1. MLPs by country
    South Africa  United Kingdom  United States   Controversy    Drug Enforcement Administration  

2. See also

3. References

4. External links

Many providers simply prefer their professional title, such as nurse practitioner (NP) or physician assistant (PA).

Because of their diverse histories, a multitude of mid-level health worker categories can be found in different countries under different titles. Their training, functions, scope of practice, regulation, and integration into the formal health system vary from country to country. Mid-level practitioners have many different titles, e.g. physician assistant, clinical officer, or nurse practitioner. They are increasingly being used to render services autonomously, particularly in rural and remote areas, to make up for physician shortages.^[3]

MLPs by country

South Africa

In 2008, a new mid-level practitioner role was introduced in South Africa, known as clinical associates. The role was intended to support the district hospital workforce.^[4]

United Kingdom

Mid-level practitioners in the UK are known as 'Advanced Clinical Practitioners' (ACP) and is an evolution of many differing professions which use various titles such as ‘Extended Scope Practitioner’ or ‘Advanced Practitioner’. Historically there has been debate over the consistency of quality in these senior clinicians and therefore it became necessary to generate a distinguished definition of the ACP role. The ACP:

• Is a registered healthcare practitioner with a minimum of 5 years clinical experience (2 years in a senior clinical role)
• Has acquired expert knowledge and complex decision making skills which may be an extension of their traditional scope of practice
• Will undertake a two-year level 7 (Master's degree) training course in Advanced Practice
• Will maintain training and CPD requirements ^[5]

This is an emerging role and is showing a good deal of promise in meeting the demands of the UK's rapidly evolving healthcare requirements. ACPs may practice in the acute setting (ED, critical care, medical or surgical wards) or community General Practice / family medicine. The majority can independently assess, investigate (through blood science / imaging / labs etc.), diagnose and formulate a treatment including prescribing medications or referring to specialist care.

The deployment of ACPs is considered to be part of a Value Based Recruitment framework driven by Health Education England (HEE). This seeks to appoint clinicians based upon their competencies, values and behaviours in support of collaborative working and delivering excellent patient care.^[6]

United States

In the United States, mid-level practitioner is a term used to describe the category of health care workers with training less than that of a physician but greater than that of more ordinary nurses and other medical assistants. In recent years some organizations and specialties have proposed the discontinuance of the term mid level in reference to professional practitioners who are not physicians.^{[7][8][9][10]} This shift follows a change in paradigm toward a collaborative team based care model.^[11][12] Other groups such as the American Academy of Family Physicians considers the term to be appropriate as it delineates a clear distinction between the training and expertise of physicians and non-physicians, and considers the term "providers" that encompasses both physicians and non-physicians to be derogatory.^[13]

The term mid-level practitioner or mid-level provider related to the occupational closure of healthcare. This concept centered around physicians as the ultimate professional responsible for healthcare. As healthcare demands have increased in the United States due to an aging population, a physician shortage and the implementation of the Patient Protection and Affordable Care Act of 2010 there has been a shift toward more independence in practice for professionals such as advanced practice nurses, pharmacists, dentists, podiatrists, dental therapists and physician assistants who were previously described as part of this category.^[14]

As an example of a shift away from the US Medicare system terms both advanced practice nurses and physician assistants as "non-physician practitioner" (NPP).^[15] Medicare will pay for emergency department services when these services meet the critical care services definition and requirements.^[16]

Controversy

The American Academy of Nurse Practitioners (AANP) released a position statement in 2009, updated in 2010, 2013 and 2015 denouncing the use of several relegating terminology. Terms such as "mid-level provider," "physician extender," "limited license provider," "non-physician provider," and "allied health provider" when referring to nurse practitioners are considered derogatory by the AANP.^[17] The American Academy of Nurse Practitioners prefers that nurse practitioners are referred to as "Nurse Practitioners," "independently licensed providers," "primary-care providers," "health-care professionals," and "clinicians." in reference to the legal and professional paradigm that nursing practice is considered separate and independent of other licensed professionals.^[18] The American Association of Nurse Anesthetist (AANA) released a position statement in 2016, updated in 2018, which opposes descriptors such as “mid-level practitioner,” “non-physician,” “physician extender,” “dependent practitioner,” and “allied health practitioner” to refer to CRNAs either individually or as part of a group; instead, the AANA recogizes the terms Certified Registered Nurse Anesthetist, CRNA, and nurse anesthetist (additional descriptors include: “Advanced Practice Registered Nurse (APRN),” “Licensed Nurse Practitioner (LNP),” “Licensed Independent Practitioner (LIP)”, Advanced Practice Provider (APP),” “advanced practice professional” or “nurse anesthesiologist”). ^[19] In a fact sheet released in 2015, the National Association of Pediatric Nurse Practitioners objects to the terminology "mid-level health care professionals" as it implies that Nurse Practitioners "provide 'average' care instead of 'high level' care". ^[20][21] Physician professional organizations such as the American Academy of Emergency Medicine utilize the term "Advanced Practice Provider (AAP)" for these clinicians. ^[22]

Drug Enforcement Administration

The term mid-level practitioner as found in the DEA classification in Section 1300.01(b28), Title 21, of the Code of Federal Regulations is not a health care designation and must not be confused with the term as it is defined above. The DEA uses the term mid-level as a means of organizing its drug diversion activities. The term mid-level practitioner as used by the DEA Office of Diversion Control include clinicians, other than a physician, dentist, veterinarian, or podiatrist, who are licensed, registered, or otherwise permitted to dispense a controlled substance in the course of professional practice.^[23][24] Some health professionals considered mid-level practitioners by the United States DEA solely for the purposes of drug diversion control include:

• Medical social workers
• Nurse practitioners
• Certified Nurse-Midwives
• Certified Nurse Anesthetists
• Clinical nurse specialists
• Pharmacists
• Clinical Psychologists
• Physician assistants

• Homeopathic physicians
• Doctors of Oriental Medicine
• Euthanasia technicians
• Naturopathic physicians
• Physiotherapists
• Optometrists
• Medical psychologists

See also

• Allied health professions
• Health human resources
• Nurse Practitioner
• Nurse Anesthetist
• Advanced Practice Registered Nurse/Advanced Practice Nurse
• Certified Nurse Midwife
• Physician Assistant

References

External links

• Global Health Workforce Alliance: mid-level health workers

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