A nurse practitioner is an advanced practice registered nurse (APRN), which is the highest clinical level within the nursing profession. NPs hold either a master’s or doctoral degree in nursing and are licensed to diagnose conditions, order tests, and prescribe medications. They sit above registered nurses (RNs) and below physicians in the healthcare hierarchy, though their exact scope of practice depends on the state where they work.
Where NPs Fit in the Nursing Hierarchy
Nursing has a clear progression of clinical levels. At the entry point are licensed practical nurses (LPNs), who complete a certificate program and handle basic patient care. Registered nurses hold either an associate’s or bachelor’s degree and take on broader responsibilities like administering medications, developing care plans, and coordinating treatment. Above RNs sit the four advanced practice roles: nurse practitioners, certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.
Of these four APRN roles, nurse practitioners are the largest group by far, with roughly 320,400 employed across the United States as of 2024. The APRN designation signals graduate-level education, national board certification, and the authority to make clinical decisions that RNs cannot, including diagnosing illness and prescribing controlled substances.
Educational Level Required
The minimum educational requirement for a nurse practitioner is a Master of Science in Nursing (MSN), which typically takes two to three years beyond a bachelor’s degree. However, the profession is actively shifting toward the Doctor of Nursing Practice (DNP) as the standard entry-level degree. The National Organization of Nurse Practitioner Faculties called for this transition by 2025, and it reaffirmed that position in 2023.
The shift is well underway. As of 2024, 439 nursing schools offer DNP programs across all 50 states and Washington, D.C., with more than 100 additional programs in the planning stages. Enrollment reached 42,767 students in 2024, and over 12,300 DNP graduates completed their degrees that year. Some NPs currently practicing with a master’s degree are returning to school for a post-master’s DNP, offered at 403 schools nationwide.
In terms of clinical training, NP programs require 500 to 750 patient care hours. That’s substantially less than physicians accumulate. Between medical school rotations and residency, doctors log between 12,000 and 16,000 hours of clinical experience before independent practice.
Practice Authority Levels by State
One of the biggest factors shaping what an NP can actually do is the state they practice in. States fall into three categories of practice authority, and the differences are significant.
- Full practice: NPs can independently evaluate patients, diagnose conditions, order and interpret tests, manage treatments, and prescribe medications including controlled substances. No physician oversight is required. The state board of nursing is the sole licensing authority.
- Reduced practice: State law requires a career-long collaborative agreement with another health provider, or it limits at least one element of NP practice. An NP in a reduced-practice state might need a physician to co-sign certain prescriptions or approve treatment protocols.
- Restricted practice: State law requires career-long supervision, delegation, or team management by another provider. NPs in these states have the least autonomy.
Prescriptive authority varies just as widely. In states like Alaska, NPs can independently prescribe Schedule II through V controlled substances, which includes medications like opioids and stimulants. In Alabama, a collaborating physician must approve the drug type, dosage, and quantity, and NPs are limited to Schedules III through V. Some states require a transition-to-practice period before NPs can prescribe independently, even if they eventually gain full authority.
Certification and Specialization
After completing their degree, NPs must pass a national board certification exam in their chosen population focus. This certification determines the specific patient groups they can treat. The most common options include:
- Family Nurse Practitioner (FNP): Covers patients across the entire lifespan, from prenatal through older adulthood. This is the most widely held certification.
- Adult-Gerontology Primary Care (AGNP): Focuses on adolescents through elderly adults in primary care settings.
- Psychiatric Mental Health (PMHNP): Covers psychiatric and mental health care across the lifespan, including prescribing psychiatric medications.
- Emergency Nurse Practitioner (ENP): A newer specialty certification for FNPs who work in emergency departments.
These certifications must be renewed periodically and require continuing education. NPs cannot practice outside their certified population focus, so an adult-gerontology NP would not treat young children.
Career Levels Within NP Practice
Many healthcare systems also create internal tiers to recognize growing expertise among NPs. These clinical ladders give NPs a way to advance without leaving patient care for management roles. A large academic health system in the Midwest, for example, developed three progressive levels: advanced, expert, and master.
At the advanced level, an NP participates in quality improvement projects and may update department practice guidelines. This requires the least clinical experience, typically around two years. The expert level involves leading quality projects and developing protocols for the institution. The master level, requiring roughly six years of practice experience, expects NPs to develop and implement guidelines that influence practice beyond their own institution, present at external conferences, and earn state or national recognition. While the specific structure varies by employer, this kind of tiered system is common at larger hospitals and health systems.
Compensation Level
NP salaries reflect their advanced standing. The median annual wage for nurse practitioners was $129,210 in May 2024, according to the Bureau of Labor Statistics. That places them well above registered nurses, whose median hovers around $86,000, but below physicians, whose median salary varies by specialty but generally starts above $200,000. NP pay varies by specialty, geographic location, and practice setting. Psychiatric mental health NPs and those in emergency or acute care settings often earn above the median.