As the role of the nurse practitioner has grown, so has specialization within the role. Gone are the days when all nurse practitioners work as family NPs. The organizations that certify NPs now offer exams in a variety of specialties, including adult, family, gerontology, acute care, family psychiatry, adult psychiatry, pediatrics and women's health.

After certification, NPs must be licensed to practice in their respective states, but the specialties in which NPs can earn licensure differ by state, overlapping like mismatched puzzle pieces. To reduce this confusion, a joint dialogue group of nursing and NP organizations came together in 2008 to create a document titled "Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education."

The report defines a new model for advanced nursing practice in which NPs are certified and licensed by the population they treat - family, adult/gerontologic, women's health/gender-specific, neonatal, pediatric, psychiatric/mental health. They may further specialize by disease or physiologic process (see figure).

Here we profile several NPs who have found a niche practice based on, or not based on, the specialty they're certified in. They may all benefit from the reorganization proposed by the APRN Consensus Model.

Seeing Children Grow
Sheila Driver is a pediatric nurse practitioner who owns her own pediatrics practice in West Jefferson, N.C. She provides primary care for patients ages 0 to 21. She further specializes in asthma as a certified asthma educator for the National Respiratory Training Center of the United States, "But I do everything," she says.

Driver believes her specialty chose her: "I worked in neonatal intensive care for several years, [but] I really wanted a chance to see the kids grow up," she explains.  So she started working with children of all ages. She appreciates the health care she provides to children as well as families. "I like working with new moms and empowering parents by not only telling them what the diagnosis is, but helping them take care of that diagnosis and prevent that diagnosis again if we can," she says.

Driver says that it may have been easier for her to get a job as a family NP, but specialties allow NPs to study a population in more depth. "It has handicapped me in a way, but I still feel like I was chosen to be a pediatric nurse practitioner, and I think that I do peds much better than a family NP. . Immunizations in themselves with children are changing daily, almost."

She believes that children who see pediatric NPs receive better care than those seeing family NPs, because there are so many changing issues in pediatric health care. "The family practice just can't keep up with all the knowledge and do the latest things with children, like developmental testing," and pediatrics provides a friendlier setting for children, she says.

Her specialty isn't what prepared her for opening her own practice, however. "I think I've learned that in my way in the last 12 years I've been a nurse practitioner." She also recommends that NP students think about the location they'll work in before choosing a specialty. "If they want to work in a big city, there are more options, but if you're working in a small, rural area like I am, it's harder to be a specialist. It's easier to be a family nurse practitioner."

The Face of Dermatology
Ted Scott, NP, is a family and dermatology NP who sees patients of all ages in the medical and surgical dermatology practice where he works in San Marco, Calif. He commonly sees patients with skin cancers and precancerous conditions, as well as conditions such as psoriasis, acne, warts and fungal infections. "I routinely do surgery to remove skin cysts, skin cancers, atypical moles and even the occasional dystrophic toenail," he notes.

Scott also spends a considerable amount of time educating patients, especially about the dangers of tanning in the sun or in tanning beds. He feels rewarded by being able to cure cancer every day.

Scott believes his family NP education prepared him well to specialize in dermatology. "I tell my NP students that they already know what normal skin looks like and that the only part they need to learn is the names of what the abnormal things are and how to treat them."

That does not mean, though, that additional education is of no use to NPs who want to practice in dermatology. "The most important thing to do is read everything you can get your hands on. There is so much information to be learned to practice dermatology that you will never run out of things to review," says Scott.