate care units) (1%, n = 14). Thirty-seven percent (n = 84) of acute care PNPs practiced in critical care, speciality care (30%, n = 69) surgical services (21%, n = 47), inpatient general pediatric care (15%, n = 34), and in progressive care units (4%, n = 10). Dual PNPs practiced most often in speciality care (30%, n = 33), followed by critical care (27%, n = 30), outpatient general pediatrics (24%, n = 27), surgical services (19%, n = 21), inpatient general pediatric care (18%, n = 20), urgent care (6%, n = 7), or progressive care units (1%, n = 1).
Respondents who indicated that they practiced in specialty settings were asked to identify their specialty practice setting. There was a broad range of responses, with primary care, acute care and dual PNPs practicing in most settings provided (Figure 2). Primary care PNPs practiced in developmental/behavioral pediatrics (3%, n = 59) more often than acute care or dual PNPs (1%). Acute care PNPs had the highest percentage of respondents practicing in oncology/hematology (10%, n = 22) and transplant specialities (6%, n = 13). Dual PNP certification was most common for those practicing in cardiology (5%, n = 18) and both high (4%, n = 14) and low acuity (3%, n = 12) emergency care/departments. The most common specialty setting for PNPs of all certification types was reported in oncology/hematology.
Overlapping primary and acute care PNP clinical competencies
Respondents were asked to identify which of the overlapping primary and acute care clinical competencies they applied in practice (Figure 3). Most primary care (84%, n = 1,616), acute care (73%, n = 168) and dual PNPs (77%, n = 86) provided care for patients with stable, acute episodic conditions. Eighty-four percent (n = 1,620) of primary care PNPs, 63% of acute care PNPs (n = 144), and 72% of dual PNPs (n = 80) managed patients with common, chronic health conditions. Consultation on the management of patients with acute or unstable conditions (not providing direct care), was reported more often by acute care PNPs (54%, n = 123) and dual PNPs (50%, n = 56) versus primary care PNPs (28%, n = 538). Longitudinal (ongoing) care of patients with stable but complex, chronic health conditions was reported commonly by primary care PNPs (85%, n = 1,637), acute care PNPs (73%, n = 167), and dual PNPs (70%, n = 78). Forty-six percent of acute care PNPs (n = 106) and 46% (n = 51) of dual PNPs reported that they managed patients requiring titration of chronic therapy compared with primary care PNPs (8%, n = 151).
Figure 3Primary and acute care pediatric nurse practitioners competencies by certification.
Respondents were surveyed regarding their practice as it relates to the distinct competencies of the primary care PNP (Figure 4). Seventy-three percent (n = 1,402) of primary care PNPs, 41% (n = 45) of dual PNPs, and 27% (n = 62) of acute care PNPs reported that they provided well-child/preventive health care maintenance. Fifty-nine percent (n = 1,138) of primary care PNPs, 22% (n = 24) of dual PNPs, and 15% (n = 35) of acute care PNPs reported that they diagnosed common mental/behavioral health conditions. Fifty-eight percent (n = 1,120) of primary care PNPs, 26% (n = 29) of dual PNPs, and 18 % (n = 42) of acute care PNPs reported that they provided longitudinal (ongoing) care of patients with common mental/behavioral health conditions.
Figure 4Primary care competencies by certification.
Respondents were surveyed regarding their practice as it relates to the distinct competencies of the acute care PNP (Figure 5). When respondents were asked if they provided care for acutely ill, unstable patients with life-threatening conditions, 67% (n = 153) of acute care PNPs, 55% (n = 61) of dual PNPs, and 14% (n = 265) of primary care PNPs reported this as part of their practice. Forty-six percent (n = 106) of acute care and dual PNPs (n = 51) and 8% (n = 151) of primary care PNPs reported that they managed patients requiring titration of IV analgesia/sedation (e.g., sedation management). Respondents were asked if they provided longitudinal (ongoing) care for patients requiring long-term use of technological devices. Thirty-nine percent (n = 89) of acute care PNPs, 37% (n = 41) of dual PNPs, and 13% (n = 251) of primary care PNPs reported this as part of their practice. Sixty-six percent (n = 150) of acute care PNPs, 53% (n = 59) of dual PNPs, and 18% (n = 347) of primary care PNPs provided perioperative and postoperative care. Fifteen percent (n = 35) of acute care PNPs, 14% (n = 15) of dual PNPs, and 4% (n = 85) of primary care PNPs provide care for patients in the operating room.
Figure 5Acute care pediatric nurse practitioners competencies by certification.
Respondents were asked if, at the time of their initial PNP preparation, they had had the opportunity to be educationally prepared to seek certification in both pediatric primary and acute care, would they have preferred this. Sixty percent (n = 1,159) of primary care PNPs would have preferred a dual PNP program, whereas one-third (33%, n = 626) would not prefer a dual PNP program. Seven percent (n = 7) had no opinion. Similarly, most (52%, n = 120) acute care PNPs would have preferred a dual PNP program. A little over one-third (38%, n = 86) of acute care certified nurse practitioners would not have preferred a dual PNP program. Nine percent (n = 20) of acute care PNPs had no opinion concerning dual PNP preparation.
Limitations
Limitations occurred with this study. Although this sample of PNPs certified through PNCB, it does not reflect the entirety of PNPs practicing in the United States, contributing to sampling bias. The American Nurses Credentialing Center allows primary care PNPs to maintain certification (although not new). Some states do not require national certification in addition to state licensure, so there may be some lack of geographic representation in the survey results. In addition, PNCB does not require active practice to maintain certification. Some certificants not currently in practice may have responded, although it would be reasonable to assume their answers would reflect their most recent practice. Certificants who were certified as primary and acute care PNPs by PNCB received the survey twice, linked to each certification. On analysis, 13 respondents completed the survey twice, which may have affected the results. The 2,265 completed surveys are statistically significant (> 300 is ideal for statistical analyses) but less than a 50% representation of the targeted population, which reduces generalizability.
DISCUSSION
A lack of diversity is noted in the demographics of PNPs, as the profession remains primarily white and female. The results indicate that most acute care PNPs work in inpatient, critical care, surgical, and specialty care settings, whereas most primary care PNPs work in outpatient general pediatrics and specialty care settings. Although the scope of practice is defined by patient care needs and not the setting, several practice settings are assumed to be specific to either primary or acute care PNP practice (
). For example, critical care is the role of the acute care PNP, as it requires the management of unstable or critically ill patients, whereas primary care is the role of the primary care PNP (
). Only 2% of primary care PNPs reported working in critical care, and 6% of acute care PNPs reported working in primary care. This suggests that most PNPs in these settings have certification congruent with their practice setting. In settings and specialties such as the emergency department (e.g., high acuity vs. low acuity/fast track), inpatient general pediatric care, progressive care, and surgical services, varying acuity can be seen, which may require a range of competencies needed to care for these patients (
). This poses a dilemma for PNPs and employers in these settings in regard to the scope of practice boundaries, as patient acuity may be fluid and dynamic. This finding may lend support for dual PNP preparation in these practice settings.
The population cared for by PNPs is defined as birth through young adulthood (
). The upper age limit has historically been defined as ages 21–24 years, but should be considered in the context of a person's developmental and physical needs and the ability to transition these patients to adult providers, versus a specific age cutoff (
). Many factors, including socioeconomics, access to adult practitioners with the necessary expertise, and family comfort with a change, may prevent or delay this transition (
). This survey revealed that PNPs, particularly acute care and dual PNPs, provided care into young adulthood and beyond. This finding was also reported by a recent practice analysis, which found that a majority of acute care PNPs (80%) reported caring for patients aged > 18 years (
). This is an area for further exploration in its relationship to particular practice settings and disease conditions, transitions of care needs, as well as published practice parameters.
A number of overlapping competencies are integrated into the practice of primary and acute care PNPs, which is reflected in the survey results. However, other competencies are deemed specific to the role of the primary care or acute care PNP. PNPs provide care across the continuum of health and illness and integrate the competencies of both the primary and acute care PNP into practice. Although this is not specific to each PNP, no population-focused competencies remained unique to the particular PNP certification. This potential misalignment of educational preparation, certification, and population-focused competencies was particularly evident in the number of acute care PNPs who provided well-child/preventive health care maintenance and diagnosis and longitudinal management of common mental/behavioral health conditions. The diagnosis and management of mental/behavioral health concerns are particularly timely, as the severe acute respiratory coronavirus 2 (SARS-CoV-2) pandemic has brought to the forefront the tremendous need for evaluation, diagnosis, and management of these conditions in a variety of settings (
). This need will likely continue because of the toll the pandemic has taken on the mental health of children or as the potential neurological impact SARS-CoV-2 infection has on the development or worsening of psychiatric conditions (
The disparity in practice related to the population-specific competencies was similarly evident in the numbers of primary care PNPs that provided perioperative and postoperative care, care for acutely ill and unstable patients with life-threatening illnesses, and other acute care competencies, such as ongoing care for patients who require the long-term use of technological devices, IV analgesia, and sedation management. Of interest was the number of PNPs who provided care in the operating room. It is unknown what type of care is provided in the operating room, but it warrants further exploration.
This integration of population-focused competencies by both primary and acute care PNPs can be hypothesized by several factors, including rapid and unpredictable changes in patient acuity in different settings; scope of practice creep; lack of an individual PNP or employer knowledge of the scope of practice designated for primary versus acute care; and geographic variations because of the lack of enforcement of the LACE model (2008) by Boards of Nursing, among others. PNPs themselves may not be sufficiently informed or concerned about their own potential risk or liability if providing care for patient populations in which they lack formal educational preparation and national certification, despite their employer's willingness to hire them. Additional factors include staffing shortages, which have been particularly impactful during the SARS-CoV-2 pandemic.
PNPs knowledgeable about the need for education aligned with certification and practice may avoid returning to school for many reasons, including the high cost of tuition and the need to limit their time out of the workforce. Given the current and predicted workforce shortage of PNPs, employers in areas that do not enforce the LACE model may continue to focus on staffing clinics, units, and other settings with PNPs whose competency is evaluated by performance rather than by current certification or educational standards. Although it was outside the scope of this study, many anecdotes have been shared that imply that some employers who are aware of the LACE model will plan to hire physician assistants or family NPs to avoid the challenge of matching a PNP who is only acute or primary care certified with unpredictable patient acuity or will fit into rigidly defined age parameters.
Conclusions
This survey demonstrates that although PNPs are primarily certified in a single population focus, the care they provide in practice integrates the primary and acute care PNP competencies across the health continuum. As the complexity of pediatric primary and acute care continues to evolve, so does the need for highly trained PNPs. The need to provide safe, seamless pediatric care as patient needs, acuity, and complexity change, regardless of setting, and ensuring that practice aligns with education and certification should prompt educators to look carefully at contemporary models of PNP education. Studies have shown that the difference in credits and cost between single population (acute or primary care) PNP programs and dual PNP programs are surprisingly small (
). Although academic programs are responsible for providing students with the educational preparation to meet eligibility for certification in a population focus, they also have the responsibility to prepare students to meet the changing landscape of pediatric care and the needs of the communities in which they practice. All of these factors highlight the need for academic programs to carefully consider dual primary and acute care programs to prepare PNPs across the continuum of care. Dual PNP programs can proactively address the need for alignment of education and certification with PNP practice and support the pediatric workforce needs of the future.
Declaration of Competing Interest
None to report.
References
APRN Consensus Work Group
The National Council of State Boards of Nursing APRN Advisory Committee
Consensus model for APRN regulation, licensure, accreditation, certification, & education.
Pediatric Nursing Certification Board. (2021a). The acute care certified pediatric nurse practitioner: Role, competencies, settings and ethics. Retrieved from https://www.pncb.org/cpnp-ac-role
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