An Advanced Practice Registered Nurse (APRN) is a nurse who has a master’s, post-master’s certificate, or practice-focused doctor of nursing practice degree in one of four specific roles. APRNs are licensed through a state board of nursing to provide patient care within their role and patient population focus, and in many states have the authority to prescribe medication and practice independently without physician oversight. Though advanced practice registered nursing is an advanced subset of registered nursing, in most states the APRN license is considered separate licensing class from RN licensure.
The International Council of Nurses defines an advanced practice nurse as a registered nurse with the expert knowledge, complex decision-making skills, and clinical competencies necessary for expanded practice. This differentiates APRNs from registered nurses (RNs) in that they are capable of taking on more complex casework and handling those cases with greater independence and discretion.
For this reason, APRNs are increasingly being relied on to meet the demand for primary and specialty healthcare practitioners, especially in rural areas and other areas underserved by physicians.
The four APRN roles currently defined in practice are:
• Nurse Practitioners (NP)
• Clinical Nurse Specialists (CNS)
• Certified Nurse-midwives (CNM)
• Certified Nurse Anesthetists (CNA)
Nurse practitioners and clinical nurse specialists are further defined by national certification in one of six patient population focus areas (Family/Individual Across the Lifespan, Adult-Gerontology (acute or primary, Women’s Health, Neonatal, Pediatrics (acute or primary), Psychiatric/Mental Health).
For certified nurse-midwives, who work with infants and women during pregnancy and throughout the lifespan, the patient population is implicit in the primary role. Nurse anesthetists may be more familiar with a particular patient population group based on practice setting, but are able to work with all patient groups under their primary role certification.
APRNs may practice independently in some states and in some roles, while in other states they are required to enter into what is known as a collaborative agreement with a supervising physician. Unlike RNs, the supervision is rarely direct, however; APRNs operate on something closer to a partnership basis with physicians even in collaborative agreements.
Advocacy from various APRN industry groups, particularly the NCSBN (the National Council of State Boards of Nursing), and the economic realities of modern healthcare delivery, is pushing a legislative blueprint called the Consensus Model toward state regulators to encourage full independent practice authority, including prescriptive authority, in all 50 states and licensing jurisdictions.
This degree of freedom does not come without dedication and study, however. APRNs have to acquire an advanced degree and pass strict state nursing board standards for licensure. Though a master’s degree in nursing remains the minimum standard for APRN licensure in all states and licensing jurisdictions, a 2004 position statement from the American Association of Colleges of Nursing (AACN) and the NCSBN recommends that a practice-focused doctorate degree (Doctor of Nursing Practice (DNP) as the minimum education requirement. Although implementation has been slow, the field is increasingly moving in that direction, with the American Association of Nurse Anesthetists committing to reaching the goal by 2025.
An Old Model May Become The Future of American Healthcare
Nurses filling advanced patient care roles is hardly a new phenomenon in the United States, heralding back to frontier days when doctors were in short supply and any nurse capable of delivering services did so to the maximum extent of their knowledge and abilities.
In the modern era, advanced practice nurses can trace their lineage through to one particular APRN role – the nurse practitioner. In 1965, responding to an increased demand for primary care providers and a shortage of trained physicians, Loretta Ford and Henry Silver, a nurse and a doctor, paired up to create the first nurse practitioner training program in Colorado.
During the same period, the practice of medicine was becoming increasingly specialized at all levels (a trend which was also responsible, in part, for the shortage of primary care physicians) and the roles of nurse practitioners also began to diverge into those various specializations. To better clarify the unique role of advanced practice nursing, the NCSBN issued a series of position papers between 1986 and 2002 that came to define advanced practice registered nursing as it exists today.
Demand for all four APRN roles is strong and likely to continue to increase in the United States. In 2016, the American Association of Medical Colleges projected that by 2025, there will be a shortfall of 90,000 physicians due to the growing demand coming from an aging population and increased access to medical insurance. The shortfall in primary care physicians alone is expected to top 30,000. Together with higher utilization rates, this is stoking rising costs. Healthcare consultancy Price Waterhouse Cooper’s projects a 6.5 percent increase in healthcare costs for 2017, identical to 2016, and more than double the rate of inflation.
Patients, insurers, and legislators are all turning to APRNs to alleviate the problems. With more than 250,000 licensed APRNs already working across the country today, patients report higher satisfaction rates with APRNs than physicians, and multiple studies have found almost identical medical outcomes. As of August 2016, fifteen states and other licensing jurisdictions have fully implemented the NCSBN Consensus Model to allow APRNs to practice and prescribe independently, and 28 others are considering or have partially implemented it.
Nurse Practitioners – Providing a Solution to the Primary Care Shortage
The most common type of APRN is still the nurse practitioner, representing well over half of advanced practice nurses in 2017 according to the U.S. Department of Health and Human Services. NPs are qualified to provide a range of both primary and acute health care services. They can diagnose and treat medical conditions and perform many of the same tasks as a physician, including writing prescriptions in about 20 states.
Becoming an NP requires a Master of Science in Nursing (MSN), post-master’s, or Doctor of Nursing Practice (DNP) in one of six clearly defined patient population foci:
- Family/Individual Across the Lifespan
- Adult-Gerontology (Acute care/primary care)
- Women’s health/gender-related
- Pediatrics (Acute care/primary care)
- Psychiatric/mental health
An NP may also select a specialty field, such as emergency care or orthopedics. Specialties do not extend outside the selected population focus and cannot replace that focus but extend and enhance the nurse practitioners knowledge and expertise in addressing a specific subset of the medical needs within that population.
All states regulate NPs. Their official designation depends on individual state licensing legislation and can include titles such as Advanced Registered Nurse Practitioner (ARNP), Advanced Practice Registered Nurse (APRN), Advanced Practice Nurse (APN), Certified Nurse Practitioner (CNP), Certified Registered Nurse Practitioner (CRNP), and Licensed Nurse Practitioner (LNP). All states, except California, Kansas, and Indiana as of 2012, also require that NPs be certified by one of the national certifying organizations for nurses.
For more information, visit the American College of Nurse Practitioners.
Clinical Nurse Specialist – Changing Healthcare From the Clinical Environment
While an NP typically provides primary care to patients, a CNS will usually work in a specialized area of nursing practice defined by parameters such as:
- Disease or medical specialty (oncology, diabetes, etc.)
- Population (children, seniors, women, etc.)
- Setting (critical care, emergency room, etc.)
- Type of care (rehabilitation, mental health, etc.)
- Type of problem (pain, eating disorders, etc.)
As with NPs, this specialization does not replace the population focus. However, it is a more critical aspect of the CNS role. With the introduction of the population focus paradigm in the Consensus Model, many CNS providers and educational programs have had to re-evaluate their specializations to address overlaps or gaps introduce between the traditional specialties and those foci. This process is still being explored as state legislation is updated across the country.
Clinical nurse specialists often take on advisory or management roles in their field. They may serve as educators or outcome managers, supervising other staff or overseeing cases to ensure the best possible treatment by using their advanced training to guide clinical treatments. They can also serve as patient facilitators and educators, guiding patients and their families through the complexities of modern specialty treatment and supporting their decision-making processes with facts and perspective.
A good example of this is gerontology CNSs, who work with elderly patients and their families during the difficult transition period from independence to long-term care or palliative treatment facilities.
Just as with NPs, each state has its own licensing requirements, which generally involve a master’s degree or higher from a clinical nurse specialist program and national certification as a CNS. Generally speaking, the CNS role is not as widely recognized as the nurse practitioner role, with Mississippi, Virginia, Pennsylvania, and New Hampshire not recognizing CNSs as APRNs as of 2017, and only 17 states allowing independent prescriptive authority to CNSs.
For more information, visit the National Association of Clinical Nurse Specialists.
Nurse-Midwife – Promoting Healthy Woman and Infants Through Evidence Based Practice
Certified nurse-midwives provide primary health care services for women from adolescence throughout their lifetimes. In additional to general primary care, nurse-midwives provide:
- Gynecological and family planning services
- Pregnancy, childbirth, and postpartum care
- Healthy newborn baby care for the first 28 days of life
- Treatment of male partners for sexually transmitted diseases
This scope of services is wider than most people generally associate with the term mid-wife, and it’s true that CNMs tend to focus on gynecological and pregnancy services. In 2014, CNMs attended just over 300,000 births, a little more than 8 percent of all births in the United States.
Another common misconception about nurse-midwives is that they are primarily used in at-home births, but that amounted to only about two percent of their work in 2014. More than half of nurse-midwives are employed by hospitals and more than 94 percent of their work is performed there.
In both their primary care and gynecological roles, nurse-midwives conduct annual exams, perform basic nutrition counseling, and provide patient and parenting education to both parents and prospective parents.
Becoming a nurse-midwife requires completing a graduate program that prepares students to take the Certified Nurse-Midwife examination offered by the American Midwifery Certification Board (AMCB) and to become state-licensed.
For more information, visit the American College of Nurse-Midwives.
Nurse Anesthetist – Meeting Demand and Reducing Costs Associated With Administering Anesthesia
Nurse anesthetists are APRNs who are qualified to administer anesthesia to patients for surgery and other procedures and to provide pre- and post-anesthesia care.
They perform physical assessments of potential patients, screening, for example, for known medication allergies and other background indicators of adverse drug reactions. They manage the drugs used for pain management and anesthesia and carefully monitor the administration of those drugs during procedures. Post-operatively, they monitor patients coming out of anesthesia and ensure their complete return to consciousness before handing them off to the recovery wards.
Anesthesiology is a tricky business and these APRNs both receive some of the most advanced education and highest pay of any of the four categories. They have also had the most difficult time receiving legislative blessing and receiving independent prescriptive authority.
But a shortage of anesthetists in the United States has left many areas with little choice but to employ and trust CRNAs. According to the American Association of Nurse Anesthetists, CRNAs are the sole provider of anesthesia services in most rural healthcare facilities in the country. Many procedures, from basic services that require local anesthetics all the way up through lifesaving emergency trauma cases, could not be performed in the majority of those settings if not for CRNAs.
Becoming a nurse anesthetist requires completing a graduate degree program so as be qualified for Certified Registered Nurse Anesthetist (CRNA) certification through the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) before then applying for advanced practice state-licensure as a CRNA.
For more information, visit the American Association of Nurse Anesthetists.