Acknowledgements

California Association of Clinical Nurse Specialists

California Association of Nurse Practitioners

California Association of Certified Nurse Midwives

California Association of Certified Registered Nurse Anesthetists

American Association of Psychiatric Nurses, California Chapter, Advanced Practice

Representatives from:

The State of California Board of Registered Nursing

The California School Nurses Association

Table of Contents

Purpose

Introduction

The Institute of Medicine Recommends Action for the Future of Nursing

Nursing Workforce Trends

History of Advanced Practice Registered Nurses

Certified Registered Nurse Anesthetist

Clinical Nurse Specialist

Nurse Practitioner

Certified Nurse Midwife

By the Numbers

Definition of Practice

Licensure, Accreditation, Certification and Education

The Future

Summary

Appendix 1: CAPNAP Board of Directors

Purpose

This document provides a brief history of Advanced Practice Nursing, identifies the number of Advanced Practice Registered Nurses (APRNs), discusses the scope of practice in California, outlines APRN licensure, accreditation, certification and education requirements, and recommends future action for APRNs in California. To assist the nursing profession, educators, regulators, and organizations to better understand APRN practice and proactively address the anticipated changes in health care legislation, the California Association of Psychiatric Mental Health Nurses in Advanced Practice (CAPNAP) facilitated the process with APRN associations and ANA\California to prepare this White Paper.

Introduction

Advanced Practice Registered Nurses (APRNs) are licensed RNs with advanced graduate degree education who function in roles that focus on the direct care of individuals There are four agreed upon APRN roles that include: certified registered nurse anesthetist (CRNA), certified nursemidwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP).[1] State nurse licensing boards regulate nursing practice and interpret the legal scope of practice for nurses. Each state individually regulates APRN practice, which may include criteria for: entry into practice, competence to practice, prescriptive authority, privileges, and reimbursement.1, [2]

The lack of a uniform model of regulation for APRNshas createdbarriers to providing care and limited nurses from practicing across states. Beginning in 2004, a work group representing nursing organizations was convened to establish a regulatory model for APRNs. In July 2008 a groundbreaking consensus document,Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education(LACE) established a model of regulation for APRNs. The plan is for the APRN Regulatory Model to be implemented in every state and nursing program by 2015.1,2

Demands for APRNs are expected to increase as efforts continue to improve patient outcomes, physician shortages develop, work-hour standards for resident physicians are implemented, patient health care demands exceed system capacity, collaborative specialty practices expand, and reimbursement methods for APRNs improve.[3],[4]The recent passage of the Patient Protection and Affordable Care Act will impact care delivery as millions more Americans are expected to obtain health care coverage. As a result, APRNs are expected to be more in demand as reforms increase the need for primary, specialty and long-term healthcare.

The Institute of Medicine Recommends Action for the Future of Nursing

In 2008, the IOM[5], in conjunction with The Robert Wood Johnson Foundation (RWJF), launched an initiative to assess and transform the nursing profession. The IOM appointed a committee on the RWJF Initiative on the Future of Nursing, to establish recommendations that will direct the future of nursing. The committee considered the obstacles all nurses encounter with the transformation of health care. The committee took particular note of the legal barriers in many states that prohibit APRNs from practicing to their full education and training. They determined that practice constraints will have to be lifted in order for nurses to assume the responsibilities they can and should be taking in the changing health care environment.

In October 2010, the Institute of Medicine (IOM) released the report, whichaddresses the fundamental role of nurses to transform thehealth care system in collaboration with government, businesses, health care organizations, professional associations, and the insurance industry. The Future of Nursing: Leading Change, Advancing Health,[6]makes recommendations that provide direction for nursing and health care. The first of the recommendationsspeaks directly to the role of APRNs.

Recommendation 1: Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training.

To achieve this goal, recommendations are made to extend Medicare, Medicaid (Medi-Cal) and third party payer reimbursement, reform scopes of practice, facilitate eligibility for hospital clinical and admitting privileges, and to amend restrictive state regulations to allow APRNS to provide care in all circumstances in which they are qualified.5

Nursing Workforce Trends

For the past decade, the U.S. has experienced a shortage of Registered Nurses (RNs). This shortage is predicated on employment of an aging nurse workforce, increasing opportunities for women in other professions, the challenging health care work environment, low job satisfaction, and a growing senior population(aging baby boomers) with complex health problems.[7],[8] The recent economic slowdown has forced a surge of RNs back into the workplace and has delayed the retirement of many. However, data indicate that as the economy rebounds, the nursing shortage will become more acute. It is estimated that by 2025 a shortfall of over one-quarter of a million nurses will develop.[9]

Since 2005 California has worked to increase the number of Registered Nurses through such means as the Nurse Education Initiative. The 2009 Annual Report[10] notes that California has expanded nursing programs, increased faculty hiring, and boosted new student enrollments. In the 2008-2009 academic year California schools graduated 10,570 RN graduates, a 10.3% increase from the previous year. Among California State University campuses, 1,765 students were enrolled in master’sdegree nursing programs and in 2008-2009,587 students graduated master’s degree nursing programs. The University of California (UC) system enrolled 852 students in master’s degree nursing programs and 194 in doctoral programs. Even with encouraging increases in nursing graduates, estimates show California’s nursing shortage will continue..[11],[12]

History of Advanced Practice Registered Nurses

A brief history of each of the four APRN roles follows:

Certified Registered Nurse Anesthetist

Certified Registered Nurse Anesthetists (CRNA) have been administering anesthesia to patients in the United States for over a hundred years. In California, the earliest Nurse Anesthetist noted in historical records was a U.S. trained British nurse who administered anesthesia at St. Mary’s Hospital in San Francisco in the 1920s. Ms. Alta Bates, for whom the community hospital in Berkeley is named, was another prominent early Californian Nurse Anesthetist. In 1936, the California Supreme Court ruled the administration of anesthesia by Nurse Anesthetists was within the legal practice of nursing.

Clinical Nurse Specialist

In 1943, Frances Reiter promoted the idea of the “nurse clinician” role. This was further promoted by nurse leaders,most notablyHildegard Peplau. This concept embodied two areas of clinical practice: 1) clinical competence in depth of understanding, range of function and breadth of services; and 2) clinical expertise in the coordination of care and responsibility for continuity of care.[13] In 1963, the Professional Nurse Traineeship Program added Clinical Nurse Specialist (CNS) education, providing a major impetus to develop graduate level program content in advanced clinical nursing. This led to the establishment of clinical specialization within graduate education programs that focused on four sub-roles: clinical practice, education, research and consultation. This multifaceted training enabled the Clinical Nurse Specialist to provide broad-based service to health care agencies, patients and families.[14] The general intent is to bring APRNs back to the bedside to provide direct and indirect care. In more recent years, CNS practice has expanded, authorizing prescriptive authority in many states and within the Veterans Administration health care system.

Nurse Practitioner

The role of the Nurse Practitioner (NP) was developed in the 1960s as a result of a shortage of primary care physicians. The University of Colorado was the first academic institution to educate Registered Nurses in this expanded role through a post-baccalaureate pediatric program. From this work a federal report was published in 1971 recommending expanded roles for nurses and endorsed funding to support their training. As a result, a number of post-baccalaureate continuing education programs of the lack of support among academic nursing for advanced degree preparation for NPs. Some nursing faculty felt Nurse Practitioners were physician-extenders and not practicing within the domain of nursing. Despite this early barrier, Master’s degree NP programs have since flourished. Today there are over 325 colleges and universities offering these programs.

Certified Nurse Midwife

Mary Breckenridge is considered the founder of the nurse midwifery movement in the United States. She developed the Frontier Nursing Service in Kentucky in 1925, a program that used public health Registered Nurses, who had been educated in England, to staff nursing centers in the Appalachian Mountains. The centers offered family health care services, as well as childbearing and delivery care to area residents.

The first nurse-midwifery education program in the U.S. began in 1932 at the Maternity Center Association of New York City. Today, all nurse-midwifery programs are in colleges and universities and nurse-midwives graduate at the Master's degree level.[15]

By the Numbers

The Health Resources and Services Administration (HRSA) estimates there to be over 3 million Registered Nurses nationwide, of which250,527, or 8.2% are Advanced Practice Registered Nurses.[16]

Type of APRN / Estimated Number / Percentage* / Average Annual Salary
Nurse Midwife / 18,492 / 7.4% / $69,222
Nurse Anesthetist / 34,821 / 13.9% / $135,776
Clinical Nurse Specialist / 59,242 / 23.6% / $74,918
Nurse Practitioner / 158,348 / 63.2% / $73,776

*Estimated numbers and their percentages add to more than the total number of APRNs because some RNs have preparation in more than one advanced practice role.

The following data were reported in the 2008 National Sample Survey of Registered Nurses:

  • Nurse Midwives have the smallest numbers among the APRN groups. Over half (50.3%) hold graduate degrees. A majority (57.9%) works in hospital settings; 25.1% are employed in ambulatory care.
  • Nurse Anesthetists have several distinguishing characteristics: they are the youngest APRN group (40% are under 45 years old), they have a higher percentage of men (40%), and earn higher annual salaries ($135,776 on average). Among Nurse Anesthetists, 65.4% hold graduate degrees.
  • Clinical Nurse Specialists showed a decline in numbers from 2004 to 2008. One reason for decline has been the lack of available CNS programs. As well, CNSs are older than other APRN groups (63.6% are over 50 years old). 49.4% of CNSs work in hospitals. More than 27% of CNSs are also prepared as NPs.
  • Nurse Practitioners represent the largest group of APRNs. Among Nurse Practitioners, 10.3% are also prepared as Clinical Nurse Specialists. Nearly 85% hold Master’s degrees and 3.9% have Doctorate degrees. More than 38% work in hospital settings, including hospital-affiliated primary care clinics. Another 35.3% of NPs are employed in ambulatory care settings outside of hospitals.

Definition of Practice

The practice of APRNs in California is determined by state law as outlined in the California Nurse Practice Act, and aligned with the American Nurses Association Standards of Practice, and national specialty nursing organizations’ practice recommendations. APRNs work in a variety of settings that include inpatient and outpatient clinical services (acute care, primary care and long-term care settings). Additionally some APRNs may practice as independent practitioners where they provide services that are reimbursed according to California statutes.

  • Certified Registered Nurse Anesthetist – The Scope and Standards for Nurse Anesthesia Practice have been developed by the American Association of Nurse Anesthetists.[17] “As anesthesia professionals, CRNAs provide anesthesia and anesthesia-related care upon request,assignment, or referral by the patient’s physician or other healthcare provider authorized by law, mostoften to facilitate diagnostic, therapeutic, and surgical procedures. In other instances, the referral orrequest for consultation or assistance may be for management of pain associated with obstetrical laborand delivery, management of acute and chronic ventilatory problems, or management of acute andchronic pain through the performance of selected diagnostic and therapeutic blocks or other forms ofpain management” (CRNA Scope and Standards for Nurse Anesthesia Practice).
  • Certified Nurse Midwife – Nurse-midwifery practice as conducted by CNMs is the independent, comprehensive management of women’s health care in a variety of settings focusing particularly on pregnancy, childbirth, the postpartum period, care of the infant, and the family planning and gynecological needs of women throughout the life cycle. The California Board of Registered Nursing enables the CNM to attend cases of normal childbirth and to provide prenatal, intrapartum and post partum care, including family planning for the mother and immediate care for the newborn, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics. “Supervision” does not require the physical presence of the supervising physician when care is rendered by the nurse midwife. CNMs practice in collaboration with physicians when appropriate. The degree of collaboration depends upon the medical needs of the individual woman or infant and the practice setting. For practices and procedures which overlap the practice of nurse-midwifery into medicine, standardized procedures must be used.[18]
  • Clinical Nurse Specialist – According to the National Association of Clinical Nurse Specialists, Clinical Nurse Specialists (CNS) are licensed registered nurses who have graduate preparation (Master’s or Doctorate) in nursing as a CNS. They are expert clinicians in a specialized area of nursing practice and function in a wide variety of health care settings. In addition to providing direct patient care, CNSs influence care outcomes by providing expert consultation for nursing staff and by implementing improvements in health care delivery systems. There are three domains of CNS practice: Patient, Nurse, and Health Care System.CNS practice integrates nursing practice, which focuses on assisting patients in the prevention or resolution of illness, with diagnosis and treatment of disease, injury and disability.[19]
  • Nurse Practitioner – The scope of practice for a nurse practitioner includes performance of assessments, promotion of health, and prevention of illness and injury. Nurse Practitioners can diagnose, order, conduct, supervise and interpret diagnostic and laboratory tests and prescribe pharmacologic and non-pharmacologic treatments to manage acute illnesses and chronic diseases.[20]

In California, the Business and Professionals Code does not differentiate the scope of practice for an APRNfrom that of a Registered Nurse. As such, NPs are authorized to diagnose and utilize prescriptive authority through a Standardized Procedure developed in collaboration with a physician and the administration of the employing agency. AStandardized Procedure is the process for granting RNsthe authority to perform those functions which may overlap with medicine.

Licensure, Accreditation, Certification and Education

As the role of the APRN has been universally accepted as a valuable member of the health care profession and the number of APRNs has subsequently grown, questions about licensure, accreditation, certification and education have emerged. Lack of common definitions and legal recognition, coupled with a proliferation of specialties and subspecialties, have encouraged the formation of the APRN Consensus Model to create standardization among APRN stakeholders. The following information has been extracted from theAPRN Consensus Paper.

Education: APRNs are educated in one of four roles (Certified Registered Nurse Anesthetists, Certified Nurse Midwives, Clinical Nurse Specialists and Certified Nurse Practitioners) and in at least one of six population areas (family/individual across the lifespan; adult/gerontology; pediatrics; neonatal; women’s health; and psychiatry/mental health). APRN education consists of core content that includes separate graduate level courses in advanced physiology/pathophysiology, health assessment and pharmacology, as well as the appropriate role-based clinical experiences. A graduate degree is the required entry level preparation for APRNs. Additionally, some programs award post-master’s certificates for Registered Nurses to function in specialized advanced practice roles.

Licensure: Individuals are licensed for practice as RNs and certified in one of the APRN roles. Education, certification, and licensure of an individual must be congruent in terms of the role and population or specialty concentrations. Education for a specialty can occur concurrently with APRN education required for licensure or through post-graduate education. Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by professional organizations. State licensing boards will not regulate the APRN at the level of specialties in the Consensus APRN Regulatory Model. Professional certification in the specialty area of practice is also recommended.

Accreditation: All APRN education programs or tracks go through a pre-approval, pre-accreditation, or accreditation process prior to admitting students. APRN education programs must be housed within graduate programs that are nationally accredited[21] and their graduates must be eligible for national certification at the advanced practice level.

Certification: Individuals who have the appropriate APRN education may sit for a national certification examination to assess competencies of the APRN, through core content, role specific content, and at least one population focus area of practice. APRN certification programs must be accredited by a national certification accrediting body.[22] As well, APRN certification programs require a continuing competence mechanism. If programs prepare graduates for both acute care and primary care roles, the graduate must be prepared with the APRN consensus-based competencies for both roles and must successfully obtain certification in both the acute and the primary care roles.