An investigation of the international literature

on nurse practitioner private practice models

J. Currie1,4 NP, BSc, MSc, PhD Candidate, M. Chiarella2
PhD (UNSW) & T. Buckley3 RN, BSc, MN, PhD

RN, RM, LLB (Hons),

1 Coordinator pre-registration Masters of Nursing, Lecturer, Sydney Nursing School, 2 Professor of Nursing, Sydney Nursing
School, 3 Coordinator for Masters of Nursing (Nurse Practitioner), Senior Lecturer, Sydney Nursing School, University of
Sydney, 4 Nurse Practitioner, Campbelltown Hospital, Sydney, NSW, Australia

CURRIE J., CHIARELLA M. & BUCKLEY T. (2013) An investigation of the international literature on
nurse practitioner private practice models. International Nursing Review 60, 435447
Aim: To investigate and synthesize the international literature surrounding nurse practitioner (NP) private
practice models in order to provide an exposition of commonalities and differences.
Background: NP models of service delivery have been established internationally and most are based in the
public healthcare system. In recent years, opportunities for the establishment of NP private practice models
have evolved, facilitated by changes in legislation and driven by identification of potential patient need. To
date, NP private practice models have received less attention in the literature and, to the authors knowledge,
this is the first international investigation of NP private practice models.
Design: Integrative literature review.
Method: A literature search was undertaken in October 2012. Database sources utilized included Medical
Literature Analyses and Retrieval (MEDLINE), the Cumulative Index of Nursing and Allied Health Literature
(CINAHL), ProQuest, Scopus and the Cochrane Database of Systematic Reviews (CDSR). The grey literature
was also searched. The following Medical Subject Headings (MeSH) and search terms used both individually
and in combination included nurse practitioners; private practice; joint practice; collaboration; and insurance,
health and reimbursement. Once literature had been identified, a thematic analysis was undertaken to extract
themes.
Results: Thirty manuscripts and five publications from the grey literature were included in the final review.
Private practice NP roles were identified in five countries, with the majority of the literature emanating from
the USA. The thematic analysis resulted in the identification of five themes: reimbursement, collaborative
arrangements, legislation, models of care and acceptability.
Conclusion: Proportionally, there are very few NPs engaged in private practice internationally. The most
common NP private practice models were community based, with NPs working in clinic settings, either alone
or with other health professionals. Challenges in the context of legislation and financial reimbursement were
identified in each country where private practice is being undertaken.
Keywords: Advanced Practice, International Health, Literature Reviews, NursePhysician, Nurse Practitioner,
Nursing Legislation, Nursing Models, Nursing Regulation, Credentialing, Registration

Correspondence address: Ms Jane Currie, Faculty of Nursing, University of Sydney, 88 Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Tel: +61-416647340; Fax:
+61 2 9036 0000; E-mail: jane.currie@sydney.edu.au.

There are no conflicts of interest.

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Literature Review

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J. Currie et al.

Introduction
Nurse practitioner (NP) models of service delivery have evolved
internationally, and in some countries, the NP models have
been established in both public and private healthcare systems.
In most countries, NP private practice models are less well
established than public NP practice models and this is further
reflected in the quantity of literature available. These roles are
relatively new to Australia and there is a paucity of literature
identifying their current shape and form. The intent of this
investigation is to explore the international literature relating to
NP private practice models to seek an understanding of how
private practice models have manifested to provide an exposition of commonalities and differences between countries.

Background
NPs are registered nurses who have been trained to perform at
an advanced level of assessment and clinical decision-making.
While the specific definition differs between countries, common
characteristics of the role include the authority to diagnose, prescription of medication, referral for investigations and referral
to other health professionals (International Council of Nursing
Nurse Practitioner/Advanced Practice Nurse Network 2013).
The first country to establish the NP role was the USA, where
the role was implemented in the 1960s to meet the rising
demand for health care in rural and underserved areas (Savrin
2009). Since the introduction in the USA, the role has been
introduced through Europe, Africa, Asia and Australasia, with
NP roles formally recognized in 23 countries by professional
organizations, the government and professional bodies (Pulcini
et al. 2012). The majority of literature on the NP role is published within the Western countries and there is less in the
English-speaking publications from Asian and African countries, although some will be cited in this review (Sheer & Wong
2008). While these roles share the title of NP, there are many differences in the character and implementation of the NP role
internationally. This includes variation in the educational background required, scope of practice, legal authority to prescribe
medications, legislation and even the definition of the NP role
(Pulcini et al. 2012; Sheer & Wong 2008).
Taking the issue of legislation as an example, in the UK, the
NP role is not formally regulated and this is reported to have led
to variation in educational preparation and inconsistency in the
model of care provided by NPs (Griffin & Melby 2006). In contrast, the role of the NP in Australia is regulated, with clear educational pathways to endorsement (Nursing and Midwifery
Board Australia 2011). Australia is similar to the USA, where
educational pathways exist and legislation provides boundaries
and restriction to the NP scope of practice. In the USA, these
boundaries and restrictions may differ from state to state

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(Pearson 2009), whereas in Australia, there is now a national

registration scheme in place, although some local differences in
poisons regulations in each jurisdiction still exist (Nursing and
Midwifery Board Australia 2011).
In Thailand, the NP role is regulated by the Thailand Nursing
and Midwifery Council and there are clear educational pathways that lead to certification. There are four NP roles in Thailand, including general, neonatal, eye and community health
(Hanucharurnkul 2007). Training for the first three of these
roles is 4 months, and for the community health, NP is 2 years
at Masters level. The Thai NP roles have been implemented in
response to workforce need, particularly physician shortage,
with a focus on the provision of community-based health care
(Hanucharurnkul 2007).
The NP roles in the UK and the USA were initially introduced to meet shortages of human resources in primary health
care, whereas in Asia, the initial positions were for clinical nurse
specialists based in the hospital setting and the role was later
developed in the primary care sector (Pulcini et al. 2012; Sheer
& Wong 2008). The private practice NP appears to be a more
recent development, and to date, only a few countries have
taken steps to facilitate this. These private practice models
potentially bring with them added complexity in terms of reimbursement of fees for service and compliance with specific legislation, although clearly it is possible for a NP to establish a
business whereby clients would pay cash. To date, there do not
appear to be any published international reviews of the NP
private practice model.

Aim
The aim of this review is to investigate and synthesize the international literature surrounding the practice model of the NP in
private practice in order to provide an exposition of commonalities and differences.

Methods
For the purpose of this review, the NP private practice model
has been defined as one by which reimbursement for health care
provided by an NP is based on fees for service received from an
individual, health insurance scheme or other third party. Identifying literature that focused specifically upon the NP in private
practice was challenging, given that the funding for healthcare
delivery services differ between countries and applying the definition of private practice required an understanding of each
service. The chosen definition is focused upon the financial
reimbursement aspect of the NP private practice model because
this appeared to be the most fundamental delineating characteristic. This definition does not therefore include the other

Nurse practitioner private practice models

characteristics of private practice, such as self-governance and

collaboration.
A literature search was undertaken during October 2012.
Database sources utilized included Medical Literature Analyses
and Retrieval (MEDLINE), the Cumulative Index of Nursing
and Allied Health Literature (CINAHL), ProQuest, Scopus and
the Cochrane Database of Systematic Reviews (CDSR). The following Medical Subject Headings (MeSH) and search terms
were used both individually and in combination, NPs; private
practice; joint practice; collaboration; and insurance, health
and reimbursement. The titles (n = 4261) and abstracts were
reviewed initially and assessed against the inclusion and exclusion criteria. Literature was excluded if it predated 2002, was
not written in the English language and had no relevance to the
private practice NP role. Literature was included if it met the
agreed definition and had relevance to a private practice NP
role. Following initial screening and removal of duplicates, 267
articles were then read, fully reviewed and further screened
against the inclusion and exclusion criteria. This yielded 27
publications and, after reviewing the reference lists of these, a
further three articles were retrieved. As there exists a paucity of
literature relating to the private practice NP role, all relevant
articles were included and a criterion for the level of research
papers was not specified.
The process of applying inclusion and exclusion criteria using
the Preferred Reporting Items for Systematic Reviews and Meta
Analysis (PRISMA) diagram is presented in Fig. 1. The 30 publications retrieved are identified in Table 1.
Grey literature was searched using the Google search engine.
Each country where private practice models had been
identified was targeted: these were Australia, South Africa,
Thailand, the USA and the UK. The grey literature was
searched by adding the name of each country to the search
term private practice nurse practitioner. Specifically, the
national Department/Ministry of Health websites for each of
the countries where private practice had been identified were
explored for relevant publications. The first 13 pages of hits
were reviewed for each country, as this was a consistent point
at which data saturation was achieved. In total, 845 websites
were reviewed, and of these, five pieces of relevant data were
retrieved. The title and websites of the five publications are
identified in Table 2.
Once the literature search was completed, the publications
were grouped by country, and a thematic analysis was undertaken to extract themes from the literature.

Results
Countries from which relevant literature relating to NP private
practice was identified included Australia, South Africa,

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Keywords: Nurse practitioners;

private practice; joint practice;
collaboration; insurance, health
reimbursement

Search Databases: CINAHL,

MEDLINE, Scopus, ProQuest,
Cochrane

n=4261
Title and abstract screened and inclusion/exclusion
criteria applied:
Inclusion:
2002Oct 2012
English language
Relevant to private practice NP model
Exclusion:
Non-nurse practitioner roles
Roles not meeting definition of private practice

n= 267
Duplicates removed: n= 45

Articles fully read and screened

against inclusion and exclusion
criteria and included
n = 27

References cited within articles

n = 30
Screened against
inclusion/exclusion criteria and
included
n=3

Final sample
Included n= 30
Fig. 1 PRISMA diagram.

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J. Currie et al.

Table 1 Results of literature search displayed in chronological order

Author

Method

Purpose

Key content/findings

Survey mailed to 3146 NPs,

response rate of 40%
n = 1241

Prescribing authority and

barriers to NP practice

Barry (2005)

Discussion paper

Establishing a private
practice

Lindeke et al.
(2005)

Survey mailed to 1583

participants, 53%
responded n = 834. Repeat
of a survey undertaken in
1996
Report

Exploration of the perceived

barriers to NP practice

24% of sample believed physician concerns about liability were a

barrier, 18% identified NP not feeling comfortable to prescribe
the selected drug; 8% no physician with whom to develop
standing orders/protocols for specific scheduled drugs
Considerations of establishing a private practice including
logistics, economic, collaborative arrangements and
partnerships
Barriers to NP included: 41% lack of public knowledge of NP role;
40% lack of understanding of NP role by other health
professionals; 40% lower salary than other nursing professionals

USA
Kaplan & Brown
(2004)

Phillips (2005)

Hansen-Turton
et al. (2006)

Clarin (2007)

Survey of 206 Health

Maintenance Organization
(HMO), response rate 54%
n = 112
Electronic survey of 1000
employees in a not for
profit organization,
response rate 21%, n = 206
Literature review

Phillips (2007)

Discussion paper

Coddington &
Sands (2008)

Literature review

Weiland (2008)

Literature review

Kaplan et al. (2009)

Pearson (2009 )

Survey, 50 item questionnaire

mailed to 2864 NPs
response rate 65%
n = 1789
Report

Bauer (2010)

Economic discussion

Brown (2007)

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National report on legislative

changes relevant to the
practice of advanced
practice nurses.
Insurance policies as a
barrier to health care
access and consumer
choice
Consumer perspectives on
NP role

Includes information on reimbursement, referral and prescription

authorities for each state in the USA

Factors affecting
collaboration between NPs
and physicians

Physicians level of understanding of the NP role was the most

significant barrier to collaboration. The physicians attitude
towards the NP in terms of the level of support provided and
the level of respect were also potential barriers to collaboration.
Discussion of educational pathways to NP role, scope of practice
of NPs and reimbursement pathway of NPs in private practice
Patients are satisfied with care provided at nurse managed clinics.
Issues surrounding reimbursement mean that productivity
needs to be increased to enhance revenue.

Challenges faced by NPs in

the USA and the UK
Cost of health care and
quality outcomes of
patients at nurse managed
clinics
Examination of the factors
that influence the ability of
NPs to practice.
Practice patterns of NPs in
Washington State

National report on legislative

changes relevant to the
practice of advanced
practice nurses
NPs as an underutilized
resource

Only 33% HMOs have a policy for credentialing NPs as primary

care providers enabling them to receive reimbursement.
Subsequently, many NPs are unable to access reimbursement
from Medicaid.
90% knew of the NP role, 58% had been treated by an NP. 82% of
NP users were satisfied with their care.

Reimbursement identified as the main barrier to NPs ability to

provide health care
Lack of physician presence was identified as a barrier in terms of
NPs having the opportunity to discuss patients care pathways.
43% of sample practised in private office practice.
Includes information on reimbursement, referral and prescription
authorities for each state in the USA

Cost-effectiveness of NPs in terms of being cheaper to employ

than physicians and their ability to provide comparable quality
of care. Legislation is a barrier to NPs working to their full
scope of practice.

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439

Table 1 Continued

Author

Method

Purpose

Key content/findings

Buppert (2010)

Column

Hansen-Turton
et al. (2010)

Discussion paper

Mandated collaboration, pros

and cons
Nurse managed health
centres (NHMC)

Maylone et al.
(2011)

Descriptive study,
convenience sample, n = 99
NPs, completed a
Dempster Practice
Behaviour Scale
Discussion paper

Legal issues associated with collaborative arrangements including

the quality of care provided, cost and liability
Reimbursement is a central issue to the financial stability of
NHMCs due to lack of credentialing of NPs as primary care
providers. NHMCs are treating large numbers of patients and
have the capacity to treat more.
NPs perceived collaboration with physicians at moderate to high
levels. In terms of conflict resolution NPs preferred
collaboration mode and compromise mode.

Presley (2010)

The relationship between

NPs and collaborating
physicians

Considerations for NPs

establishing rural private
practice
Broadening the scope of
practice of NPs

Fairman et al.
(2011)

Discussion paper

Lee (2011)

Discussion paper

Restrictions imposed by
collaborative arrangements

Pericak (2011)

Discussion paper

Increased autonomy for NPs

as a solution to the
physician shortage

Case study

Case study of establishing a

private practice

Economic analysis
commissioned by Office of
the Chief Nursing Officer,
Queensland Health
Discussion paper

Economic analysis of private

practice business models
in Queensland

Australia
Cashin (2006)

Deloitte (2010)

Harvey (2011)

Legislation as a barrier to
NPs working to full scope
of practice
Acceptability of NP care

Parker et al.
(2012a)

Qualitative, focus groups,

n = 77 across 5 States and
Territories

Parker et al.
(2012b)

Survey delivered online,

n = 1883, 95% response
rate n = 1784

Acceptability of NP care

Literature review

Overview of the NP role

within SA

Report

Review of the role of

privately practicing nurses
within SA

South Africa
Geyer et al. (2002)

Regensberg (2008)

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Financial balance and acceptance were identified as significant

challenges.
NPs are a potential solution to the future shortage of doctors,
particularly in primary health care. State-based regulations are a
major barrier to NPs working to the full scope of their training
and competence.
NPs need autonomy to deliver competent care independent of that
of physicians. States should allow NPs to practice without
supervisory and collaboration clauses.
NPs are a potential solution to decreased access to health care in
underserved areas and a shortage of primary care physicians

One NPs experience of establishing a mental health private NP

practice in Australia. Includes discussion of income,
stakeholders and workload.
Models analysed included emergency department, aged and
palliative care, mental health, chronic disease and services
provided by eligible midwives
Legislation surrounding collaborative arrangements and
reimbursement is the most restrictive to the practise of NPs
Lack of understanding between the role of NPs and practice
nurses. Understanding the level of training undertaken by
NPs was associated with higher acceptability and also an
understanding of what care NPs could safely provide.
87% would be prepared to see a NP for some of their primary
healthcare needs. Lower income participants found NP led care
more acceptable than higher earning participants. Women are
more accepting of the NP role.
Identifies areas of NP practice and a detailed review of the
legislation surrounding the NP role in public and private
practice.
Outline of the challenges and rewards of private practice for
nurses

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J. Currie et al.

Table 1 Continued

Author
Thailand
Hanucharurnkul
et al. (2002)

Hanucharurnkul
(2007)
UK
Crumbie (2006)

Method

Purpose

Key content/findings

Descriptive study, sample

included 63 nurse led
private clinics from 7
provinces and 3518 clients.

To explore the practice

characteristics of private
rural clinics

Descriptive report

Overview of role of NPs in

Thailand

87% of the nurses were qualified to baccalaureate level, 8%

Masters level. Main barrier to the private clinic role was the
legislative prohibitions on prescribing.
90% of the clients were satisfied with the service, average cost of
care was 50% lower than that provided by physician.
Overview of the historical development, educational preparation
and legislation.

Case study

NP partnership within GP
surgery

Establishment of an NP partnership within a GP surgery in Lake

District, UK. Includes overview of legislation enabling nurse
partnerships.

GP, general practice; NP, nurse practitioner.

Table 2 Included results from grey literature search

Author

Title

Website

Society of Private Nurse Practitioners

South Africa (2005)
South African Nursing Council (2005)
KPMG (2011)

The constitution of the Society of Private Nurse Practitioners South Africa

http://www.nurses.org.za

Nursing Act 2005 (No. 33 of 2005)

Economic analysis commissioned by Nursing and Midwifery Officer,
Western Australia
Membership survey
Australias first stand alone NP clinic closes

http://www.info.gov.za
http://www.health.wa.gov.au

American Association of NPs (2012)

Guest & Dahl (2012)

http://www.aanp.org
http://www.abc.net.au

NP, nurse practitioner.

Thailand, the UK and the USA, as identified in Table 1. In other

countries where NP roles exist, such as Holland, Taiwan, Japan
and New Zealand, the literature did not identify private practice
NP models of practice. As an example, a number of the UK
publications identified nurse-led clinics within hospital outpatient services that share some characteristics of NP private
practice, specifically in terms of the level of independence and
self-governance with which they function (Flynn & Whitehead
2006; Judd 2009; Sharples et al. 2002). However, these NP-led
clinic roles do not meet the definition of private practice used
for this review as the NP care is not reimbursed on a fee for
service basis.
The majority of the literature related to NP private practice
was from the USA (n = 21). The number of NPs in the USA has
been estimated at 128 000 (Auerbach 2012) and the quantity of
literature may well be a direct reflection of the number of NPs

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along with the longevity of the private NP role and the model
for health funding in the USA, which is predominantly privately
funded with subsidized health care available to the uninsured
(USA DoH & Human Services). The other four countries where
NP private practice models were identified have in common
healthcare systems that are based upon universal cover1 with
private health care available to those electing to be insured
(DoHA Australia 2012a; DoH South Africa 2012; Ministry of
Public Health Thailand 2012; DoH UK 2013).

Universal health cover refers to health provision that all people can use
including health promotion, health prevention, curative treatment and
rehabilitative services. These health services are of sufficient quality to be
effective whilst ensuring that the use of them does not expose the user to
financial hardship (WHO 2013).

Nurse practitioner private practice models

A thematic analysis of the content of the publications formally included in this review was undertaken. A number of
themes were determined; some showed commonalities and
some showed marked differences between countries. The most
prevalent themes were reimbursement and financial viability
and collaborative arrangements. The themes of models of care,
legislation and acceptability were also identified.

Discussion
There are far fewer NPs working in private practice models per
overall numbers of NPs identified than there are working in
non-private practice models. Even within the USA, where NP
services are more established than in other countries, only 6%
(national total NPs n = 128 000) of NPs function within a
private practice model (American Association of Nurse
Practitioners 2012; Auerbach 2012). This compares with an estimated 10% (national total NPs n = 845) within Australia
(Department of Health Victoria 2013), although the small
overall numbers may inflate the percentage somewhat (Buckley
et al. 2013; Porter 2012). From the literature, it was not possible
to determine the proportions of NPs in private practice in the
other countries.
Legislation

Legislation underpins the NP role in all countries included in

this review, with the exception of the UK, where the NP role is
currently unregulated. In the USA, Australia and South Africa,
legislation exists, which facilitates NPs to work in private practice by enabling the reimbursement of fees for service [Health
Legislation Amendment (Midwives and Nurse Practitioners)
Act (Cth) 2010; Pearson 2009; South African Nursing Council
2005 (Nursing Act No. 33 of 2005); Medical Schemes Act (No.
131 of 1998)]. In each country, the legislation also outlines the
requirements associated with working in private practice,
including specific authority to prescribe medications and refer
for diagnostic investigations. In some countries, collaborative
arrangements are required and these refer to a formalized agreement between a NP and a physician, whereby a physician is
involved in the care provided by the NP (Harvey 2011). The
level of involvement varies in accordance with the legislation
and may involve the physician countersigning medication and
treatment charts within specified time periods or the NP discussing a patients plan of care with a physician or transferring
care if required (Kaplan et al. 2009; Lee 2011).
The legislation that features predominantly within the literature relates to reimbursement and collaborative arrangements,
which have been reported as barriers to establishing NP
private practice (Bauer 2010; Buppert 2010; Clarin 2007;

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441

Fairman et al. 2011; Weiland 2008). There is evidence that legislation is poorly understood by NPs (Kaplan & Brown 2004)
and, in some circumstances, is difficult to comply with (Geyer
et al. 2002).
As an example of the complexity of the legislation, historically in South Africa, NPs who wanted to practise privately
had the option to establish a group practice within the community and provide primary care services (Geyer et al. 2002).
Regulation 387 of the Nursing Act (1978) (South African
Nursing Council) stipulated that nurses and midwives may
only enter a group practice with a person registered under the
same Act (Geyer et al. 2002). This precluded them working in
collaboration with physicians or allied health professionals,
unless an exemption to this regulation was approved by the
Nursing Council. This legislation has since been amended and
health professionals registered under different Acts may now
be employed by each other (Health Professionals Amendment
Act 29 of 2007 of the Health Professions Act 56 of 1974).
In the USA, the legislation underpinning the practice of NPs
differs between States quite markedly and has implications for
the NPs scope of practice and ability to access reimbursement.
For instance, in Alabama and West Virginia, a prescriptive
agreement between the NP and supervising physician is
required in order for the NP to prescribe, whereas in Washington and Wyoming, this is not required (Pearson 2009). Similarly, in the State of Delaware, physician involvement is
necessary in the diagnosis and treatment of patients under the
care of a NP, whereas this is not required in Montana (Pearson
2009).
It has been argued that the legislation surrounding the NP
role in the USA has imposed constraints that impede the NPs
ability to function to their full scope of practice, in both private
and public roles (Weiland 2008). The process of accessing a
physician for a countersignature or for consultation can be
time-consuming and places restrictions on the NPs ability to
practise (Lee 2011). It has been proposed that revising these
areas of legislation, in particular, would allow NPs far greater
independence in their practice (Pericak 2011) and would
improve their ability to maximize their scope of practice to the
benefit of patients.
Models of care

Across all countries where private practice was identified, the

focus of the private practice was community based. Hospitalbased NP private practice was not identified in any of the articles reviewed. The private practice NP roles common to South
Africa, Thailand, the USA and Australia were communitybased, NP-led, private clinics and health centres (Cashin 2006;
Geyer et al. 2002; Hansen-Turton et al. 2006; Hanucharurnkul

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J. Currie et al.

et al. 2002; Presley 2010). In the USA, NP private practices have

been established in retail clinics within shopping centres, rural
health clinics and Nurse Managed Health Centres (NMHC;
Hansen-Turton et al. 2010; Lee 2011).
In South Africa, private NPs appear to be less well established
than those in public health and NP private practices mainly
focus upon the provision of community-based mother and
child services, general care and wound care (Geyer et al. 2002).
It is unclear how many NPs work in private practice within
South Africa. Registered nurses, NPs and midwives have the
legal authority to work in a private practice role [Nursing Act
(33 of 2005)]. There is a Society of Private Nursing Practitioners
that provides information to nurses working in private practice
roles, although these nurses are not specifically NPs (Regensberg
2008).
In Thailand, the private model is also community based,
with nurse-led private clinics established in remote communities that would otherwise have limited access to health care
(Hanucharurnkul et al. 2002). It is unclear what proportion of
these nurse-led clinics is run by NPs; research showed that 8%
were qualified to Masters level and 87% to Baccalaureate level
(Hanucharurnkul et al. 2002). One may deduce that those
qualified to Masters level are more likely to be NPs since the
predominant form of training for community health NPs
within Thailand is at Masters level. Many of the nurses running
these clinics have full-time, hospital-based roles and they
operate their community-based, private clinics outside of their
normal working day in order to ensure that their community
has access to health care (Hanucharurnkul et al. 2002). For
the nurses who are not qualified as NPs, legislation exists
which permits them to prescribe medication under the authorization of a physician. This legislation is difficult to comply
with as there are very few physicians available in the remote
communities to authorize their prescriptions (Hanucharurnkul
2007).
In Australia, NPs work in private clinics based in community
settings (Guest & Dahl 2012; Revive Clinic 2011). The literature
provides evidence of one mental health private practice clinic,
which has been active since 2006 (Cashin 2006).
In the UK literature, one privately practicing NP was identified and this position was based within a general practice (GP)
surgery, within which the NP was an equal partner, thereby
receiving reimbursement for fees for service against the GP contract (Crumbie 2006). Changes to the UK legislation pertaining
to GP contracts, which occurred in 2004, provided the opportunity for nurses to become either full equal partners, fixed share
or salaried partners within GP surgeries. There were no other
examples of private practice NP roles found in the literature
within the UK.

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Common to these NP private practices internationally is

the focus on primary health care and disease prevention. The
rural-based private clinics in Thailand and NMHCs in the
USA are commonly located within underserved areas where
ratios of general practitioners per head of population are low.
These clinics and health centres serve to increase access to care
and focus on providing primary health care and preventative
health care (Hansen-Turton et al. 2010; Hanucharurnkul
2007).
Reimbursement

Reimbursement appears as one of the key considerations and

barriers to the development and sustainability of the private
practice NP model (Barry 2005; Presley 2010). One NP private
practice clinic closed recently in Australia, reportedly as a result
of constraints with reimbursement, which impeded its economic viability (Guest & Dahl 2012). NPs in Australia receive
85% reimbursement of fee for service from Medicare, compared
with the 100% received by physicians. NPs in private practice in
Australia have access to a limited number of Medicare Benefit
Schedule (MBS) items, only four items, compared with physicians who can access many more (MBS online). These four
items are characterized by their length of consultation. For
example, a short patient consultation with limited examination
and management is valued at $9.20, of which the NP may
receive 85%, $7.85. A 40-min consultation involving extensive
history taking and examination and management is valued at
$56.30, of which the NP receives $47.90 reimbursement from
Medicare (Medicare Benefits Scheme 2013 online). For the
provision of comparable services, the scheduled fees for general
practitioners are $16.60 and $103.50, respectively, more than
double the reimbursement of an NP. Specific procedures, such
as an incision and drainage of an abscess are not included in the
four NP items, whereas physicians can claim for their procedures. This situation may encourage NPs in private practice to
charge patients above the scheduled fee, seeking co-payment
from their patients on top of the insurance reimbursement
in order to sustain the financial viability of their practice. It
may also encourage the establishment of clinics in affluent
areas where co-payment is more likely to be acceptable to the
consumer.
Particularly relevant to Australian rural and remote
healthcare provision, the telehealth initiative was introduced in
July 2011 and this has enabled privately practicing NPs to participate in video consultation with a specialist or consultant
physician over a distance of greater than 15 km or at any aged
care facility or Aboriginal Medical Service (DoHA 2012b).
There are 12 time-dependent telehealth item numbers available
to NPs. These item numbers allow NPs to be reimbursed for

Nurse practitioner private practice models

telephone or video consultations undertaken with a specialist

seeking advice on behalf of a patient, although an NP is unable
to seek reimbursement in the capacity of a consultant if contacted by another health care professional in request for their
advice using these telehealth item numbers.
In Australia, NP private practice has been forecast as potentially financially viable in certain models of care and less so in
others (Deloitte 2010; KPMG 2011). One of the more financially viable roles may be a joint privatepublic arrangement
where NPs are based within a private practice and effectively sell
their services to the public health system (Deloitte 2010). The
joint privatepublic arrangement may yield benefits to patient
care by reducing the fragmentation of services from hospital to
community settings (Deloitte 2010) and it may be well suited to
aged and palliative care and wound care services (KPMG 2011).
To date, there are no documented examples of joint private
public NP services in Australia.
In the USA, the federal Balanced Budget Act (1997) granted
NPs health care provider status, which in effect authorizes direct
reimbursement from Medicare services in all settings (Phillips
2007). As in Australia, there are disparities between physician
and NP reimbursement, which mean that in specific states of
the USA NPs are reimbursed at 85% of the physician rate for
providing a comparable service (Phillips 2005). In New York,
NPs may register as Medicaid providers and be reimbursed at
100% of the physician rate, whereas in Illinois, NPs who are registered as Medicaid providers are reimbursed at 70% of the physician rate, unless they choose to bill under a physician and
thereby receive 100% reimbursement (Phillips 2005). In Florida,
Medicaid reimburses NPs at 80% of the physician rate, unless a
physician countersigns the chart within 24 h, in which case
100% reimbursement is paid (Phillips 2005). Conversely, in
Connecticut, the law prevents insurers from requiring supervision or signature by any other healthcare provider as a condition of reimbursement to NPs (Phillips 2005).
Third party payers, such as health insurance funds, are sometimes reluctant to recognize NPs as independent practitioners
and pay them accordingly, which in some circumstances has
contributed to lower salaries for NPs (Buerhaus 2010;
Hansen-Turton et al. 2010; Lindeke et al. 2005). Legislation
exists in certain states of the USA that prevents third party
insurers, such as private health insurance companies, from discriminating against NPs by not recognizing and credentialing
them as primary care givers (Hansen-Turton et al. 2010). In
states where this does not exist or is not enforced, it has been
noted that certain private health insurance companies do not
reimburse NPs as primary care givers, which has a direct effect
on their level of reimbursement (Hansen-Turton et al. 2010).
This is particularly challenging for those providing care within

2013 International Council of Nurses

443

NHMCs, who often struggle for reimbursement as a consequence. Despite this, the NHMCs are thriving and have recorded over 2.5 million patient encounters each year with the
capacity to care for even more (Hansen-Turton et al. 2006,
2010). The government has offered financial grants to some
NHMCs to relieve the financial burden (Hansen-Turton et al.
2010).
In circumstances where it is difficult to obtain direct reimbursement, NPs in the USA appear to seek alternative methods
of reimbursement, which includes billing through medical practitioners. While this enables the sustainability of their role, it
can hide the contribution they are making to patient care,
impede their ability to practise truly independently (Weiland
2008) and potentially deter them from establishing independent
private practices. In recent years, NPs in the USA have been
included on some managed care provider panels, which was
perceived as a sign of increasing acceptance (Towers 2005).
However, as previously stated, in certain States, NPs are currently unable to receive 100% reimbursement for the service
they provide and, in order to sustain private practice, NPs must
ensure high volumes of patients (Coddington & Sands 2008;
Presley 2010).
Ensuring high volumes of patients has the potential to
encourage NPs to work more quickly and to perhaps be less
thorough and it may even herald a cultural shift in the way NPs
approach care. Literature from the public sector has reported
that NPs spend longer periods of time consulting with their
patients, which has been linked to patient satisfaction and the
quality of care provided by NPs (Horrocks et al. 2002; Laurant
et al. 2008). Increasing the number of patients treated and
shortening consultation time may impact on the level of patient
satisfaction and the quality of care provided.
In Thailand, patients paid directly for the services the NPs
provided and, in instances where patients could not afford
the costs associated, some clinics allowed payment in vegetables rather than money (Hanucharurnkul et al. 2002). The
remote community clinics are up to 50% lower in cost than
the same services provided by physicians and this has allowed
the clinics to be more accessible for the communities they
served and increased patient satisfaction (Hanucharurnkul
et al. 2002).
Collaborative arrangements

The legislative requirements for collaboration between an NP

working in private practice and a physician are common to the
USA and Australia (Phillips 2007; Buppert 2010; National
Health (Collaborative Arrangements for Nurse practitioners)
Determination 2010). Some physicians charge NPs a fee to
establish a collaborative arrangement and finding a physician

444

J. Currie et al.

to collaborate with can cause significant delays to NPs opening

their private practice (Buppert 2010). A collaborative arrangement is a prerequisite for reimbursement in Australia and is a
requirement for the referral of specific investigations and prescriptions in the USA (Harvey 2011; Pearson 2009).
There are reports from the USA that identify the collaborative arrangement as positive for NPs in terms of their perceived confidence and empowerment (Maylone et al. 2011),
particularly regarding prescribing (Kaplan & Brown 2004).
There is also evidence from the Canadian public sector that
collaboration improves the development of professional relationships between NPs and other health professionals (Mian
et al. 2012).
In the USA, it has been identified that the success of collaboration is underpinned by the physicians understanding of
the NP role and scope of practice and the difficulty has been
that this is often poor (Bailey et al. 2006; Clarin 2007). The
intent of collaboration was to foster a collegial relationship
between physicians and NPs, enabling safe practice in the provision of care (Coeling & Cukr 2000). However, in circumstances where this has not been achieved, the relationship
moves from collegiality to one more aligned with traditional
nurse and doctor hierarchical boundaries, in which the NP
strives to prove their competence (Bailey et al. 2006). This
undermines the intent of the relationship and may encourage
a culture of external authority and dependence rather than
fostering NP independence. The alternative to collaborative
arrangements is to allow the NP to practise autonomously as
intended, without formal collaboration, and to receive equal
and unrestricted access to reimbursement (Lee 2011; Partin
2010).
Acceptability

One of the most critical factors in establishing both private and

public NP-led care is its acceptability to society. Evidence from
Washington State, USA, has shown a rise in the acceptability of
NP-led care to a point where NPs are one of the most commonly used alternatives to physician-led care (Brown 2007). In
Australia, consumer understanding of the level of education
undertaken by an NP working in primary care has been associated with a higher level of acceptability of the role (Parker et al.
2012a; Parker et al. 2012b). Understanding the level of education and the purpose of the NP role was connected to a perception of a division of labour, in terms of appreciating which
health professionals were best suited to specific episodes of care.
As such, NPs were deemed appropriate for minor injury and
illness and health education, whereas doctors more appropriate
for serious health complaints (Parker et al. 2012a). Women are
also more likely to accept the care provided by an NP compared

2013 International Council of Nurses

with men (Parker et al. 2012b). In Thailand, the private NP

community clinics have met with high satisfaction from consumers largely because they are cheaper and provide an efficient
and friendly service that is close to home (Hanucharurnkul
et al. 2002).
The acceptance of NP private practice models among physicians appears mixed in both the USA and the Australia (Clarin
2007; Presley 2010). In the literature, there is speculation that
physicians are responsible for specific constraints placed on NPs
in terms of reimbursement and collaborative arrangements
(Hansen-Turton et al. 2006; Harvey 2011). However, those
engaged in collaboration are supportive (Clarin 2007). It has
been proposed that NPs need to become more involved in
policy-making, educating physicians and engaging with them
more effectively (Pericak 2011).

Limitations
In presenting the results of this review, identifying literature
pertaining to the role of the private NP was challenging. The
majority of existing literature on the NP role focuses on
elements of the public role, rather than the private, and this
may be a reflection of the infancy of the role and the number
of NPs engaged in private practice. The exclusion and inclusion criteria for the literature search focused upon literature,
which held relevance to the NP private practice role, and
while this is an ambiguous term, it was necessary in order to
identify the full body of literature available. If the exclusion
and inclusion criteria had been more specific, then papers
identifying collaboration and reimbursement issues may not
have been identified.
Despite the breadth of this search, very few international
papers were identified that reported private practice NP models.
When interpreting the results of this review, it is possible that
the body of literature presented here provides a limited perspective of the true state of NP private practice internationally.
However, this review will provide initial insight into a topic area
that is less well explored than its public NP counterpart and
potentially stimulate further exploration of the practice model
of the private practice NP.

Conclusion
This review has provided an investigation and synthesis of the
international literature surrounding NP private practice models
and explored the commonalities and differences therein. There
appear to be very few published accounts of NPs engaged in
private practice. In countries where private practice is established, these practice models are predominantly community
based rather than hospital based and more often located in
underserved areas of the community. It seems worldwide that

Nurse practitioner private practice models

the demand for health care is increasing and evidence presented

in this review shows a trending increase in the acceptability of
NP-led care. The main barrier to the further development of NP
private practice models appears to be the content of the legislation, which makes a number of the key functions of the private
NP dependent on the authority of physicians. The effect of this
is difficulty in establishing and sustaining NP private practice.
Establishing reimbursement pathways is a core challenge and it
is perhaps a testament to the services provided by NPs that,
despite this, some NP private practices are thriving and the
NHMCs in the USA are an example of this. The legal requirements for collaboration hold similar challenges and, as this
investigation identifies, can impose constraints on the NPs
ability to work to the full scope of their practice.

Author contributions
JC: study design, data collection, analysis and interpretation of
literature, discussion, writing, manuscript preparation; MC:
interpretation of literature, discussion, writing; TB: interpretation of literature, discussion, writing.

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